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Giving New Life to Dead Bones

Scott Tintle, MD, fellow in the department of Orthopaedic Surgery, examines patient Adam Segal's progress at a recent follow-up appointment
According to the Agency forHealthcare Research and Quality, more than 285,000 total hip replacementsare performed each year in the United States. Since 1960, improvements in jointreplacement techniques have greatly increased the effectiveness of total hipreplacement, allowing adults suffering from chronic arthritis to get back totheir daily lives without pain in as little as six weeks. While most artificialhip joints in use today will last 10-20 years, like all devices, the artificialhip joint – which replaces the natural hip bone with a metal ball andresurfaces the hip socket with a metal shell and plastic liner – wears out overtime. For younger patients, this means a second surgery (and maybe even athird) will be required to replace the artificial joint. Fortunately, a rareprocedure now being offered by specialists at Penn Medicine provides along-term alternative for younger patients with chronic hip pain.

For 26-year-old Adam Segal, a Penn Medicine patient whostarted experiencing pain in his hip in the spring of 2011, a temporary fixthat would wear out over time was no solution at all. Segal was approaching hisfinal days as a law school student when he first started to feel pain in hiship. With the Bar exam just months away, he pushed the pain out of his mind andfocused on his studies. Some time later, as the pain got worse and walkingbecome onerous, Segal sought help from an orthopaedic specialist.

X-rays and an MRI confirmed Segal was suffering frombilateral osteonecrosis, also known as avascular necrosis (AVN) – a conditionthat occurs when bones lose their blood supply. When translated,“osteonecrosis” means “bone death.” Over time, the condition leads to severepain and arthritis. “By the time I saw a specialist, I was walking with alimp,” he said. “My MRI showed the necrosis in both of my hips had advancedbeyond the point where the typical theraputic procedures would help, so Istarted looking into my options. I didn’t want to get artificial joints thatwould wear out in 15 or 20 years, but my options were limited. Then, I heardabout FVFG.”

Pioneered in 1979, the Free Vascularized Fibular Graft(FVFG) procedure was originally developed as an alternative to total hipreplacement, particularly for younger patients suffering from AVN. Though thereare no known causes for AVN, several risk factors have been identified,including prolonged steroid use, alcohol consumption, trauma, or blood clottingdisorders. However, in cases like Segal’s, roughly 25 percent of patientsdevelop AVN with no known cause.IMG_0082“Instead of using an artificial joint that wears out overtime, FVFG uses live bone taken from the fibula in the lower leg and theconnected blood vessels to restore circulation to the hip,” explains L. ScottLevin, MD, FACS, Penn Medicine’s chairman of Orthopaedic Surgery, professor ofSurgery (Division of Plastic Surgery), and the Paul B. Magnuson Professor ofBone and Joint Surgery. “We replace the dying piece of bone in the hip with thesegment from the fibula. Once the blood vessels are connected, the hip is givena new blood supply that allows it to regenerate.”

The four-hour FVFG procedure is performed by surgeonsspecially trained in orthopaedics and microsurgery. Despite positive resultsand encouraging data from studies on FVFG outcomes, the unique skill setrequired to perform the surgery limits the number of hospitals capable ofoffering procedure. 

Segal underwent FVFG surgery on his right hip in earlyNovember. Today, he is on crutches and feels only mild levels of discomfort. Inthe coming weeks, he will begin weight-bearing exercises. Segal’s surgical teamis hopeful that he will be fully recovered early in the new year. Despite thelengthy recovery, particularly when compared to the six weeks it typicallytakes patients to recover from a total hip replacement, Levin says in thelong-run the FVFG procedure will be worth it.

“In only a few months, Adam will be able to walk, run and goback to his daily life. His own hip will be regenerating with a fresh bloodsupply, eliminating the need for total hip replacement procedures,” Levin said.“Had he chosen hip replacement with artificial joints, his initial recoverytime would have been shorter, but it’s likely he would have needed multiple hipreplacement revisions over the course of his life to replace the worn outjoints.” 

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