Published on in Orthopaedics Update
When A.L. was 11 years old, he complained of pain in his left hip. The pain subsided, but a week and a half later, A.L. came home crying and barely able to walk. The pain in his hip had become “excruciating.”
A.L.’s parents took him to the local Emergency Room, where an X-ray showed the ball-shaped head of the A.L.’s thigh bone had deteriorated. Doctors believed the boy may have a rare genetic condition known as Legg-Calve-Perthes disease, in which the femoral head loses its blood supply, causing the bone to die and eventually collapse. Years before, A.L.’s uncle had been diagnosed with the same disease. To confirm the diagnosis, A.L. was referred to a children’s hospital, where an MRI confirmed the diagnosis.
Referral to a team specializing in pediatric hip disorders
A.L. was referred to CHOP’s Hip Disorders Program for treatment. After examining A.L. and reviewing test results, Dr. Sankar and his clinical team discussed multiple treatment options with the family. The conservative approach included prolonged crutch use and physical therapy, with the standard surgical approach being a femoral osteotomy.
But because of A.L.’s age, the recommended approach was an advanced, specialized procedure called core decompression and microsurgical free vascularized fibula grafting. While the parents considered the options, A.L. did his own research and told his parents he believed the vascularized fibular grafting surgery would offer him the best chance to return to his active lifestyle.
Vascularized fibular grafting to preserve the hip
Vascularized fibular grafting is a complex procedure in which dead bone is removed and replaced with a section of the patient’s own fibula bone. Dr. Sankar (a hip specialist) and Dr. Levin (a microsurgical specialist) worked in conjunction to perform this operation, which is only offered at certain pediatric hospitals in the country, but has the potential to directly increase blood flow to the hip.
During the microvascular portion of the surgery, Dr. Levin moved live tissue, bone and tiny blood vessels less than a millimeter thick into new positions in the leg and hip. The blood vessels were then sewn together using thin sutures and needles less than 60 microns thick (equal to 0.06 millimeters). This type of microvascular surgery requires advanced expertise and a specialized skill set.
After surgery, Dr. Levin held a doppler device to A.L.’s hip and the boy’s parents heard the blood circulating through his hip bone once again.
Seven months after surgery, A.L. was cleared to bear weight on his leg. By Spring, he was cleared to rejoin his baseball team in a limited capacity. After a year in physical therapy and 15 months after surgery, A.L. was allowed to participate fully in sports – just in time for wrestling season.
After a slow start on the mat, A.L. regained his skills, speed and strength, earning his way to a second place in the middle school regional championship and the Inter County Wrestling League’s "Little Engine That Could" award for the best eighth-grade wrestler.
Wudbhav N. Sankar, MD, is Director of the Young Adult Hip Preservation Program and heads the Hip Disorders Program, both at Children’s Hospital of Philadelphia. L. Scott Levin, MD, FACS, FAOA, is Director of the Hand Transplantation Program at CHOP, Chair of the Department of Orthopaedic Surgery at Penn Medicine, and Professor of Plastic Surgery at the Perelman School of Medicine at the University of Pennsylvania.