Patient Handbook

dukehealth.org/fvfg
Patient
Handbook
Free Vascularized Fibular Graft
contents
2
The procedure
4
Before your surgery
5
During your surgery
6
After your surgery
10
Frequently asked questions
Overview
The free vascularized fibular graft procedure was developed as an
alternative to total hip replacement for patients suffering from
osteonecrosis, also known as avascular necrosis (AVN).
Osteonecrosis literally means “bone death.” There are multiple causes
of this condition, and it occurs in a variety of patients and in a variety of
anatomical locations. When this condition occurs in the hip, it can cause
significant pain and disability to the patient. As this disease frequently
occurs in younger patients, in whom total joint replacement is not the
best solution, removing the dead bone and replacing it with healthy bone
and a new blood supply—preserving the patient’s native hip bone—is
currently the best solution for this challenging problem.
The technique was pioneered by Duke orthopaedic surgeon James
Urbaniak, MD, in 1979. Since then, more than 2,500 free vascularized
fibular graft procedures have been performed by the Duke team.
Patients from all over the world come to Duke University Medical Center
to have this procedure performed. Within Duke Orthopaedics, you’ll
find a comprehensive team of surgeons, physician assistants, nurses,
anesthesiologists, physical therapists, occupational therapists, and patient
resource managers who devote themselves to serving osteonecrosis
patients. Each member of our dedicated staff works cooperatively to
provide you with the most accurate information and best possible care in
a compassionate and timely manner. We are here to address the concerns
and support the needs of every free vascularized fibular graft patient.
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Duke Orthopaedics
Candidates of the Procedure
Office Procedures
This procedure was developed for young
patients; any patient over age 50 is not a
candidate. Due to possible complications,
the surgery is also limited to patients that
do not have sickle cell disease. If you have
been diagnosed with osteonecrosis of
the hip, and meet these limitations, you
may be eligible for the free vascularized
fibular graft procedure.
Services
Our clinical service coordinators are
the first clinic staff you will meet as you
arrive in our clinic. They will assist with
checking you in for your appointment,
collect your payment, and give you any
additional information pertinent to your
office visit. Patient representatives will
then consult with you about insurance
benefits and financial needs.
Have your local orthopaedic surgeon
complete the Avascular Necrosis
Referral Protocol form, downloadable at
dukehealth.org/FVFG. This form details
the information needed to determine if
you are a surgical candidate. If you are a
candidate for the free vascularized fibular
graft procedure, we will contact you and
your referring doctor. If you are not a
candidate, the x-rays and MRI will be
returned to your referring doctor.
Your Care Team
Nurses
The office nurses will assist you in the
examining room. They are also available
to answer questions or concerns that you
may have.
Insurance
Your insurance policy is a contract
between you and your insurance
company. It is essential that you review
your policy and become familiar with
your benefits and provisions. In general,
we file insurance as a courtesy to the
patient. Any dispute regarding payment
is between the patient and insurance
company. Insurance plans usually require
pre-authorization, and our patient
representatives start this process as soon
as your surgery date has been determined.
Please verify that this step has been
accomplished when you check into the
clinic. If you have any questions about
your coverage, contact your insurance
agent. Questions regarding the filing of
claims or the responsibility of payment
can be discussed with the patient
representative handling the claims.
Laboratory
If needed, lab tests will be performed at
our clinic during return clinic visits.
Radiology
Our on-site radiology technicians
specialize in working with orthopaedic
patients. At each postoperative visit, you
will have x-rays taken. You will
not need a MRI at any time following
your surgery. The MRI obtained
prior to surgery is for diagnostic
purposes; x-rays are used to follow
the postoperative progression of
bone healing.
Important Numbers
AVN Coordinator 919-668-5259 (tel)
919-668-5476 (fax)
Billing 919-620-4555 (local)
800-782-6945 (toll-free)
The CPT codes for free vascularized fibular graft are 27071, 27170, and 20955.
The ICD diagnosis code for avascular necrosis of the femoral head is 733.42.
Free Vascularized Fibular Graft Patient Handbook
3
Before Your Surgery
There are some medications that
can interfere with your surgery.
The following drugs and dietary
supplements should be discontinued:
Several tests and procedures will be performed:
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Two weeks before surgery
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Alpha-omega supplements
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Fish oil
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Vitamin E
One week before surgery
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Aspirin products
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Anti-inflammatory medications
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Anticoagulants (blood thinners)
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Immunosuppressants (i.e.,
methotrexate, CellCept, Plaquenil)
Duke Orthopaedics
X-rays to measure the amount of dead bone
MRI (magnetic resonance imaging) to further determine the extent
of avascular necrosis
A physical exam and other lab studies at the time of admission
Your surgeon will schedule the surgery date once the review of your
clinical history, x-rays, and MRI has been completed. The scheduling
secretary will contact you by letter or telephone with the date
of surgery. Additional information will be given at that time in
preparation for surgery.
For patients who require surgery on both sides of the hips, the hip most
severely affected is operated on first; three months later the operation is
performed for the opposite hip. The follow-up surgery will be scheduled
at the time of discharge from the hospital or at subsequent office visits.
During Your Surgery
Two teams of specialty-trained surgeons
will be present for your free vascularized
fibular graft. One team works on the hip
area, and the other team works on the
lower leg (the area of the fibula).
During the surgery, an incision is made
along the hip so that the dead bone may
be removed and the remaining bone
prepared to receive the graft. An incision
is made in the lower leg to remove a
segment of the fibula and its attached
blood vessels. The fibular segment of
bone is then inserted into the hip bone.
The blood vessels (artery and vein) in the
hip region are connected to the vessels
of the fibular graft with microsurgical
techniques by either sutured connection
or vascular coupler.
The circulation is carefully checked to
ensure blood flow into the hip, and the
incisions are closed. A bulky dressing
and cradle boot are applied to the lower
leg to immobilize it for comfort. The
cradle boot is usually removed after five
days. A bandage is applied to the hip. The
dressing and bandage can be removed five
to seven days following surgery.
During Your Hospital Stay
After surgery, you will be given
anticoagulants (blood thinners), which
help to prevent blood from clotting too
quickly and to enhance blood flow to the
grafted area.
On postoperative day 1, a physical
therapist will begin guiding you in
crutch-walking, muscle-strengthening
exercises, and which activities to limit
during your recovery period.
The total length of the hospital stay is
usually three to four days, including the
day of surgery. Discharge usually occurs
on postoperative day 3. Your hospital
stay may be longer if your surgeon
recommends later discharge.
We are often asked for a recommended
method of travel—car or plane. Consider
the total length of time of transport from
the hospital to your home when planning
the method of travel. Usually, the shortest
travel time is the best.
Free Vascularized Fibular Graft Patient Handbook
5
After Your Surgery
Wound Care
Swelling
Your Recovery
Your incisions should be kept clean and
dry. The dressing can be removed on
the day following your return home. No
drainage is expected from your incision,
and minimal redness is expected around
your incision. If you develop drainage or
redness, contact your surgeon’s office.
Postoperative swelling and a bruised
appearance in the leg and hip region are
common following a free vascularized
fibular graft. The majority of the swelling
will be located closest to the surgical site.
As you are more active and have your
foot below your heart, swelling in the leg
will occur below the area of surgery in
the lower leg and the foot. The swelling
is usually less in the morning and greatest
at the end of the day.
While your hip bone re-vascularizes, the
surface of the femoral head is very weak.
In addition, the femur (leg bone) is 80
percent weaker because of the surgery.
Therefore, it is very important to use your
crutches and stay within the limits placed
on weight-bearing. Any weight above the
following prescribed amounts can cause
collapse of the femoral head. Please also
note that lack of postoperative pain does
not indicate the rate of healing.
Showering may be resumed seven days
after surgery or when there has been
no drainage for the preceding 48 hours.
Wash gently over the incisions with warm
sudsy water, rinse with clear water, and
pat dry. You may leave the incisions
open to the air or re-cover with a clean,
dry dressing. If the dressing gets wet at
any time, it should be removed and the
incisions cleaned.
Do not apply any creams or ointments
to the incision until your Steri-Strips are
removed. (You can remove them between
10 and 14 days following the surgery.)
You may have had a plastic drain tube
placed during surgery. If you had a
drain, you most likely have clear plastic
dressing on the site where the drain
exited the skin. If a small amount of
fluid collects under this area, it is not a
problem; simply change the dressing. If
the dressing leaks, it needs to be replaced.
Use the dressing material given to you at
the time of discharge from the hospital.
Let us know if you have any concerns
about the appearance of your incisions.
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Duke Orthopaedics
Periodically elevate your leg to help
reduce swelling: Lie down in bed three
to four times a day with the operated
leg resting on several pillows. Do this
for 20 minutes at a time to help decrease
the swelling in your leg. If you have
persistent swelling and pain that does
not decrease with elevation, contact your
surgeon’s or primary care doctor’s office.
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Do not bear weight during the first
six weeks
At week 7, begin by bearing 20 pounds
Increase weight-bearing on the operated
leg by 10 pounds every two weeks until
body weight is met
Constipation
Constipation is a common problem
associated with decreased activity,
decreased fluid intake, and the use of
narcotic pain medication. You will be
discharged with a stool softener, which is
important to take as directed. You should
also pay close attention to your fluid
intake by drinking a lot of fluids and
eating a diet high in fiber and roughage.
Bran cereals, prunes, prune juice, highfiber bread, and raw fruits and vegetables
will help reduce constipation. If necessary,
a mild laxative may be used.
Fever
It is not uncommon to run a low-grade
fever following major surgery, and it may
last a week or up to 10 days. If you have
a persistent fever above 101.5°F with
pain, irritation of your incision, burning
in the urinary area, or a productive
cough, call your surgeon’s office.
The progression to full, unassisted
weight-bearing depends on the stage of
your avascular necrosis and whether both
hips are affected, follow-up x-rays, and
symptoms. After your surgeon reviews
your postoperative x-rays, you will be
instructed when to discontinue crutches.
Some patients prefer to use a walker
instead of crutches for greater stability,
particularly in the home. The progression
with weight-bearing remains the same
with walkers. Likewise, a wheelchair is
not required postoperatively, but some
patients prefer a wheelchair at work or
around the home after having surgery on the second hip.
Sitting
To get up from a chair, hold both crutches
in one hand and push up from the chair
with your other hand. Once up, place one
crutch under each arm.
To sit back down, take the crutches out
from underneath both arms. Hold the
crutches together in one hand and reach
back for the chair with your other hand.
This makes the transfer smooth and
decreases the risk of putting too much
weight on your operated leg.
Exercise
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Stairs
To go up stairs, lead with your “good”
leg, followed by your operated leg and
crutches.
Descend stairs with your crutches first,
followed by your operated leg, then your
“good” leg. If a railing is available, hold
both crutches under one arm and use the
railing for support in the other hand.
Activity Level
We encourage you to be up and active as
you recover; most patients will feel like
doing more activities after the first week
home from surgery. We do recommend
periodic rest with the operated leg
elevated above the level of the heart.
Fatigue following the surgery varies from
person to person and should completely
resolve by three months.
Sleep
Even though you are tired, you might find
it difficult to fall asleep at night during
the first weeks after free vascularized
fibular graft surgery. Sleep in the most
comfortable position for you. However,
most patients wait until at least two
weeks have passed before lying on the
operated side.
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Continue the exercise program you
began in the hospital.
Walking is excellent exercise to help
build strength, but only after crutches
have been discontinued.
Swimming or aquatic exercises can
be started six weeks following surgery.
(Ensure safe access to the pool. Be sure
to use steps or ramp access rather than
ladder.)
Stationary biking may be started six
weeks after surgery with resistance on
the pedals. You may use resistance to
the same degree as you are permitted
to have weight on the operated leg. The
amount of resistance can be progressed
at the same rate as weight-bearing.
Avoid tennis, jogging, basketball, or
other sports that require a lot of
stop–start or cause jarring.
Stop any form of exercise that causes
new or increased pain. The desired form
of exercise can be tried again in two
weeks, but if the pain returns, that form
of exercise is to be avoided. For further
guidance, consult your surgeon at your
next office visit.
Travel
If you need a temporary handicapparking permit, the application form
may be obtained through your local
DMV office. Fill out the patient part of
the form and send it to your surgeon’s
office for the doctor’s signature. For
residents of North Carolina, our clinic
can provide the application form.
Returning to Work
The length of disability from work varies
from person to person and depends on the type of work and the severity of avascular necrosis.
Most patients return to sedentary work
with the use of crutches within six weeks.
Please keep in mind that someone else
will need to drive within that period.
If your job requires walking without
crutches, you may return four months
to a year following surgery.
If your job requires strenuous, manual
labor, you may return after one year.
Please complete the disability
questionnaire, available through your
local disability office, if a doctor’s
statement is required.
Returning to School
The length of time away from school
will depend on the modifications that
will be required to get to and from the
classroom. Most school-age patients
have homebound tutoring arranged
through the school system for the first
six weeks.
Sexual Intercourse
Intercourse may be resumed when you
feel your body has sufficiently recovered
from surgery. As a guide, remain passive
until after the three-week exercises are
performed without pain. Women should
consider delaying intercourse for six
weeks to avoid stress on vascular repair.
You should wait two weeks from the time
of surgery to do any traveling outside
the home. You can drive after the first
six weeks or earlier, if permitted by your
surgeon. Avoid twisting your operated
leg while getting in and out of the car.
Free Vascularized Fibular Graft Patient Handbook
7
Follow-Up Visits
All free vascularized fibular graft
patients require lifetime x-ray
surveillance. Follow-up office visits are
scheduled at the time of discharge from
the hospital and at subsequent office
visits. If interval visits are required,
they can be scheduled by calling the
Appointment Office at 919-613-7797
or 800-851-5811. If a problem arises
that will require you to be seen on an
emergency basis, call your surgeon’s
office, or if after hours, call 919-684-8111
and ask for the orthopaedic resident on call.
With Duke Orthopaedics surgeons
AP pelvis and frog leg lateral x-rays will
be obtained at six weeks, three months,
six months, one year, and every year
thereafter.
With local/referring orthopaedic
surgeons
Many of our patients have follow-up visits
performed by their local orthopaedic
surgeon. You will be seen postoperatively
at six weeks for weight-bearing
instructions and gait training. AP pelvis
and frog leg lateral x-rays are obtained at
three months, six months, and yearly.
After the six-month visit, your local
orthopaedic surgeon will send us a
summary letter and x-rays for review.
After the reviews of x-rays, your Duke
orthopaedic surgeon will relate his/her
findings in a letter. It is our practice to
review all x-rays and send a letter to
the patient or local surgeon as soon as
possible.
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Duke Orthopaedics
Recovery Timeline
After 1 week
Showering
if no drainage at incision site for
the preceding 48 hours
2 weeks
Travelling outside your home
4 weeks
Bathing
6 weeks
First postoperative office visit
Gradual weight-bearing on
operated leg
Return to driving
3 to 6 months
Walking without crutches
Full weight-bearing
The Second Surgery
If both of your hips have developed avascular necrosis, surgery
may be performed on the second hip approximately three months
following the first surgery.
To speed your recovery and prepare your body for the second surgery,
do not bear weight on the first hip for six weeks following the surgery.
At week 7, add 25 to 30 pounds of weight-bearing, and increase
weight-bearing on the operated leg by 10 pounds every two weeks.
Adding swimming, aquatic exercises, and/or stationary biking
three times a week—following the first six weeks of zero weightbearing—will help you be best prepared for upcoming surgery on
the second side.
Using your crutches correctly
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To determine the proper crutch length, allow three finger spaces
between your underarm and the top of the crutch when standing
erect with shoulders relaxed.
The far end of the crutches should come to a point 2 inches to side
and 6 inches in front of the foot.
The handle position should not allow the elbows to flex beyond
30 degrees.
To avoid injuries to nerves and blood vessels in the shoulder area,
do not make a habit of leaning on the axillary bar (the top bar).
Support your body weight in the hands—not under your arms.
Put away any throw rugs at home, as your crutches or toes could easily
catch on them.
After walking outside, check your crutch tips for gravel or other objects
that could cause the crutches to slide on the floor.
Exercise caution when walking from one floor surface to another,
such as linoleum to carpet.
The pads at the ends of crutches are susceptible to wear and tear and
can be replaced as needed. The pads should be replaced before the
pattern disappears or the concave surface flattens. Replacements are
available at most drugstores or health equipment stores.
Non-weight bearing (figure A)
is accomplished by always keeping
the operated leg off the ground.
Your whole body weight should be
shared evenly between the crutches.
Throughout the gait cycle, keep
the hip and the knee joint of the
operated leg in a flexed position.
With partial weight-bearing
(figure B) , the crutches are moved
forward with the affected foot
making gentle floor contact in a
line horizontal with the crutch tip.
The amount of weight placed on a
foot can be determined by placing
the uninvolved foot on a telephone
book next to a scale. Then place the
affected foot on the scale bearing
weight until the scale reads the
desired number of pounds.
If recommended by your surgeon, canes may be used to unload up to
15 percent of your body weight. The cane should be held in the hand
opposite the operated leg since it takes less pressure in that hand to
relieve hip pressure. The cane and operated leg should move together,
and it is very important for the handle to be comfortable to hold.
FIG A
FIG B
Free Vascularized Fibular Graft Patient Handbook
9
Frequently Asked Questions
What are the risk factors for developing
avascular necrosis (AVN)?
How long can I wait to make a decision
regarding surgery?
How long does the free vascularized
fibular graft surgery take?
In children, the most common risk factors
are trauma, slipped capital femoral
epiphysis, and steroid use. Other factors
are Legg–Calvé–Perthes syndrome and
idiopathic (unknown) causes.
Avascular necrosis is a progressive
condition. Progression may be observed
as early as one month or it may take
several months. Progression usually
occurs in less than 20 months.
The surgical procedure lasts
approximately three hours. Anesthesia
duration is approximately four hours.
In adults, the most common risk factors
are steroid use, alcohol consumption,
trauma, coagulopathies (blood clotting
disorders), and abnormal anatomy.
About 25 percent of patients develop
avascular necrosis with no known cause.
What is a free vascularized fibular graft?
A free vascularized fibular graft consists
of removing dead bone that has a poor
blood supply from the hip (figure A),
and replacing it with a healthy segment
of vascularized (blood-rich) bone from
the fibula (the smaller bone in the lower
leg, as shown in figures B and C). The
fibula segment serves as a graft. The
goal of the free vascularized fibular
graft is to preserve the femoral head
(hip bone) rather than replace it with an artificial joint.
What are the advantages of a free
vascularized fibular graft?
The advantage of a vascularized fibular
grafting is that the bone is transferred
“alive,” which means an early take and
better results. In addition, the blood
vessels spread out and form new bone to
strengthen the operated area.
If I have avascular necrosis, can both hips
be operated on at the same time?
No, but if the unoperated hip is or
becomes symptomatic, then the second
hip surgery will be performed two to
three months later.
What is the process to get admitted for
surgery?
On the day prior to surgery, you will need
to confirm your pre-surgery arrival time
by calling a phone number that we will
provide. On the day of surgery, you will
be admitted through the operating room.
Will I need a blood transfusion?
Fewer than 2 percent of patients require
a blood transfusion. Some patients prefer
to donate their own blood in advance to
use after the surgery, if required. This
is called autologous blood donation.
Some patients are unable to give their
own blood. If so, a family member or
friend with the same blood type may
donate for the patient. This is called
directed donation. In addition, there is
blood available from the blood bank.
Also, medications to increase red blood
cell production, such as epoetin alfa,
are available. These medications allow
your body to boost blood count without
donated blood.
Can I have visitors?
Your family (limited to two members)
may accompany you to the preoperative
holding area and will then be instructed
to wait in the family waiting area. Your
surgeon will speak to your family after
the procedure.
What should I bring to the hospital?
Bring personal items and toiletries that
you are accustomed to using at home.
You may want your own pajamas a day
or two after your surgery. Generally, a
hospital gown is preferred immediately
after surgery. A pair of comfortable flat
shoes is also recommended. Bring your
medications. Large amounts of money and
jewelry should be left at home. No jewelry
is permitted in the operating room.
What happens to the lower leg after the
fibula bone is removed?
The fibula is a minimally weight-bearing
bone and acts as strut for muscle
attachment. For this surgery, the middle
portion of the bone is removed, leaving
the top and bottom of the bone without
change. No plating is required and there
is no change in the appearance of the
lower leg except for the incision on the
outside of the leg. Sometimes patients
have transient swelling, numbness, and/
or weakness, and these symptoms usually
resolve during the early postoperative
recovery period.
What will the scar on the hip and lower
leg look like?
See figure D (incisions highlighted).
10 Duke Orthopaedics
Will I be on any medications after
surgery?
What kind of therapy will I have following
surgery?
Routine anticoagulation (blood thinning)
medications, in the form of aspirin,
dipyridamole (Persantine), and dextran,
are given after surgery. Dextran will
be given to you over a three-day period
while you are in the hospital. Aspirin
and dipyridamole are taken for six
weeks. An iron supplement may also be prescribed.
Physical therapy with a therapist is
only necessary while in the hospital.
Swimming and stationary bicycling are
highly recommended after the first sixweek postoperative period.
If needed, pain medicine taken before
discharge from the hospital may be
continued for one to two weeks following
surgery. After discontinuing the
prescribed pain medicine, we recommend
acetaminophen (Tylenol) for pain control.
Please follow the manufacturers’ dosing
guidelines for proper usage. If you are
unable to take acetaminophen, then other
over-the-counter pain medicines will be
recommended.
For your routine medications,
discuss with your surgeon when to
resume taking them. Medicines for
immunosuppression (Methotrexate or
CellCept) or medicines that may increase
bleeding (NSIADs or aspirin) are
included in this group.
Your dentist may ask if you have been
prescribed antibiotics as part of your graft
surgery. (Antibiotics are recommended
with total hip replacements.) Since your
own bone is used for the graft, antibiotics
are not required.
Additional variations in your
postoperative medication schedule will
be explained at the time of discharge
from the hospital and is dependent on
your individual clinical history.
FIG A
Will I need any special devices at home?
You will need crutches or a walker, and
your physical therapist will assess which
device is best for you. If you already
have crutches or a walker, bring them
with you to the hospital on the day
of your surgery. The equipment you
bring will be assessed by your physical
therapist for safety.
Optional durable goods for home use
include a wheelchair, an elevated toilet
seat, handrails around the toilet, and
a tub seat. Your discharge planner will
assist you with any special needs.
FIG B
How long does the recovery take?
Recuperation is variable and depends
on each person. Some patients feel like
their health and strength return one to
three months after surgery. Most feel
“back to normal” once they become full
weight-bearing.
How often do I need to return to Duke for
follow-up visits if I live far away?
You only need to come to Duke once for
follow-up: at one year after surgery. Your
local orthopaedic surgeon can see you
for the other follow-up visits.
FIG C
FIG D
Free Vascularized Fibular Graft Patient Handbook
11
DEL
Duke Clinic
200 Trent Drive
5th Floor, Orange Zone, Room 5332
Durham, NC 27710
BOX
DUMC 3466
Durham NC 27710
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