What is the role of bone graft in the treatment of avascular necrosis (AVN)?

Updated: Dec 05, 2020
  • Author: Sunny B Patel, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

Bone graft options include structural cortical or medullary bone graft and vascularized bone graft with either a muscle-pedicle bone graft or free vascularized fibular graft. [31]

Bone grafting is combined with the following:

  • Core decompression, which may interrupt the cycle of ischemia
  • Excision of sequestrum, which may inhibit revascularization of the femoral head
  • Period of limited weight bearing

The best results have been reported with free vascularized bone grafts. Success rates of 70% and 91% have been reported in two small series. [32, 33]

Advantages of free vascularized grafts compared with total hip arthroplasty include the following:

  • Healed femoral head may allow more activity
  • No foreign body–associated complications occur
  • If performed during early AVN, lifelong survival of the femoral head is possible
  • The patient has the option of total hip arthroplasty in the future

Disadvantages of free vascularized grafts include the following:

  • Longer period of recovery
  • Less complete pain relief
  • Variable success rate
  • Lack of effectiveness in advanced disease

In a review of bone grafting through a window at the femoral head-neck junction, Zuo et al found that factors predicting good clinical success were absence of femoral head collapse or degree of collapse < 2 mm (Association Research Circulation Osseous [ARCO] stage IIIa). Surgical failure rates were high in patients with femoral head collapse >2 mm (ARCO stage IIIb and IIIc) and in those with necrotic lesions involving the lateral pillar (L2 and L3 type). Finally, patients  40 years of age and older had a worse prognosis than those younger than 40. [34]


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