Agency for Healthcare Research and Quality, more than 285,000 total hip replacements are performed each year in the United States. Since 1960, improvements in joint replacement techniques have greatly increased the effectiveness of total hip replacement, allowing adults suffering from chronic arthritis to get back to their daily lives without pain in as little as six weeks. While most artificial hip joints in use today will last 10-20 years, like all devices, the artificial hip joint – which replaces the natural hip bone with a metal ball and resurfaces the hip socket with a metal shell and plastic liner – wears out over time. For younger patients, this means a second surgery (and maybe even a third) will be required to replace the artificial joint. Fortunately, a rare procedure now being offered by specialists at Penn Medicine provides a long-term alternative for younger patients with chronic hip pain.
For 26-year-old Adam Segal, a Penn Medicine patient who started experiencing pain in his hip in the spring of 2011, a temporary fix that would wear out over time was no solution at all. Segal was approaching his final days as a law school student when he first started to feel pain in his hip. With the Bar exam just months away, he pushed the pain out of his mind and focused on his studies. Some time later, as the pain got worse and walking become onerous, Segal sought help from an orthopaedic specialist.
X-rays and an MRI confirmed Segal was suffering from bilateral osteonecrosis, also known as avascular necrosis (AVN) – a condition that occurs when bones lose their blood supply. When translated, “osteonecrosis” means “bone death.” Over time, the condition leads to severe pain and arthritis. “By the time I saw a specialist, I was walking with a limp,” he said. “My MRI showed the necrosis in both of my hips had advanced beyond the point where the typical theraputic procedures would help, so I started looking into my options. I didn’t want to get artificial joints that would wear out in 15 or 20 years, but my options were limited. Then, I heard about FVFG.”Pioneered in 1979, the Free Vascularized Fibular Graft (FVFG) procedure was originally developed as an alternative to total hip replacement, particularly for younger patients suffering from AVN. Though there are no known causes for AVN, several risk factors have been identified, including prolonged steroid use, alcohol consumption, trauma, or blood clotting disorders. However, in cases like Segal’s, roughly 25 percent of patients develop AVN with no known cause. “Instead of using an artificial joint that wears out over time, FVFG uses live bone taken from the fibula in the lower leg and the connected blood vessels to restore circulation to the hip,” explains L. Scott Levin, MD, FACS, Penn Medicine’s chairman of Orthopaedic Surgery, professor of Surgery (Division of Plastic Surgery), and the Paul B. Magnuson Professor of Bone and Joint Surgery. “We replace the dying piece of bone in the hip with the segment from the fibula. Once the blood vessels are connected, the hip is given a new blood supply that allows it to regenerate.”
The four-hour FVFG procedure is performed by surgeons specially trained in orthopaedics and microsurgery. Despite positive results and encouraging data from studies on FVFG outcomes, the unique skill set required to perform the surgery limits the number of hospitals capable of offering procedure.
Segal underwent FVFG surgery on his right hip in early November. Today, he is on crutches and feels only mild levels of discomfort. In the coming weeks, he will begin weight-bearing exercises. Segal’s surgical team is hopeful that he will be fully recovered early in the new year. Despite the lengthy recovery, particularly when compared to the six weeks it typically takes patients to recover from a total hip replacement, Levin says in the long-run the FVFG procedure will be worth it.
“In only a few months, Adam will be able to walk, run and go back to his daily life. His own hip will be regenerating with a fresh blood supply, eliminating the need for total hip replacement procedures,” Levin said. “Had he chosen hip replacement with artificial joints, his initial recovery time would have been shorter, but it’s likely he would have needed multiple hip replacement revisions over the course of his life to replace the worn out joints.”