Introduction: The purpose of this study was to evaluate the effectiveness of free vascularized fibular grafting (VFG) for the treatment of osteonecrosis of the femoral head.

Materials and Methods: We reviewed the results in a consecutive series of 115 hips (88 patients) who had undergone free VFG between July 1991 and February 1999. Among them, 46 hips (32 patients, 28 males and 4 females) were available with periodic follow-up of at least 5 years. The mean follow up period was 7.1 years (range, 5 to 13 years). An average age of patients was 37.6 years at the time of VFG. We performed survival analysis by the Kaplan-Meier method according to the stage, etiology, age of patients, size of involvement, and degree of collapse of the femoral head. We used the Harris hip score for clinical evaluation, and used plain radiographs and MRIs for radiological evaluation.

Results: The survival rates were 85% in Ficat stage 2a, 34.7% in stage 2b, and 76.2% in stage 3. Eleven hips were evaluated as failures of VFG of which 7 hips were converted to a prosthetic joint. Harris Hip Scores were 67.8 points preoperatively, and increased to 80.4 points postoperatively. Good or excellent results were found in 69.5% of hips clinically and 56.5% of the hips radiologically. Age and size of necrosis affected the postoperative Harris Hip Score significantly, but other factors did not.

Discussion: Free VFG for the early osteonecrosis of femoral head revealed satisfactory results with good survival of the joint and improvements in Harris Hip Scores.

The purpose of this study was to determine the annual incidence of Perthes’ disease in Korea and compare this with other populations. A survey identified all newly diagnosed children with Perthes’ disease aged 14 years or younger in South Honam, Korea, between January 1999 and December 2001. A total of 84 children were included: 29 in 1999, 28 in 2000 and 27 in 2001. The mean annual incidence was 3.8 per 100 000. This is similar to that reported in other Asian countries, but higher than in black populations and lower than in Caucasians.

Free, vascularised fibular grafting is well described in limb salvage surgery. The mechanical properties of the fibula make it ideal for replacement of bony defects after tumour resection and it can be sacrificed with minimal morbidity. We review the outcome of a consecutive series of 24 patients.

Between 1993 and 2002 we performed free vascularised fibular grafts in 24 patients as part of a limb salvage procedure following tumour excision. Pre-operatively patients were staged using the Musculoskeletal Tumour Society (MSTS) system. Post-operatively patients were followed up with radiographs and clinical examination. From the radiographs graft hypertrophy and time to bony union was documented. Functional outcome was assessed using the MSTS scoring system. Complications were recorded.

There were 15 women and 9 men with a mean age of 26 years (6–52). Mean follow up was 51 months (12–106). There were 19 malignant tumours, all stage 2b, and 5 giant cell tumours. The mean length of graft was 12.5 cm. (4.5–25). 16 grafts were used in the upper limb and 8 in the lower limb. Arthrodesis was performed in 8 cases and intercalary reconstruction in 16 cases. Fixation of grafts was achieved with a plate and screws in 21, a blade plate in 2 and an IM nail in 1. In 6 cases the resected tumour bone was reinserted as autograft after extracorporeal irradiation. In all but one patient the tumour margins were clear. Primary bony union was achieved in 22 patients (92%) at a mean of 35 weeks (12–78). Graft hypertrophy was seen in 7/29 cases (24%). Complications included 2 wound breakdowns, 3 stress fractures, 1 muscle contracture, 1 malunion and 1 painful plate. Overall 8 patients (33%) required second operation. 2 patients died of recurrent disease and one has metastases. The mean MSTS functional score was 87% (80–93).

Free vascularised fibula grafts offer a reliable method of reconstruction after excision of bone tumours. The complication rate appears high and some patients require a revision procedure. However, the problems are relatively easy to correct, bony union is achieved in the majority and functional outcome is good.

Introduction: It is very important to evaluate the healing process in the femoral head after free vascularized fibular graft (VFG) in osteonecrosis of the femoral head (ONFH). Bone scintigraphy combined with a pinhole collimator, which is simple and not expensive, is used for very high resolution images of small organs, such as thyroid and certain skeletal regions. The purpose of this study was to assess the changes using pinhole bone scintigraphy in ONFH after VFG.

Materials and Methods: Changes of Tc-99m-HDP pinhole bone scintigraphy were analyzed in 22 cases of ONFH which were treated with VFG and had satisfactory results in patient evaluations at least 2 years after surgery. Harris Hip Scores were 90 points or more; and femoral head collapse was less than 2 mm.

Results: The results were: (1) At 1 week, the pinhole image showed no significant change in cold area but two linear RI uptakes corresponding to the fibular graft were noted. (2) At 3 months, localized hot uptakes just above the tip of the graft were observed in 17 cases (77.2%), and diffuse increased uptake surrounding the cold area were observed. (3) At 6 months, localized hot uptake were increased in size and replaced cold areas and delineated the shape of the superolateral aspect of the femoral head. (4) At 1 year, increased RI uptake of the superolateral aspect of the femoral head expanded medially in all cases. (5) After 2 years, cold areas faded away in 18 cases (81.8%).

Discussion: In conclusion, the authors believe that the Tc-99m-HDP pinhole bone scintigraphy is an excellent method to delineate the healing process in ONFH after VFG.

Introduction: Osteonecrosis of the femoral head remains a challenging problem especially in young patients. The purpose of this study was to evaluate the clinical results of a viable iliac bone graft for treating osteonecrosis of the femoral head.

Materials and Methods: Seventy-one hips in 52 patients underwent a viable iliac bone graft (9 hips-vessel pedicle iliac bone graft and 62 hips-muscle pedicle iliac bone graft). The clinical and radiographic results were evaluated after an average of 3 years and 4 months (range, 2 to 5 years). Patient age ranged from 20 to 40 years with an average of 31 years. Twenty-three hips were classified as Ficat stage 2 disease and 48 as stage 3 disease. The causes of osteonecrosis were excessive alcohol consumption in 30, steroid use in 13, posttraumatic in 4, decompression sickness in 1, and unknown in 23 hips. The clinical results were evaluated based on the patients’ satisfaction and pain score. The radiographical results were evaluated by serial follow-up roentgenography and pinhole bone scintigraphy.

Results: The clinical and radiological results were satisfactory. Overall, the survival rate was 96 percent. Excellent results were obtained in 15 hips, good in 39, fair in 6 and poor in 8. Three hips underwent total hip replacement, including one infected case. Excellent or good results were obtained in 82 percent of stage 2 cases and in 65 percent of stage 3 cases. The serial roentgenographic examination revealed a gradual incorporation of the grafted bone, and the scintigraphic examination revealed a gradual increase in the uptake which suggested an increased blood supply to the femoral head.

Discussion: The overall results of viable iliac crest bone grafting were very satisfactory. This technique is recommended particularly for young patients with stage 2 or 3 osteonecrosis of the femoral head. Pinhole bone scintigraphy was quite useful for evaluating the healing process after the revascularization procedure.

In 1980, Morrison and O’Brien reported their experiences with the reconstruction of an amputated thumb using a wrap-around neurovascular free flap from the great toe, but its indication has been limited distal to the metacarpophalangeal joint.

We have performed 37 wrap-around free flaps from the great toe for the reconstruction of thumbs amputated at distal or proximal to the MP joint. The amputation was distal and proximal to the MP joint in 25 and 12 cases respectively.

The opposition of reconstructed thumb to the other fingers was completely possible in all cases amputated distal to the MP joint. In the 12 cases amputated proximal to the MP joint of the thumb, opposition was completely possible in 6 cases in which the lilac bone block was fixated in the position of 30° flexion and 45° internal rotation. However, in the other six cases in the fixation of 30° flexion and 30° internal rotation, the opposition of the reconstructed thumb to the ring and little fingers was impossible in five cases and only to the little finger in one case.

We concluded that amputation proximal to the MP joint is not an absolute contraindication to the wraparound free flap procedure for thumb reconstruction. However, for a better functional outcome we recommend iliac bone block fixation in the position of 30° flexion and 45° internal rotation.

Fifty-four cobalt-chrome alloy femoral heads were retrieved at revision surgery or at post-mortem; 23 came from uncemented, eight from hybrid and 23 from cemented hip arthroplasties. The uncemented and hybrid implants had porous coating, metal backing and modular femoral heads; with one exception none of the cemented implants had any of these. Twenty-five of the 31 heads from uncemented and hybrid arthroplasties, and 11 of the 23 heads from cemented arthroplasties showed surface damage involving more than 25% of the surface. Scanning electron microscopy revealed multidirectional fine scratches 1 micron to 10 microns in depth and width which appeared to have been made by fine, hard particles. There was a higher rate of such damage in the uncemented and hybrid arthroplasties than in the cemented implants, suggesting that the abrasive particles were mainly released from the metal, rather than from the cement or polyethylene components of the implants.

The total plasma alkaline phosphatase level has long been recognised as an indicator of osteoblastic activity, but lack of specificity makes it an insensitive index of the progress of disease and the response to treatment. Selective precipitation by wheatgerm lectin allows measurement of the plasma bone-specific alkaline phosphatase. We measured the plasma levels of this isoenzyme in 170 normal Chinese adolescents and adults, in 49 adults with fractures of a long bone, in 15 patients with osteosarcoma and in 38 patients with osteolytic metastases. The enzyme activity was also determined in 39 patients with liver disease. Of the patients with fractures, 94% had increased plasma activity during the healing process. The level was also increased in those with osteosarcoma but not in those with osteolytic bone metastases. There was no significant increase in activity in the patients with liver disease. We conclude that the plasma bone-specific alkaline phosphatase activity is a sensitive and reliable measure of osteoblastic activity.