Failed vascularized proximal fibular epiphyseal transfer for hip reconstruction following infection in children

Treatment of the sequellae of hip infection with epiphyseal destruction in children has had limited success to date. The aim of this study was to report mid-term results after hip epiphyseal reconstruction using a proximal vascularized fibular graft in three children presenting with massive epiphyseal destruction of the proximal femur following infection.

Three children suffered from hip articular destruction type IVB according to the Choi classification after neonatal septic arthritis. The mean age at reconstruction was 4.3 years (range 3-6 years). The Hunka et al. criteria were used to evaluate the functional results, and the clinical evaluation was based on the Musculo-Skeletal Tumor Society (MSTS) score. Growth and fusion of the graft and hip morphology were evaluated on simple X-rays and by magnetic resonance imaging (MRI). A ratio between cephalic diameter and inter-acetabular gap was defined on the MRI scan as the "acetabular filling index".

No intraoperative complication was reported. With a mean follow-up of 4.8 years (3-6 years), the MSTS score was 22.7/30 (range 20-26), while the average lower limb length discrepancy was 3 cm. Patient 1 required a secondary derotation osteotomy of the femur because of abnormal external rotation and a bad result due to the unexplained occurrence of a painful and stiff hip joint. A secondary distal transfer of the greater trochanter was performed in patient 2, and good results based on Hunka et al.'s criteria were achieved. The X-rays of patients 1 and 2 showed signs of bone growth and a major remodeling process; the MRI filling indices were 83 and 67%, respectively. Patient 3 developed an early slipped capital (fibular) epiphysis 1 month postoperatively, which was treated by percutaneous pinning; this early complication led to a bad result with full resorption of the graft.

In contrast to its success in upper limb reconstruction, in this series of three patients with hip articular destruction, articular reconstruction using a vascularized proximal fibula graft was disappointing and led to unsatisfactory results in terms of hip reconstruction. Such a procedure is complex and highly demanding, necessitating extremely intensive post-operative care. An early slipped capital epiphysis can lead to full graft resorption. Consequently, despite important adaptation and remodeling of the graft, the authors do not recommend this procedure at this location.