The pain Letisha Goodlett felt in her right hip would come and go; sometimes it extended to her lower right back and knee, as well. “I walk a lot because I don’t drive, so my doctor thought I’d been doing too much walking,” she recalls.

Ms.Goodlett, now 30, took an anti-inflammatory medicine when the pain flared up, but one morning in May 2002, it was so intense she couldn’t move. “When the pain hit, it hit hard. I called in sick from work and made an appointment with a chiropractor,” says Ms.Goodlett. An x-ray showed something unusual on her right hip. Two orthopaedists and one MRI later, the Jersey City woman headed for University Hospital in Newark, where, she was told, an innovative microvascular procedure was available that could prevent the need for a hip replacement.

Why would an otherwise healthy young woman even be considered as a candidate for hip replacement? Ms. Goodlett was diagnosed with avascular necrosis of the hip, a well-documented yet mysterious orthopaedic condition in which normal blood flow to the hip’s femoral head is interrupted. Over time, without an adequate blood supply, the femoral head—the “ball” that fits into the hip’s “socket”—collapses, and severe arthritis of the hip joint follows.

Dr. John Capo and Dr. Virak Tan

A few causes of avascular necrosis (also called osteonecrosis) are known: a fracture to the femoral head, steroid use, excessive alcohol consumption, and a rare metabolic condition, Gaucher disease. “Most of the time, though, we don’t know why avascular necrosis occurs,” says Dr. John Capo, assistant professor of orthopaedics at New Jersey Medical School and chief of the division of hand and microvascular surgery at University Hospital. About two-thirds of the people who develop avascular necrosis of the hip are in their 20s and 30s. “That adds to the mystery. Unfortunately, because these are young people, they often go undiagnosed and untreated for awhile. The pain they feel in the hip and groin is dismissed as nothing serious. They might get an x-ray, but in the early stage of avascular necrosis, nothing shows up.”

Avascular necrosis, which is diagnosed in about 20,000 people each year, can cause excruciating pain, limit mobility, and become quite serious. Dr. Capo and his partner, Dr. Virak Tan, assistant professor of orthopaedics at New Jersey Medical School and a hand and microvascular surgeon at University Hospital, have seen patients with avascular necrosis of the hip using canes, crutches, and even wheelchairs to get around. Once the femoral head collapses, one of the treatment options is a hip replacement. “For an older person, that might be an acceptable choice,” says Dr. Tan. “However, we try to avoid hip replacement in younger patients. Under the best of circumstances, a hip replacement lasts about 18-20 years. A person who has a hip replacement at 30 would likely need another at 50, and second hip replacements are more difficult to perform and generally do not do as well as the first.”

	MRI Scan showing AVN changes in Right Hip (Left side of image) compared to normal Left Hip.

Fortunately for younger patients, a highly specialized microvascular procedure can restore the hip and avoid the need for a hip replacement. Free fibular grafting is performed at only a few centers nationally, including University Hospital. As the name suggests, the procedure involves removing the affected bone from the patient’s hip, taking a piece of healthy bone and its blood supply from his or her fibula (located in the lower leg), and grafting it into place in the hip. “Essentially, we’re taking dead bone out and putting good bone in,” says Dr. Capo. “To restore the blood flow, the healthy blood vessels from the fibula are attached to blood vessels in the hip area. As the bone graft heals, it becomes fused to the surrounding bone.”

	Before & after: X-ray with Fibula graph in place.

Free fibular grafting is a complex procedure that requires two surgical teams and takes about six hours to complete. One team removes the dead bone (a process called core decompression) and isolates the blood vessels that will be attached. The second team harvests the fibula and its blood supply. Then, the bone graft is inserted into the femoral head and the vessels are connected. “Even though it’s a complicated procedure, free fibular grafting has relatively few complications,” says Dr. Tan. “There are the risks involved any time anesthesia is used, as well as possible infection or wound healing problems. Rarely, a patient has temporary numbness in the foot on the leg where the graft was taken.”

After a few days in the hospital, the patient returns home for the recovery period. Free fibular grafting isn’t a quick fix. The patient is on crutches for the first three months and must avoid placing full weight on the affected leg for up to six months. Certain activities, such as running and aerobics, are off limits for about one year.

Ms. Goodlett, whose avascular necrosis is believed to have been caused by steroids she took for a skin condition, says her recovery has gone well—both times. Although initially her problem was in the right hip, evaluation and MRI testing showed early stage avascular necrosis in her left hip. Dr. Capo says that once avascular necrosis is detected (and most is not caught in the early stage), there’s usually not a lengthy monitoring period. “We don’t want to watch for too long,” he notes. “The key is treating the patient before the femoral head collapses.”

Ms. Goodlett had her first surgery at the end of August 2002 and her second procedure in April 2003. She was officially discharged at the end of May 2003, and today is pain free. “I’m back to normal and feeling great,” says Ms. Goodlett, who has only accolades for both doctors. “They are wonderful. Dr. Tan, who was my primary doctor, explained everything to me, and if I didn’t understand, he’d explain it again. Best of all, I feel like myself again.”

To arrange for a consultation with Drs. Capo or Tan, please call 973-972-0763.