Proximal femur fractures after free vascularized fibular grafting to the hip

The management of symptomatic femoral head osteonecrosis in young, active patients is troublesome and controversial. At the authors' institution, 707 consecutive free vascularized fibular grafts were performed for femoral head osteonecrosis between October 1979 and October 1995. Patients who underwent this procedure were at increased risk for proximal femur fractures because of the 16 to 21 mm core drilled through the lateral femoral cortex for removal of the avascular bone and placement of the fibular graft. An ongoing prospective database of patients who underwent this procedure was accessed to determine the incidence of and factors associated with postoperative subtrochanteric femur fractures. Eighteen subtrochanteric fractures occurred for an overall incidence of 2.5%. All fractures occurred through the core decompression site in the lateral femoral cortex. The treatment was nonoperative in seven patients and operative in 11. Fourteen of 18 fractures (77%) healed with an average of 4.1 months until radiographically documented union. Four fractures had nonunions develop, three of which later healed with bone grafting and internal fixation, whereas the fourth eventually required conversion to total hip arthroplasty. Twelve fractures in 251 patients occurred when the weightbearing regimen was touchdown weightbearing for the first 6 weeks and five fractures in 456 patients occurred when the weightbearing regimen was changed to nonweightbearing. The results indicate that nonweightbearing in the immediate postoperative period is associated with the lowest fracture rate.