Under general anesthesia, patient is put in the supine position with a sandbag behind the operated side of the pelvis. A long and curve skin incision is made on the iliac crest 8 cm pass the anterior superior iliac spine (ASIS), along the inguinal ligament, with the distal limb extended medially to the hip joint (Fig. 43.2). The femoral artery and the vein are looped to identify the external iliac artery. By gentle traction on the external iliac artery, tributaries of the external iliac artery can be exposed. The superficial circumflex iliac vessels and the deep circumflex iliac vessels are usually arising from the external iliac vessels just opposite to the origin of the inferior epigastric artery and could be easily traced to the inner lip of the iliac crest, into which feeding branches were sent (Fig. 43.3a). The external and internal oblique abdominal muscles are cut from its insertion on iliac crest. Dissection of the vascular pedicle should be carefully performed after opening the inguinal ligament and the transversalis fascia. The first few tributaries behind the inguinal ligament can be ligated. Beyond the point of ASIA, a sleeve of iliacus muscles should be left on the inner lip of the iliac bone that encases the vascular pedicle to avoid overzealous dissection and inadvertent tear of the feeding vessels. A suitable-size bone graft is harvested with its attached vascular bundle and muscle sleeve (Fig. 43.3b).

The hip joint is exposed by using the inferior limb of the skin incision. Between the sartorius muscle and the tensor fascia latae (Smith-Petersen’s interval), the anterior hip joint capsule is exposed by retracting the rectus femoris medially and the hip abductors laterally. The anterior joint capsule is incised in an H-shape manner to expose the head-neck junction of the hip joint. Rotation and manipulation of the hip will bring the femoral head into view. A bone trough about 1.5 cm × 3 cm is made in the femoral neck leading into the head using sharp narrow osteotomies (Fig. 43.3a). Repeated sharp cuts along the top end of the trough open into the ischemia area of the femoral head. The hard and sclerotic avascular bone is removed using high-speed burrs as thoroughly as possible. If the cartilage is cracked that can been seen directly from the inside, careful out-pushing of the cartilage shell from inside the femoral head can correct the indentation and make it more congruent with the acetabulum.

The void and cavity after debridement is filled with bone chips by gentle impaction of a layer of cancellous bone to the subchondral level. The remaining space is to be filled in with a tailored piece of iliac crest bone with its intact blood supply of DCIA. A tunnel below the iliopsoas is made by blunt dissection with the hip in flexion. A large-size Penrose drain is passed beneath the inguinal ligament along the tunnel as a channel to transfer the graft to the anterior aspect of the femoral neck. The entire graft is slid into the Penrose drain and wrapped by it. By carefully pushing of the graft from the inside of the iliopsoas, the graft can be transferred to the anterior hip with intact pedicle. The Penrose drain is then incised completely with scissor to bring out the graft. As long as the graft is transferred to the anterior hip joint, it can be trimmed to a suitable size to be inserted through the bone trough into the femoral head. The graft can be pushed into the trough to produce a locked-in position and additional holding implant is unnecessary.

Postoperatively, the surgically treated hip is put in a position with 30° flexion and neutral rotation. This posture is advised for approximately 1 week to relax the tension of the vascular pedicle. Hip motion is encouraged as tolerated. The patients are instructed to use double crutches to avoid full weight bearing on the involved limb for 6 weeks. During the following weeks, the amount of weight bearing can be gradually increased by using a single crutch and progresses to a fully unassisted weight bearing by 6 months.

The indications for VIBG have not been well established in the literature. The factors affecting treatment results include staging (demonstration of the lesion by radiograph or magnetic resonance imaging, size of the necrotic segment, location of lesion relative to the weight-bearing area, the amount of femoral head depression, and the acetabular involvement), risk factors (use of steroid, medical comorbidities, or systemic disease), and patient-specific factors (age, activity level, or body mass).

In a survey of treatment modalities in the North America, total hip replacement is the most commonly selected treatment of postcollapse ONFH, and core decompression is the most frequently offered treatment for symptomatic precollapse ONFH [11]. Vascularized bone grafting is suggested by only 3–10 % of the responders who are active members of the professional society. It is generally agreed that a symptomatic case with the lesion size more than 30 % of the femoral head needs operative treatment to prevent early collapse of the femoral head. For asymptomatic necrotic lesions with an area smaller than 30 % of the femoral head, close follow-up without treatment appears to be adequate in most of the cases [3, 4, 12].

In the literature, most of the studies of VIBG reported a mix group of hips ranging from precollapse stage to early postcollapse stage. In a study of 33 segmental collapse hips, 26 ARCO stage IIIA and 7 ARCO stage IIIB, only 24 % of the hips treated with VIBG survived without converting to total hip replacement with a mean survival of 74 months. The authors concluded that VIBG is not indicated for the treatment of ONFH with segmental collapse [13]. Other studies also reported similar results in postcollapse hips with a relatively low successful rates [9, 10, 14, 15]. As a contrast, Babhulkar reported a clinical success rate of 95 % in 22 ARCO III hips with a follow-up period of 5–8 years by using vascularized iliac pedicle grafting [16]. However, by looking at the illustrated cases in that report, many of the clinically successful cases showed radiographic collapse of the femoral head. Based on the findings, the rational indication for VIBG should be ONFH without collapse in a young active patient with the lesion more than 30 % of the femoral head. Contraindications include a segmental collapse hip, preexisting thromboembolic disease, a risk of bleeding or thrombocytopenia, a questionable vascular supply to the iliac graft due to factors such as surgery or trauma, multifocal osteonecrosis involving the ilium, untreated inguinal or femoral hernia, and asymptomatic hips [13].