Modified Vascularised Posterior Inter-trochanteric Bone Grafting Technique for the Treatment of Femoral Head Necrosis: A Technical Note Based on Cadaveric Models

Modified Vascularised Posterior Inter-trochanteric Bone Grafting Technique for the Treatment of Femoral Head Necrosis: A Technical Note Based on Cadaveric Models | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Modified Vascularised Posterior Inter-trochanteric Bone Grafting Technique for the Treatment of Femoral Head Necrosis: A Technical Note Based on Cadaveric Models Yingkai Zhang, Tianle Ma, Chang Jiang, Bingxuan Hua, Lu Cao, Zuoqin Yan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6848458/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Dec, 2025 Read the published version in BMC Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background​ Osteonecrosis of the femoral head (ONFH) is a challenging orthopedic condition that often leads to progressive joint destruction and disability. This study aims to simplfy the surgical tehniques and idealize the position of bone grafting for the repair of ONFH, and its preliminary clinical results were reported.​ Methods​ Anatomical studies were first conducted on four fresh frozen cadaveric specimens (8 hips). Arterial perfusion was performed to precisely investigate the medial femoral circumferential vessels supplying to the posterior greater intertrochanter. Based on the anatomical findings, vascularised posterior inter-trochanteric bone graft and the corresponding surgical instruments were meticulously designed to ensure accurate creation of the decompression tunnel and precise fitting of the bone graft​From August 2018 to August 2021, a total of 20 patients (24 hips) underwent the medial femoral circumferential vascularized posterior intertrochanteric bone grafting procedure at our institution. Clinical data, imaging findings, ARCO staging, and Harris hip scores were systematically collected. Intraoperative parameters, including operative time and blood loss, were also recorded. Postoperatively, patients were followed up for at least two years. Hip preservation failure was defined as a decrease in the Harris score, radiographic progression of ONFH, or the necessity for THA.​ Results​ The cadaveric study revealed that the deep branch of the medial femoral circumflex artery (MFCA) consistently gave rise to 2–3 branches supplying the posterior intertrochanteric bone. The first branch originated from the superior margin of the quadratus femoris attachment, and the remaining two branches were located beneath the quadratus femoris. The branches supplying the posterior intertrochanteric bone are carefully dissected and preserved, a 4-5cm long, 1.5-16 cm thick and deep bone graft is cut, which is used to improve the vascularization and mechanical stability within the osteonecrosis.​There are 20 patients (24 hips) prospectively enrolled, including 15 male patients (19 hips). The average postoperative followup duration was 24.2 ± 5.6 months. Four patients had to undergo THA due to disease progression, while the remaining 20 hips continued to be monitored. The final mean postoperative Harris hip score (HHS) was 75.1 ± 13.7. Among the 24 hips, 20 did not require THA, resulting in a hip preservation rate of 83%. Based on comprehensive evaluations of clinical function, symptoms, and radiographic findings, 71% of the hips were considered to have achieved successful hip preservation.​ Conclusions​ The modified vascularized posterior intertrochanteric bone grafting is a simple yet effective hip - preserving surgical technique. It enables precise placement of the vascularized bone graft directly under the subchondral bone, and the good blood supply of the graft significantly promotes bone repair. This technique provides a simple，reliable and ideal graft position to repair the ONFH, the clinical outcomes seem to be related to the degree of femoral head collapse, with less favorable results associated with more severe collapse, its long term efficacy needs studied further. Clinical trial number: Not applicable (Retrospective Study). Osteonecrosis of the femoral head Medial femoral circumflex vascularized bonegrafting Hip-preserving surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Osteoncerosis of the Femoral head (ONFH) is a debilitating orthopedic disease, usually due to trauma, prolonged high-dose corticosteroid use, and excessive alcohol consumption. Currently, the number of patients with non-traumatic osteonecrosis of the femoral head (ONFH) has reached 8.12 million in China alone [ 1 ] . The ONFH often progresses insidiously and rapidly [ 2 ] , and eventually leading to severe hip osteoarthritis, causing joint pain and mobility impairment. For younger patients, early total hip arthroplasty (THA) increases the likelihood of future revision surgeries [ 3 ] . Consequently, early diagnosis and hip-preserving treatments have become key research focuses. Hip-preserving surgery has shown effectiveness in alleviating symptoms and delaying or even avoiding THA. There are various hip-preserving surgical techniques available, including core decompression, bone grafting, and osteotomy. Among these procedures, bone grafting is the most widely used hip preservation surgery in the ONFH, which can be categorized into non-vascularized bone grafting (NVBG) [ 4 ] and vascularized bone grafting (VBG) [ 5 ] . NVBG for the ONFH primarily involves different decompression pathways to remove necrotic bone tissue, followed by reconstruction of the femoral head using autologous cancellous and cortical bone, allografts, or bone substitutes. This approach aims to restore the circulation and the mechanical stability within the osteonecrosis. Compared with VBG, NVBG is relatively simple, less invasive, but does not directly restore blood supply to the necrotic area [ 6 ] . Given that inadequate blood supply to the necrotic area is a well-recognized pathological basis of ONFH, efforts have been made to restore the vascularization and mechanical strength simutaniously by VBG [ 7 ] . The vascularized fibular grafting (VFG) and peritrochanteric bone flap grafting are most commonly used VBG techniques. VFG, particularly free vascularized fibular grafting (FVFG), has become one of the most widely accepted hip-preserving procedures, demonstrating favorable long-term outcomes [ 8 ] . However, it often requires harvesting autologous fibula and vascular anastomosis, making the surgery technically demanding and more invasive [ 9 ] . In 1979, Hori et al. [ 10 ] proposed using vascular bundle implantation by introducing the ascending branch of the lateral circumflex femoral artery to treat ONFH. Vascularized peritrochanteric bone flap grafting commonly utilizes vascularized iliac bone flaps, anterior or posterior greater trochanteric bone flaps, or corresponding muscle-pedicle bone flaps to repair the femoral head via a core decompression channel. Compared to FVFG, the main advantages of peritrochanteric bone flap grafting include a single surgical incision, preservation of fibular function, and no need for vascular anastomosis [ 11 ] . Additionally, the cancellous bone in the flap directly contacts the original cancellous bone of the femoral head, which promotes better integration compared to the periosteal cortical-cancellous contact in fibular grafting. Due to the lack of appropriate surgical tools, it is difficult to place the bone graft 3-5mm beneath the subchondral bone plate within the center of the osteonecrosis compared with FVFG, making its clinical results less favorable [ 12 ] . This study introduces modified vascularised posterior inter-trochanteric bone grafting technique by a special surgical tools, aiming to simplify the procedure and enhance surgical precision. This technique allows to place the vascularized posterior intertrochanteric bone graft 3-5mm right beneath the subchondral bone plate without compromising the vacular pedicles, thus the blood supply and biomechanical stability is effectively restored. It provides a simple and reliable hip preserving surgical method for the ONFH. . Material and Methods Cadever study Arterial perfusion and anatomical dissection were performed on four fresh-frozen cadaveric specimens (8 hips) to explore the feasibility of the modified medial femoral circumflex artery (MFCA) deep branch–based greater trochanteric bone flap grafting. The anatomical study aimed to verify the surgical rationale and identify key technical aspects of this procedure. A set of specialized surgical instruments for the modified MFCA deep branch greater trochanteric bone flap grafting was designed, refined through cadaveric and clinical applications, and ultimately used to establish a standardized operative protocol for treating pre-collapse stage osteonecrosis of the femoral head. Clinical study General Information From August 2018 to August 2021, 24 patients of ARCO IIC-IIIA ONFH are enrolled in this study under their informed consent. The study was approved by the Ethics Committee of Zhongshan Hospital, Fudan University The staging of femoral head necrosis was based on the 2019 version of the ARCO staging system. The Harris Hip Score (HHS) was used as the main evaluation for hip function and symptoms.: The score includes pain, function, joint range of motion, and deformity. The total score is 100, with classifications as follows: Good: 80–100, Fair: 70–80 and Poor: below 70. The imaging and ARCO staging changes of the femoral head were used as objective indicators for the progression of femoral head necrosis postoperatively. Based on imaging follow-up changes, the progression of necrosis was categorized as "improved or stable" and "progressed." The hip-preserving effect was classified as "successful" or "failed" based on a combination of the HHS score and objective imaging changes. Postoperative follow-up defined hip replacement surgery on the operative side as the endpoint for hip preservation failure. The inclusion and exclusion criteria are as follows: Inclusion Criteria: Diagnosis of ONFH was confirmed by hip MRI and X-ray. ARCO IIC, IIIA were selected. Undergoing hip-preserving surgery. Age between 18 and 60 years old. Willingness to participate in the clinical study. Exclusion Criteria: Presence of other hip joint diseases. Previous hip surgery ARCO stage I, IIA, IIB, III B, IIIC or IV The design of surgical tool and Surgical procedure Surgical tool To enhance the precision and simplicity of key procedures during the modified medial femoral circumflex artery deep branch greater trochanteric bone grafting (MFCVBG)—including bone flap harvesting, necrotic lesion debridement and decompression, and graft insertion—this study has designed and developed a complete set of dedicated surgical instruments tailored to the local anatomical characteristics of the femoral head-neck region (Fig. 1 ), for which a patent has been filed. The specialized instruments include: a custom-designed bone chisel for harvesting the greater trochanteric bone flap, a graduated guide pin (Kirschner wire), a large-diameter trephine drill, a trephine sleeve, a sleeve impactor, a twisting extractor, a flat-head rasp, a graft sizer, and a stabilizer. Among them, the trephine drill, sleeves, flat-head rasp, and graft sizer come in three different diameter specifications that are compatible with each other, thereby accommodating the needs of patients with varying anatomical profiles. Surgical procedure The patient is positioned in the 90-degree lateral decubitus position. The traditional posterior-lateral approach to the hip is used with a curved incision over the posterior-lateral hip, layered dissection, blunt separation of the gluteus maximus, and excision of the greater trochanteric bursa. The hip is then internally rotated to expose the superior and inferior gluteal muscles, and the quadratus femoris is dissected to reveal the main trunk and branches of the MFCA deep branch. Once the main trunk is located, it is traced laterally, where branches are observed extending to the greater trochanter and intertrochanteric ridge. The blood flow of the bone flap can be preliminarily assessed by palpating the arterial pulsation in the branch. The terminal branches of the MFCA deep branch are ligated and cut. At the posterior aspect of the femur, near the greater trochanter and intertrochanteric ridge, a bone flap of approximately 4–5 cm x 1.5-2 cm x 1.5-2 cm is harvested using a specialized bone knife. The bone flap generally retains two vascular branches, and the blood supply can be further assessed based on the bone’s trabecular bleeding. Some vascular pedicles may be released to allow the bone flap to be repositioned. The bone flap and vascular pedicle are protected with saline-soaked gauze. A bone window of 16mm, 18mm, or 20mm is created in the femoral head-neck region using the specialized instruments. Under fluoroscopy, the reamer is used to drill until the joint surface subchondral bone is reached, 3–5 mm deep. The bone core is extracted, and necrotic bone is removed with a burr and curette. The floor of the decompression channel is smoothed using a flat rasp. Fresh cancellous bone or synthetic bone is implanted into the decompression channel, and for mild femoral head collapse, the shape is restored during the bone graft pressurization. The vascularized bone flap is inserted into the femoral head-neck decompression cavity, ensuring that the cancellous bone side faces up and tightly conforms to the wall of the decompression channel. The cortical bone side and vascular pedicle should face downward to prevent twisting, compression, or excessive traction. The bone flap is appropriately pressed into place to ensure good compression between the upper edge of the bone flap and the bottom of the decompression channel. A 3.5mm hollow screw is used for fixation, and appropriate pressure is applied. Once the position is confirmed under fluoroscopy, saline is used to irrigate the area, and careful electrocoagulation is performed for hemostasis. Artificial bone may be used to fill the area from which the bone flap was harvested from the greater trochanter. A drainage tube is placed, and the incision is closed layer by layer with compression dressing (Fig. 2 ). Clinical Outcomes Risk Factors for Poor Hip Preservation Effect and Disease Progression: The basic patient data (gender, affected side, age, BMI), necrosis type (steroid, alcohol, trauma, idiopathic), preoperative ARCO stage, preoperative necrosis range indicators (MRI combined necrosis angle, necrosis index, modified necrosis index), preoperative and postoperative HHS scores, bone flap-related issues (e.g., poor bone flap positioning, delayed healing, downward displacement, low metabolic state of the bone flap, coronal, sagittal, and horizontal positioning angles) were analyzed to evaluate their correlation with postoperative imaging changes and the effectiveness of hip-preserving treatment. The aim was to evaluate factors leading to femoral head collapse. Comparison of Hip Preservation Effect Across Different ARCO Stages: In this study, patients were grouped into ARCO II and ARCO IIIA stages based on preoperative staging. The two groups were compared in terms of gender, affected side, age, BMI, necrosis type and necrosis range-related indicators to evaluate the impact of preoperative ARCO staging on the modified MFCA deep branch greater trochanteric bone flap grafting surgery. A survival curve for hip preservation was constructed with joint replacement as the endpoint event. Statistical Methods: Statistical analysis was performed using SPSS 25.0. The Kolmogorov-Smirnov test was used to assess the normality of the distribution of continuous variables. If the distribution was normal, the results were described as mean ± standard deviation; categorical variables were described as frequencies and percentages. Independent sample t-tests or Mann-Whitney U tests were used to compare differences between continuous variables in two groups. Rank correlation analysis was used for the correlation analysis between hip preservation effectiveness, imaging changes, HHS scores, and continuous variables. Pearson’s chi-square test or Fisher’s exact test was used for the relationship between categorical variables (e.g., bone necrosis etiology, stage, classification, and other potential risk factors). A P-value of < 0.05 was considered statistically significant. Results Cadaveric Anatomy A detailed dissection was performed to expose the major hip external rotator muscle group behind the femoral head and neck (Fig. 3 A, B) as well as the vascular distribution (Fig. 3 C). The medial femoral circumflex artery (MFCA) deep branch passes between the obturator externus and the short adductor muscles to reach the posterior femoral neck, and then runs obliquely upward and laterally, traveling between the obturator externus and the quadratus femoris, eventually penetrating the obturator internus tendon and the deep sides of the superior and inferior gemelli muscles. The deep branch of the medial femoral circumflex artery (MFCA) gives rise to 2–3 branches supplying the greater trochanter, running horizontally across the intertrochanteric ridge and widely distributing in a "raven's foot" pattern in the posterior region of the greater trochanter and intertrochanteric area. The anatomical location of these branches is constant, with diameters reaching over 1mm (Fig. 3 D). Further dissection of the deep branch of the MFCA shows a constant anastomosis with branches of the inferior gluteal artery (Fig. 3 D). A bone flap of size 4–5 cm × 1.5-2 cm × 1.5-2 cm was harvested from the region supplied by the deep branch of the MFCA at the greater trochanter and intertrochanteric area (Fig. 3 E), where rich vascular distribution inside the bone flap was observed (Fig. 3 F). By performing latex injection on the deep femoral artery in 4 cadaver models, we confirmed that the MFCA deep branch sends 2–3 branches to the greater trochanter region, which supplies the modified MFCVBG (Modified Femoral Circumflex Vessel Graft Bone Grafting) surgical area, with a constant anatomical location. After bone harvesting, abundant small arteries were observed within the bone flap, corroborating the substantial bleeding from the bone flap during surgery. This further supports that the bone flap has rich blood supply. The modified femoral medial circumflex artery deep branch greater trochanter bone flap transplantation surgery is based on clear anatomical principles. The bone flap, with its constant anatomical location and rich blood supply, can theoretically restore blood supply and mechanical structure in femoral head necrosis (ONFH) during the collapse phase . Cohort Overview and Baseline Perioperative Characteristics of the Study Subjects This study prospectively included 20 patients with a total of 24 hips. Among them, 15 were male (19 hips). The average follow-up time after surgery for the 24 hips was 24.2 ± 5.6 months. Four patients underwent total hip replacement (THR) due to necrosis progression and were excluded from further follow-up. The remaining 20 hips did not undergo replacement, and no subjects dropped out of the study midway. The average Harris Hip Score (HHS) at the final follow-up was 75.1 ± 13.7. Among the 20 hips that did not undergo THR, the hip preservation rate was 83%. Based on a combination of hip function, symptoms, and objective imaging findings, 71% of the hips were classified as having a successful hip preservation outcome. Surgical and Postoperative Follow-up Results Risk Factors for Poor Clinical Outcomes and Hip Preservation Failure: During the follow-up period, preoperative ARCO staging (P < 0.05) and HHS scores (P < 0.01) were significantly correlated with postoperative hip preservation outcomes. ARCO IIIA stage hips with preoperative local collapse and microfractures, along with lower HHS scores, were identified as risk factors for poor hip preservation outcomes. Additionally, postoperative downward displacement of the bone flap (P < 0.05), improper bone flap positioning (P = 0.089), or delayed healing (P = 0.089) may be associated with poor hip preservation effectiveness. However, the latter two factors did not reach statistical significance (Table 1 ). Comparison of Hip Preservation Outcomes in Different ARCO Stages: In this study cohort, 12 hips with ARCO II and 12 hips with ARCO IIIA stage hip necrosis were included. There were no significant differences between the two groups in terms of gender, side of surgery, age, BMI, necrosis type, related necrosis range indicators, and follow-up time for hips that did not undergo replacement. For ARCO IIIA stage hips, 4 cases showed continued collapse after undergoing modified MFCVBG surgery and eventually received total hip arthroplasty (THA), resulting in a hip preservation rate of 67%. In contrast, no patients with ARCO II stage hip necrosis underwent THA after the modified MFCVBG surgery, resulting in a hip preservation rate of 100%. The hip preservation survival curve with THA as the endpoint event for both groups is shown in Fig. 3 . There were significant differences in HHS scores between the ARCO II and IIIA groups at preoperative and final follow-up time points. The HHS scores of the ARCO II group were significantly higher than those of the ARCO IIIA group. Preoperative hip preservation outcomes were significantly better in the ARCO II group compared to the ARCO IIIA group, with the hip preservation excellent rate being 100% in the ARCO II group and 44% in the ARCO IIIA group (Table 2 ). Case Examples A 41-year-old female patient with a history of long-term oral corticosteroid use for chronic urticaria presented with bilateral steroid-induced osteonecrosis of the femoral head (ONFH). MRI confirmed bilateral involvement, and the left hip was classified as ARCO stage IIB. Given the pre-collapse status of the lesion and the patient’s young age, she was selected for hip-preserving treatment using the modified medial femoral circumflex artery (MFCA) deep branch–based greater trochanteric vascularized bone flap grafting (modified MFCVBG). Under general anesthesia, the patient underwent the modified MFCVBG procedure. Intraoperatively, the deep branch of the MFCA was carefully dissected, and two sizable arterial branches supplying the posterior intertrochanteric region were preserved. A 4.5 cm × 1.8 cm × 1.5 cm vascularized bone flap was harvested with its pedicle intact. Using the customized surgical instruments, a decompression tunnel was accurately created to reach 3–5 mm beneath the subchondral bone in the weight-bearing area of the femoral head. The bone flap was then implanted with the cancellous side facing upward and fixed using a 3.5 mm hollow screw. No pedicle torsion or compression occurred. Postoperative recovery was uneventful. At 3 months, the patient had regained nearly full range of motion, and the Harris Hip Score (HHS) improved from 68 preoperatively to 87. Follow-up imaging at 6, 12, and 24 months showed continuous integration of the bone flap with the host bone, no signs of collapse, and well-maintained joint space. Importantly, no progression of the necrotic lesion was observed. SPECT/CT performed at 3 and 12 months postoperatively demonstrated robust metabolic activity within the grafted bone flap and surrounding formerly necrotic region. The imaging confirmed sustained viability of the flap, with no perfusion deficits detected in the MFCA-supplied area. This supports the hypothesis that direct placement of a vascularized bone flap beneath the subchondral plate not only provides immediate mechanical support but also promotes revascularization and osteogenesis in the critical load-bearing zone. This case exemplifies several key advantages of the modified MFCVBG technique: • Anatomical precision: The customized instruments facilitated exact trajectory and depth control for the decompression tunnel; • Biological viability: The preserved vascular pedicle ensured sustained blood supply to the graft; • Biomechanical effectiveness: The subchondral placement of the flap offered optimal structural support; • Clinical efficacy: No femoral head collapse or symptomatic progression occurred at 2 years postoperatively.(Fig. 4 ). This outcome underscores the value of combining anatomical insights, specialized instrumentation, and vascularized tissue transfer in the early intervention of steroid-induced ONFH Discussion Early diagnosis of femoral head necrosis and hip preservation surgeries have become one of the main research focuses in recent years [ 14 ] . The key aspect of hip preservation surgery lies in the thorough removal of necrotic bone tissue, restoration of blood supply to the femoral head and necrotic areas, and reconstruction of the internal structure and mechanical stability of the femoral head, with the core goal being to improve symptoms, delay, or even avoid total hip arthroplasty [ 15 ] . Currently, there are various surgical techniques for hip preservation, and this study mainly focuses on a systematic investigation of the modified medial femoral circumflex artery (MFCA) deep branch trochanteric bone flap transplantation. In 1949, Phemister first proposed the femoral head decompression and bone grafting technique through the femoral trochanter [ 16 ] , which gradually became the most classic and widely applied technique in hip preservation surgery. This technique primarily involves drilling a hole beneath the greater trochanter via a lateral approach, performing marrow decompression to the femoral head necrosis area, using curettes and other tools to remove necrotic bone, and then grafting bone or using other bone substitute materials to fill the defect, providing subchondral support to prevent cartilage collapse. Compared with other surgical techniques, the major advantage of femoral head decompression and bone grafting is its minimally invasive nature and ease of operation. However, complete removal of the necrotic area during the procedure is challenging. Some studies suggest that the effect of the window decompression and bone grafting technique for treating non-collapsed femoral head necrosis is generally satisfactory, but it is less effective for collapsed femoral heads [ 17 , 18 ] . For this reason, it is currently believed that window decompression and bone grafting should be used cautiously for patients with collapsed femoral heads, large necrosis areas, and severe involvement of the femoral head lateral pillar [ 19 ] . This study also confirmed that the treatment effect is poor for patients with ARCO III stage and cumulative weight-bearing areas of bone necrosis. Among the various factors causing femoral head necrosis, the lack of blood supply to the necrotic area is widely recognized as the pathological basis. Therefore, there has been a push to restore vitality to the previously necrotic regions by reintroducing blood supply. In 1979, Hori et al. [ 10 ] proposed the use of vascular bundle implantation, introducing the ascending branch of the lateral femoral circumflex artery for the treatment of femoral head necrosis. Although this technique has become less commonly used due to its insufficient mechanical support and weak osteoinductive capacity, a variety of vascularized bone flap transplantation techniques have been developed and applied in the treatment of femoral head necrosis. For specific populations, particularly young patients, vascularized bone flap transplantation may be a more cost-effective option compared to direct joint replacement [ 20 ] . Through postoperative SPECT/CT, we can assess the bone vitality of the femoral head and subchondral bone [ 21 ] . We found that the modified MFCA deep branch trochanteric bone flap transplantation technique effectively restores the metabolic activity of both the bone flap and the surrounding former necrotic region. Therefore, theoretically, this technique could improve the success rate of hip preservation. However, due to limitations in surgical design and technology at the time, the original technique was relatively complex and did not yield optimal results. Building upon the original method, this study simplified the surgical operation and improved the precision of the procedure by designing and using specialized surgical tools and refining standardized surgical processes. The research group has previously verified the biomechanical stability of the modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation through finite element analysis [ 12 ] , showing promising clinical outcomes. The modified MFCVBG procedure seems to offer superior hip preservation results in ARCO stage II patients. For ARCO IIIA patients, increasing the precision of decompression and bone flap placement based on the current modified MFCVBG procedure is expected to more thoroughly remove necrotic bone tissue and restore femoral head mechanical stability, which should theoretically improve the success rate of hip preservation. However, when comparing different hip preservation techniques, aside from the procedure's inherent effectiveness, other factors such as patient characteristics, the surgeon's experience, surgical trauma, difficulty of the operation, and potential impacts on future joint replacement surgery must also be considered, making comparisons and selections of surgical techniques a challenging issue in the treatment and research of osteonecrosis of the femoral head (ONFH) [ 22 ] . The commonly used vascularized bone flap transplantation techniques in clinical practice can be mainly divided into vascularized fibula transplantation and hip circumferential bone flap transplantation. Vascularized fibula transplantation is usually performed by placing a free fibula through the femoral trochanteric decompression channel, with the fibula's blood vessels typically anastomosed to the ascending branches of the lateral femoral circumflex artery and its accompanying vein [ 23 ] . Due to the need for microvascular anastomosis in vascularized fibula transplantation, the procedure becomes more complex and time-consuming. Cao et al. [ 24 ] designed a randomized controlled trial involving bilateral femoral head necrosis patients, in which one side underwent vascularized fibula transplantation, and the other side received core decompression combined with autologous bone grafting. They demonstrated that vascularized fibula transplantation had superior short-term results. The modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation used in this study is also a form of vascularized bone flap transplantation. Vascularized hip circumferential bone flap transplantation often uses vascularized iliac bone flaps, anterior and posterior greater trochanteric bone flaps, or corresponding musculocutaneous bone flaps, with femoral head repair performed via the bulbous-shaped decompression channel of the femoral head neck [ 25 ] . Generally speaking, compared with vascularized fibula transplantation, the greatest advantage of circumferential hip bone flap transplantation is the single surgical incision, no need to sacrifice fibular function, and no vascular anastomosis. Furthermore, the cancellous bone of the bone flap directly contacts the original cancellous bone of the femoral head, which facilitates better healing compared to the cortical-cancellous bone contact in fibula transplantation [ 26 ] . The modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation used in this study significantly reduced blood loss and surgical time compared to Cao's vascularized fibula transplantation cohort, demonstrating that the procedure's difficulty and hip preservation efficacy are superior to that of vascularized fibula transplantation. Limitations: This study is a single-center, single-cohort study with a limited sample size, and it has not compared the results with other hip preservation techniques. Therefore, the findings need to be validated in larger-scale follow-up cohorts and controlled studies. The modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation requires a learning curve, and achieving optimal surgical results requires a certain amount of experience. Conclusion The modified MFCA deep branch greater trochanteric bone flap grafting is based on well-defined anatomical principles and is enhanced by customized surgical tools, allowing for the maximal removal of necrotic bone and precise placement of the bone flap deep into the subchondral bone. This provides optimal biomechanical stability and offers an improved solution for hip preservation in ONFH. However, the study also indicates that hip preservation outcomes are less favorable in cases where the necrosis involves the weight-bearing region, progresses to ARCO stage III, or is associated with lower preoperative Harris scores. Therefore, the application of this technique requires individualized assessment to optimize patient selection and improve treatment success rates. Declarations Ethics approval and consent to participate This clinical study was approved by Zhongshan Hospital Fudan University’s institutional review board (B2019-135R). This study was conducted in accordance with the Declaration of Helsinki. All the patients consented to participate in this study, and informed consents were signed by themselves in all instances. Consent for publication The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets of the current study are available from the corresponding author upon reasonable request. Funding This study was funded by National Natural Science Foundation of China (82172413 and 82372393), Shanghai Shenkang Hospital Development Center Clinical Research Plan (SHDC12023111) and the Jinshan District Fifth Cycle Excellent Youth Training Program (JSYQ-2023-05). The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Authors' contributions ZYK, MTL and JC involved in making the conception and design of research and carried out drafting of the article. YZQ and CL had the conception and design of the study, and made a final approval and guarantor of the manuscript. YZQ and ZYK carried out the acquisition of data and made a final approval. HBX and JC contributed on collecting parents’ information. All authors read and approved the final manuscript. Acknowledgements: The authors would like to thank all the reviewers who participated in the review. References Zhao DW, Yu M, Hu K, et al. Prevalence of Nontraumatic Osteonecrosis of the Femoral Head and its Associated Risk Factors in the Chinese Population: Results from a Nationally Representative Survey. Chin Med J (Engl). 2015;128(21):2843–50. Mont MA, Zywiel MG, Marker DR, McGrath MS, Delanois RE. 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Zhang Y, Wang X, Jiang C, Hua B, Yan Z. Biomechanical research of medial femoral circumflex vascularized bone-grafting in the treatment of early-to-mid osteonecrosis of the femoral head: a finite element analysis. J Orthop Surg Res. 2022;17(1):441. Yoon BH, Mont MA, Koo KH, et al. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head. J Arthroplasty. 2020;35(4):933–40. Migliorini F, La Padula G, Oliva F, Torsiello E, Hildebrand F, Maffulli N. Operative Management of Avascular Necrosis of the Femoral Head in Skeletally Immature Patients: A Systematic Review. Life (Basel). 2022. 12(2): 179. Palekar G. Hip Preservation With Autologous Osteoblast Cell-Based Treatment in Osteonecrosis of the Femoral Head. Orthopedics. 2021;44(2):e183–9. PHEMISTER DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg Am. 1949;31A(1):55–66. Watters TS, Browne JA, Orlando LA, Wellman SS, Urbaniak JR, Bolognesi MP. Cost-effectiveness analysis of free vascularized fibular grafting for osteonecrosis of the femoral head. J Surg Orthop Adv. 2011;20(3):158–67. Richard MJ, DiPrinzio EV, Lorenzana DJ, Whitlock KG, Hein RE, Urbaniak JR. Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head. Injury. 2021;52(12):3653–9. Shi J, Chen J, Wu J, et al. Evaluation of the 3D finite element method using a tantalum rod for osteonecrosis of the femoral head. Med Sci Monit. 2014;20:2556–64. Pierce TP, Jauregui JJ, Elmallah RK, Lavernia CJ, Mont MA, Nace J. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015;8(3):228–32. Cao L, Liao Y, Song C, et al. Quantitative Characterization of Bone Viability of Femoral Head and Subchondral Bone by Using Single Photon Emission Computerized Tomography/Computerized Tomography (SPECT/CT). Med Sci Monit. 2020;26:e922624. Huang ZQ, Fu FY, Li WL, et al. Current Treatment Modalities for Osteonecrosis of Femoral Head in Mainland China: A Cross-Sectional Study. Orthop Surg. 2020;12(6):1776–83. Öztürk K, Baydar M, Alpay Y, Şencan A, Orman O, Aykut S. Clinical results of free vascularized fibula graft in the management of precollapse osteonecrosis of the femoral head: A retrospective clinical study. Acta Orthop Traumatol Turc. 2022;56(2):105–10. Cao L, Guo C, Chen J, Chen Z, Yan Z. Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial. Clin Orthop Relat Res. 2017;475(9):2230–40. Cho KJ, Park KS, Yoon TR. Muscle pedicle bone grafting using the anterior one-third of the gluteus medius attached to the greater trochanter for treatment of Association Research Circulation Osseous stage II osteonecrosis of the femoral head. Int Orthop. 2018;42(10):2335–41. Maus U, Roth A, Tingart M, et al. [S3 Guideline. Part 3: Non-Traumatic Avascular Necrosis in Adults - Surgical Treatment of Atraumatic Avascular Femoral Head Necrosis in Adults]. Z Orthop Unfall. 2015;153(5):498–507. Tables Table 1 Analysis of Factors Related to Hip Preservation Outcomes of Modified MFCVBG Surgery Hip preservation outcomes good fair poor P value Number of hips 8 9 7 >0.05 Gender (Male/Female) 6/2 8/1 5/2 >0.05 Surgical Side (Left/Right) 4/4 6/3 3/4 >0.05 Age 35.4 ± 11.4 40.2 ± 15.3 29 ± 12.3 >0.05 BMI (Body Mass Index) 23.1 ± 2.5 24.6 ± 5.1 23.6 ± 4.4 >0.05 Type of Necrosis (Hormonal Alcoholic/Idiopathic) 5/2/1 6/2/1 4/2/1 >0.05 ARCO Staging <0.05* Stage II (A/B/C) 1/3/1 1/2/3 0/0/1 Stage III 3 3 6 Preoperative HHS Score (Harris Hip Score) 72.5 ± 6.4 76.5 ± 4.2 65.7 ± 5.1 <0.01* Final Follow-up HHS Score (Harris Hip Score) 86.5 ± 8.2 83.1 ± 6.6 58.4 ± 16.6 <0.01* Postoperative Bone Graft Malposition 0 1 2 0.089 Postoperative Bone Graft Healing Delay 0 1 2 0.089 Postoperative Bone Graft Downward Displacement 0 0 3 0.1 *P 0.05 Gender (Male/Female) 9/3 10/2 >0.05 Surgical Side (Left/Right) 6/6 7/5 >0.05 Age 33.4 ± 10.1 34.5 ± 9.7 >0.05 BMI (Body Mass Index) 22.6 ± 4.1 24.1 ± 3.2 >0.05 Type of Necrosis (Hormonal Alcoholic/Idiopathic) 7/3/2 8/3/1 >0.05 Preoperative HHS Score (Harris Hip Score) 70.6 ± 5.2 64.2 ± 4.5 <0.01* Final Follow-up HHS Score (Harris Hip Score) 85.2 ± 6.7 69.5 ± 10.3 <0.01* Hip preservation outcomes <0.01* good 5 1 fair 6 4 poor 1 3 THA 0 4 *P < 0.05, statistically significant. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Dec, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 16 Sep, 2025 Reviews received at journal 15 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviews received at journal 28 Aug, 2025 Reviewers agreed at journal 22 Aug, 2025 Reviewers invited by journal 23 Jun, 2025 Editor invited by journal 23 Jun, 2025 Editor assigned by journal 20 Jun, 2025 Submission checks completed at journal 20 Jun, 2025 First submitted to journal 08 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6848458","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475474512,"identity":"1b20474d-8b6e-4fef-837b-edc8a97ea9a9","order_by":0,"name":"Yingkai Zhang","email":"","orcid":"","institution":"Zhongshan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Yingkai","middleName":"","lastName":"Zhang","suffix":""},{"id":475474514,"identity":"f27b84e3-cf6c-4ba7-bb6e-6ab99b2b5dbf","order_by":1,"name":"Tianle Ma","email":"","orcid":"","institution":"Zhongshan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Tianle","middleName":"","lastName":"Ma","suffix":""},{"id":475474515,"identity":"f30004fd-9270-436b-b407-9bb91e8182bd","order_by":2,"name":"Chang Jiang","email":"","orcid":"","institution":"Zhongshan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Chang","middleName":"","lastName":"Jiang","suffix":""},{"id":475474516,"identity":"ba9e6f37-4a3f-4779-ae7c-9b24262c3670","order_by":3,"name":"Bingxuan Hua","email":"","orcid":"","institution":"Zhongshan Hospital Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Bingxuan","middleName":"","lastName":"Hua","suffix":""},{"id":475474517,"identity":"11ab7209-62ef-41b4-91e0-55c81d8c95f3","order_by":4,"name":"Lu Cao","email":"","orcid":"","institution":"Jinshan Hospital of Fudan University","correspondingAuthor":false,"prefix":"","firstName":"Lu","middleName":"","lastName":"Cao","suffix":""},{"id":475474518,"identity":"b04101d2-db7a-49f0-9828-71c29a204ef8","order_by":5,"name":"Zuoqin Yan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBAC+/bmgw8keGzq7Y83EKnFgOdYsoGFTFoCw5kDxGqRyDETqLA5nMBwI4FILeYSCWYMN3KY8xhnPt54g6HGJpqgFsueB2kPZ5xhK2aWTiu2YDiWlttAUM/xhOPGkj08jG3SOWYSjA2HidByILFN+u8/CcYeyTNEajE4kcwmIcFjkDhDgodILZI9x5gNJHgSjA14gH5JIMYv/Oz9H4FR+V/OgP3wxhsfamyI8AuyIyUSSFEO0UKqjlEwCkbBKBgZAADUFj/A0mlpPQAAAABJRU5ErkJggg==","orcid":"","institution":"Zhongshan Hospital Fudan University","correspondingAuthor":true,"prefix":"","firstName":"Zuoqin","middleName":"","lastName":"Yan","suffix":""}],"badges":[],"createdAt":"2025-06-08 16:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6848458/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6848458/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03313-w","type":"published","date":"2025-12-02T15:58:14+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85619148,"identity":"e40309b0-496c-41e1-a0ee-537fd749d8fd","added_by":"auto","created_at":"2025-06-29 14:54:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":136399,"visible":true,"origin":"","legend":"\u003cp\u003eA. Specialized surgical instruments: custom-designed osteotome for harvesting the greater trochanter bone flap, large-diameter trephine, trephine sleeve, sleeve impactor, flat-headed rasp, bone gauge sleeve, and stabilizer.\u003c/p\u003e\n\u003cp\u003eB. The large-diameter trephine and trephine sleeve are used to remove necrotic bone.\u003c/p\u003e\n\u003cp\u003eC. The use of specially designed instruments allows for maximal removal of necrotic bone tissue and enables the bone flap to be implanted deep into the subchondral bone.\u003c/p\u003e\n\u003cp\u003eD. The sleeve impactor is used to extract necrotic bone tissue.\u003c/p\u003e\n\u003cp\u003eE. The flat-headed rasp is used to smooth the bottom of the decompression channel.\u003c/p\u003e\n\u003cp\u003eF. The bone gauge sleeve is used to measure the size of the vascularized bone flap and to adjust the fit of the bone flap within the decompression channel.\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6848458/v1/1bb457dd3c78603e6a43e0d6.jpg"},{"id":85617549,"identity":"bb6a8e40-072a-4d0d-9d1c-c0ab3eba99e4","added_by":"auto","created_at":"2025-06-29 14:46:41","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61886,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic diagram of the surgical steps for modified deep branch of the medial circumflex femoral artery greater trochanteric bone grafting.\u003c/p\u003e\n\u003cp\u003eA. The blood supply to the bone flap is preliminarily assessed by palpating the pulsation of the arterial branches, and the terminal branch of the deep branch of the medial femoral circumflex artery (MFCA) is ligated and severed distally.\u003c/p\u003e\n\u003cp\u003eB. A bone flap measuring approximately (4–5) cm × (1.5–2) cm × (1.5–2) cm is harvested using a specialized osteotome at the MFCA branch attachment site in the posterior region of the greater trochanter and intertrochanteric area.\u003c/p\u003e\n\u003cp\u003eC. The vascular pedicle is mobilized to allow transposition of the bone flap to the femoral head decompression site.\u003c/p\u003e\n\u003cp\u003eD. Intraoperatively, the blood supply to the bone flap can be assessed by observing bleeding from the cancellous bone of the flap.\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6848458/v1/61ee8ec69b028f262e2f25c0.jpg"},{"id":85617552,"identity":"11b08c9c-0824-46d2-a147-e8123f298b2d","added_by":"auto","created_at":"2025-06-29 14:46:41","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":231734,"visible":true,"origin":"","legend":"\u003cp\u003eA. Major muscles located posterior to the femoral head and neck; B. Complete exposure and detachment of the quadratus femoris muscle; C. Distribution of major blood vessels posterior to the femoral head and neck; D. The deep branch of the medial circumflex femoral artery (yellow arrow) distributes to the posterior greater trochanter and intertrochanteric region, forming an anastomosis with the inferior gluteal artery's communicating branch (blue arrow), with a constant anatomical location; E. Harvesting of the deep branch of the medial circumflex femoral artery for greater trochanteric bone grafting; F. Rich vascular distribution within the bone graft.\u003c/p\u003e","description":"","filename":"Picture3..jpg","url":"https://assets-eu.researchsquare.com/files/rs-6848458/v1/5b9ed6c013e78bd7e3bae23e.jpg"},{"id":85619150,"identity":"16c85b8c-f7e4-488d-9ecf-832696602566","added_by":"auto","created_at":"2025-06-29 14:54:41","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":13796,"visible":true,"origin":"","legend":"\u003cp\u003eHip preservation survival curves for different ARCO stages (with joint replacement as the endpoint event).\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6848458/v1/8bff1d9375630151f8d81d26.jpg"},{"id":85617567,"identity":"3380e1e5-229f-4a06-96ec-2de2b95eb833","added_by":"auto","created_at":"2025-06-29 14:46:42","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":113805,"visible":true,"origin":"","legend":"\u003cp\u003eCase of modified medial femoral circumflex artery deep branch greater trochanteric bone grafting:\u003c/p\u003e\n\u003cp\u003eA. Preoperative anteroposterior (AP) X-ray; B. Postoperative day 3 AP X-ray; C. 6-month postoperative AP X-ray; D. 12-month postoperative AP X-ray; E. 24-month postoperative AP X-ray; F. Preoperative frog-leg lateral X-ray; G. Postoperative day 3 frog-leg lateral X-ray; H. 6-month postoperative frog-leg lateral X-ray; I. 12-month postoperative frog-leg lateral X-ray; J. 24-month postoperative frog-leg lateral X-ray; K. Preoperative MRI; L. Postoperative day 3 MRI; M. 6-month postoperative MRI; N. 12-month postoperative MRI; O. 24-month postoperative MRI; P. Preoperative SPECT/CT; Q. 3-month postoperative SPECT/CT; R. 12-month postoperative SPECT/CT.\u003c/p\u003e\n\u003cp\u003eSPECT/CT showing the progression from a low metabolic state at the time of necrosis to active metabolism in the bone graft and surrounding formerly necrotic areas postoperatively, indicating a good blood supply around the graft. At the final follow-up, normal metabolic signals in the bone graft suggest successful graft survival.\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6848458/v1/f37a2c4a96871d7c387ccf77.jpg"},{"id":97723964,"identity":"011014c8-6b3d-44c7-bd44-e18abee90c30","added_by":"auto","created_at":"2025-12-08 16:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1383331,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6848458/v1/fed025d7-d25e-45f4-948c-1d6164a6e4d8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modified Vascularised Posterior Inter-trochanteric Bone Grafting Technique for the Treatment of Femoral Head Necrosis: A Technical Note Based on Cadaveric Models","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteoncerosis of the Femoral head (ONFH) is a debilitating orthopedic disease, usually due to trauma, prolonged high-dose corticosteroid use, and excessive alcohol consumption. Currently, the number of patients with non-traumatic osteonecrosis of the femoral head (ONFH) has reached 8.12\u0026nbsp;million in China alone\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The ONFH often progresses insidiously and rapidly\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, and eventually leading to severe hip osteoarthritis, causing joint pain and mobility impairment. For younger patients, early total hip arthroplasty (THA) increases the likelihood of future revision surgeries\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Consequently, early diagnosis and hip-preserving treatments have become key research focuses. Hip-preserving surgery has shown effectiveness in alleviating symptoms and delaying or even avoiding THA.\u003c/p\u003e \u003cp\u003eThere are various hip-preserving surgical techniques available, including core decompression, bone grafting, and osteotomy. Among these procedures, bone grafting is the most widely used hip preservation surgery in the ONFH, which can be categorized into non-vascularized bone grafting (NVBG)\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e and vascularized bone grafting (VBG)\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. NVBG for the ONFH primarily involves different decompression pathways to remove necrotic bone tissue, followed by reconstruction of the femoral head using autologous cancellous and cortical bone, allografts, or bone substitutes. This approach aims to restore the circulation and the mechanical stability within the osteonecrosis. Compared with VBG, NVBG is relatively simple, less invasive, but does not directly restore blood supply to the necrotic area\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Given that inadequate blood supply to the necrotic area is a well-recognized pathological basis of ONFH, efforts have been made to restore the vascularization and mechanical strength simutaniously by VBG\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. The vascularized fibular grafting (VFG) and peritrochanteric bone flap grafting are most commonly used VBG techniques. VFG, particularly free vascularized fibular grafting (FVFG), has become one of the most widely accepted hip-preserving procedures, demonstrating favorable long-term outcomes\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. However, it often requires harvesting autologous fibula and vascular anastomosis, making the surgery technically demanding and more invasive \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn 1979, Hori et al. \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e proposed using vascular bundle implantation by introducing the ascending branch of the lateral circumflex femoral artery to treat ONFH. Vascularized peritrochanteric bone flap grafting commonly utilizes vascularized iliac bone flaps, anterior or posterior greater trochanteric bone flaps, or corresponding muscle-pedicle bone flaps to repair the femoral head via a core decompression channel. Compared to FVFG, the main advantages of peritrochanteric bone flap grafting include a single surgical incision, preservation of fibular function, and no need for vascular anastomosis\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Additionally, the cancellous bone in the flap directly contacts the original cancellous bone of the femoral head, which promotes better integration compared to the periosteal cortical-cancellous contact in fibular grafting. Due to the lack of appropriate surgical tools, it is difficult to place the bone graft 3-5mm beneath the subchondral bone plate within the center of the osteonecrosis compared with FVFG, making its clinical results less favorable\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. This study introduces modified vascularised posterior inter-trochanteric bone grafting technique by a special surgical tools, aiming to simplify the procedure and enhance surgical precision. This technique allows to place the vascularized posterior intertrochanteric bone graft 3-5mm right beneath the subchondral bone plate without compromising the vacular pedicles, thus the blood supply and biomechanical stability is effectively restored. It provides a simple and reliable hip preserving surgical method for the ONFH. .\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCadever study\u003c/h2\u003e \u003cp\u003eArterial perfusion and anatomical dissection were performed on four fresh-frozen cadaveric specimens (8 hips) to explore the feasibility of the modified medial femoral circumflex artery (MFCA) deep branch\u0026ndash;based greater trochanteric bone flap grafting. The anatomical study aimed to verify the surgical rationale and identify key technical aspects of this procedure. A set of specialized surgical instruments for the modified MFCA deep branch greater trochanteric bone flap grafting was designed, refined through cadaveric and clinical applications, and ultimately used to establish a standardized operative protocol for treating pre-collapse stage osteonecrosis of the femoral head.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical study\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Information\u003c/h2\u003e \u003cp\u003eFrom August 2018 to August 2021, 24 patients of ARCO IIC-IIIA ONFH are enrolled in this study under their informed consent. The study was approved by the Ethics Committee of Zhongshan Hospital, Fudan University The staging of femoral head necrosis was based on the 2019 version of the ARCO staging system. The Harris Hip Score (HHS) was used as the main evaluation for hip function and symptoms.: The score includes pain, function, joint range of motion, and deformity. The total score is 100, with classifications as follows: Good: 80\u0026ndash;100, Fair: 70\u0026ndash;80 and Poor: below 70.\u003c/p\u003e \u003cp\u003eThe imaging and ARCO staging changes of the femoral head were used as objective indicators for the progression of femoral head necrosis postoperatively. Based on imaging follow-up changes, the progression of necrosis was categorized as \"improved or stable\" and \"progressed.\" The hip-preserving effect was classified as \"successful\" or \"failed\" based on a combination of the HHS score and objective imaging changes. Postoperative follow-up defined hip replacement surgery on the operative side as the endpoint for hip preservation failure.\u003c/p\u003e \u003cp\u003eThe inclusion and exclusion criteria are as follows:\u003c/p\u003e \u003cp\u003eInclusion Criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiagnosis of ONFH was confirmed by hip MRI and X-ray.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eARCO IIC, IIIA were selected.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUndergoing hip-preserving surgery.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAge between 18 and 60 years old.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWillingness to participate in the clinical study.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eExclusion Criteria:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePresence of other hip joint diseases.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrevious hip surgery\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eARCO stage I, IIA, IIB, III B, IIIC or IV\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe design of surgical tool and Surgical procedure\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSurgical tool\u003c/h2\u003e \u003cp\u003eTo enhance the precision and simplicity of key procedures during the modified medial femoral circumflex artery deep branch greater trochanteric bone grafting (MFCVBG)\u0026mdash;including bone flap harvesting, necrotic lesion debridement and decompression, and graft insertion\u0026mdash;this study has designed and developed a complete set of dedicated surgical instruments tailored to the local anatomical characteristics of the femoral head-neck region (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), for which a patent has been filed.\u003c/p\u003e \u003cp\u003eThe specialized instruments include: a custom-designed bone chisel for harvesting the greater trochanteric bone flap, a graduated guide pin (Kirschner wire), a large-diameter trephine drill, a trephine sleeve, a sleeve impactor, a twisting extractor, a flat-head rasp, a graft sizer, and a stabilizer. Among them, the trephine drill, sleeves, flat-head rasp, and graft sizer come in three different diameter specifications that are compatible with each other, thereby accommodating the needs of patients with varying anatomical profiles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eThe patient is positioned in the 90-degree lateral decubitus position. The traditional posterior-lateral approach to the hip is used with a curved incision over the posterior-lateral hip, layered dissection, blunt separation of the gluteus maximus, and excision of the greater trochanteric bursa. The hip is then internally rotated to expose the superior and inferior gluteal muscles, and the quadratus femoris is dissected to reveal the main trunk and branches of the MFCA deep branch. Once the main trunk is located, it is traced laterally, where branches are observed extending to the greater trochanter and intertrochanteric ridge. The blood flow of the bone flap can be preliminarily assessed by palpating the arterial pulsation in the branch. The terminal branches of the MFCA deep branch are ligated and cut. At the posterior aspect of the femur, near the greater trochanter and intertrochanteric ridge, a bone flap of approximately 4\u0026ndash;5 cm x 1.5-2 cm x 1.5-2 cm is harvested using a specialized bone knife. The bone flap generally retains two vascular branches, and the blood supply can be further assessed based on the bone\u0026rsquo;s trabecular bleeding. Some vascular pedicles may be released to allow the bone flap to be repositioned. The bone flap and vascular pedicle are protected with saline-soaked gauze. A bone window of 16mm, 18mm, or 20mm is created in the femoral head-neck region using the specialized instruments. Under fluoroscopy, the reamer is used to drill until the joint surface subchondral bone is reached, 3\u0026ndash;5 mm deep. The bone core is extracted, and necrotic bone is removed with a burr and curette. The floor of the decompression channel is smoothed using a flat rasp. Fresh cancellous bone or synthetic bone is implanted into the decompression channel, and for mild femoral head collapse, the shape is restored during the bone graft pressurization. The vascularized bone flap is inserted into the femoral head-neck decompression cavity, ensuring that the cancellous bone side faces up and tightly conforms to the wall of the decompression channel. The cortical bone side and vascular pedicle should face downward to prevent twisting, compression, or excessive traction. The bone flap is appropriately pressed into place to ensure good compression between the upper edge of the bone flap and the bottom of the decompression channel. A 3.5mm hollow screw is used for fixation, and appropriate pressure is applied. Once the position is confirmed under fluoroscopy, saline is used to irrigate the area, and careful electrocoagulation is performed for hemostasis. Artificial bone may be used to fill the area from which the bone flap was harvested from the greater trochanter. A drainage tube is placed, and the incision is closed layer by layer with compression dressing (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical Outcomes\u003c/h3\u003e\n\u003cp\u003eRisk Factors for Poor Hip Preservation Effect and Disease Progression:\u003c/p\u003e \u003cp\u003eThe basic patient data (gender, affected side, age, BMI), necrosis type (steroid, alcohol, trauma, idiopathic), preoperative ARCO stage, preoperative necrosis range indicators (MRI combined necrosis angle, necrosis index, modified necrosis index), preoperative and postoperative HHS scores, bone flap-related issues (e.g., poor bone flap positioning, delayed healing, downward displacement, low metabolic state of the bone flap, coronal, sagittal, and horizontal positioning angles) were analyzed to evaluate their correlation with postoperative imaging changes and the effectiveness of hip-preserving treatment. The aim was to evaluate factors leading to femoral head collapse.\u003c/p\u003e \u003cp\u003eComparison of Hip Preservation Effect Across Different ARCO Stages:\u003c/p\u003e \u003cp\u003eIn this study, patients were grouped into ARCO II and ARCO IIIA stages based on preoperative staging. The two groups were compared in terms of gender, affected side, age, BMI, necrosis type and necrosis range-related indicators to evaluate the impact of preoperative ARCO staging on the modified MFCA deep branch greater trochanteric bone flap grafting surgery. A survival curve for hip preservation was constructed with joint replacement as the endpoint event.\u003c/p\u003e\n\u003ch3\u003eStatistical Methods:\u003c/h3\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS 25.0. The Kolmogorov-Smirnov test was used to assess the normality of the distribution of continuous variables. If the distribution was normal, the results were described as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation; categorical variables were described as frequencies and percentages. Independent sample t-tests or Mann-Whitney U tests were used to compare differences between continuous variables in two groups. Rank correlation analysis was used for the correlation analysis between hip preservation effectiveness, imaging changes, HHS scores, and continuous variables. Pearson\u0026rsquo;s chi-square test or Fisher\u0026rsquo;s exact test was used for the relationship between categorical variables (e.g., bone necrosis etiology, stage, classification, and other potential risk factors). A P-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e "},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003cp\u003eCadaveric Anatomy\u003c/p\u003e\n \u003cp\u003eA detailed dissection was performed to expose the major hip external rotator muscle group behind the femoral head and neck (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eA, B) as well as the vascular distribution (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eC). The medial femoral circumflex artery (MFCA) deep branch passes between the obturator externus and the short adductor muscles to reach the posterior femoral neck, and then runs obliquely upward and laterally, traveling between the obturator externus and the quadratus femoris, eventually penetrating the obturator internus tendon and the deep sides of the superior and inferior gemelli muscles. The deep branch of the medial femoral circumflex artery (MFCA) gives rise to 2\u0026ndash;3 branches supplying the greater trochanter, running horizontally across the intertrochanteric ridge and widely distributing in a \u0026quot;raven\u0026apos;s foot\u0026quot; pattern in the posterior region of the greater trochanter and intertrochanteric area. The anatomical location of these branches is constant, with diameters reaching over 1mm (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eD). Further dissection of the deep branch of the MFCA shows a constant anastomosis with branches of the inferior gluteal artery (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eD). A bone flap of size 4\u0026ndash;5 cm \u0026times; 1.5-2 cm \u0026times; 1.5-2 cm was harvested from the region supplied by the deep branch of the MFCA at the greater trochanter and intertrochanteric area (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eE), where rich vascular distribution inside the bone flap was observed (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003eF).\u003c/p\u003e\n \u003cp\u003eBy performing latex injection on the deep femoral artery in 4 cadaver models, we confirmed that the MFCA deep branch sends 2\u0026ndash;3 branches to the greater trochanter region, which supplies the modified MFCVBG (Modified Femoral Circumflex Vessel Graft Bone Grafting) surgical area, with a constant anatomical location. After bone harvesting, abundant small arteries were observed within the bone flap, corroborating the substantial bleeding from the bone flap during surgery. This further supports that the bone flap has rich blood supply. The modified femoral medial circumflex artery deep branch greater trochanter bone flap transplantation surgery is based on clear anatomical principles. The bone flap, with its constant anatomical location and rich blood supply, can theoretically restore blood supply and mechanical structure in femoral head necrosis (ONFH) during the collapse phase .\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eCohort Overview and Baseline Perioperative Characteristics of the Study Subjects\u003c/h2\u003e\n \u003cp\u003eThis study prospectively included 20 patients with a total of 24 hips. Among them, 15 were male (19 hips). The average follow-up time after surgery for the 24 hips was 24.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 months. Four patients underwent total hip replacement (THR) due to necrosis progression and were excluded from further follow-up. The remaining 20 hips did not undergo replacement, and no subjects dropped out of the study midway. The average Harris Hip Score (HHS) at the final follow-up was 75.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7. Among the 20 hips that did not undergo THR, the hip preservation rate was 83%. Based on a combination of hip function, symptoms, and objective imaging findings, 71% of the hips were classified as having a successful hip preservation outcome.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eSurgical and Postoperative Follow-up Results\u003c/h2\u003e\n \u003cp\u003eRisk Factors for Poor Clinical Outcomes and Hip Preservation Failure:\u003c/p\u003e\n \u003cp\u003eDuring the follow-up period, preoperative ARCO staging (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and HHS scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were significantly correlated with postoperative hip preservation outcomes. ARCO IIIA stage hips with preoperative local collapse and microfractures, along with lower HHS scores, were identified as risk factors for poor hip preservation outcomes. Additionally, postoperative downward displacement of the bone flap (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), improper bone flap positioning (P\u0026thinsp;=\u0026thinsp;0.089), or delayed healing (P\u0026thinsp;=\u0026thinsp;0.089) may be associated with poor hip preservation effectiveness. However, the latter two factors did not reach statistical significance (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eComparison of Hip Preservation Outcomes in Different ARCO Stages:\u003c/p\u003e\n \u003cp\u003eIn this study cohort, 12 hips with ARCO II and 12 hips with ARCO IIIA stage hip necrosis were included. There were no significant differences between the two groups in terms of gender, side of surgery, age, BMI, necrosis type, related necrosis range indicators, and follow-up time for hips that did not undergo replacement.\u003c/p\u003e\n \u003cp\u003eFor ARCO IIIA stage hips, 4 cases showed continued collapse after undergoing modified MFCVBG surgery and eventually received total hip arthroplasty (THA), resulting in a hip preservation rate of 67%. In contrast, no patients with ARCO II stage hip necrosis underwent THA after the modified MFCVBG surgery, resulting in a hip preservation rate of 100%. The hip preservation survival curve with THA as the endpoint event for both groups is shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eThere were significant differences in HHS scores between the ARCO II and IIIA groups at preoperative and final follow-up time points. The HHS scores of the ARCO II group were significantly higher than those of the ARCO IIIA group. Preoperative hip preservation outcomes were significantly better in the ARCO II group compared to the ARCO IIIA group, with the hip preservation excellent rate being 100% in the ARCO II group and 44% in the ARCO IIIA group (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eCase Examples\u003c/h2\u003e\n \u003cp\u003eA 41-year-old female patient with a history of long-term oral corticosteroid use for chronic urticaria presented with bilateral steroid-induced osteonecrosis of the femoral head (ONFH). MRI confirmed bilateral involvement, and the left hip was classified as ARCO stage IIB. Given the pre-collapse status of the lesion and the patient\u0026rsquo;s young age, she was selected for hip-preserving treatment using the modified medial femoral circumflex artery (MFCA) deep branch\u0026ndash;based greater trochanteric vascularized bone flap grafting (modified MFCVBG).\u003c/p\u003e\n \u003cp\u003eUnder general anesthesia, the patient underwent the modified MFCVBG procedure. Intraoperatively, the deep branch of the MFCA was carefully dissected, and two sizable arterial branches supplying the posterior intertrochanteric region were preserved. A 4.5 cm \u0026times; 1.8 cm \u0026times; 1.5 cm vascularized bone flap was harvested with its pedicle intact. Using the customized surgical instruments, a decompression tunnel was accurately created to reach 3\u0026ndash;5 mm beneath the subchondral bone in the weight-bearing area of the femoral head. The bone flap was then implanted with the cancellous side facing upward and fixed using a 3.5 mm hollow screw. No pedicle torsion or compression occurred.\u003c/p\u003e\n \u003cp\u003ePostoperative recovery was uneventful. At 3 months, the patient had regained nearly full range of motion, and the Harris Hip Score (HHS) improved from 68 preoperatively to 87. Follow-up imaging at 6, 12, and 24 months showed continuous integration of the bone flap with the host bone, no signs of collapse, and well-maintained joint space. Importantly, no progression of the necrotic lesion was observed.\u003c/p\u003e\n \u003cp\u003eSPECT/CT performed at 3 and 12 months postoperatively demonstrated robust metabolic activity within the grafted bone flap and surrounding formerly necrotic region. The imaging confirmed sustained viability of the flap, with no perfusion deficits detected in the MFCA-supplied area. This supports the hypothesis that direct placement of a vascularized bone flap beneath the subchondral plate not only provides immediate mechanical support but also promotes revascularization and osteogenesis in the critical load-bearing zone.\u003c/p\u003e\n \u003cp\u003eThis case exemplifies several key advantages of the modified MFCVBG technique:\u003c/p\u003e\n \u003cp\u003e\u0026bull; Anatomical precision: The customized instruments facilitated exact trajectory and depth control for the decompression tunnel;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Biological viability: The preserved vascular pedicle ensured sustained blood supply to the graft;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Biomechanical effectiveness: The subchondral placement of the flap offered optimal structural support;\u003c/p\u003e\n \u003cp\u003e\u0026bull; Clinical efficacy: No femoral head collapse or symptomatic progression occurred at 2 years postoperatively.(Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThis outcome underscores the value of combining anatomical insights, specialized instrumentation, and vascularized tissue transfer in the early intervention of steroid-induced ONFH\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eEarly diagnosis of femoral head necrosis and hip preservation surgeries have become one of the main research focuses in recent years \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The key aspect of hip preservation surgery lies in the thorough removal of necrotic bone tissue, restoration of blood supply to the femoral head and necrotic areas, and reconstruction of the internal structure and mechanical stability of the femoral head, with the core goal being to improve symptoms, delay, or even avoid total hip arthroplasty\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Currently, there are various surgical techniques for hip preservation, and this study mainly focuses on a systematic investigation of the modified medial femoral circumflex artery (MFCA) deep branch trochanteric bone flap transplantation.\u003c/p\u003e \u003cp\u003eIn 1949, Phemister first proposed the femoral head decompression and bone grafting technique through the femoral trochanter \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, which gradually became the most classic and widely applied technique in hip preservation surgery. This technique primarily involves drilling a hole beneath the greater trochanter via a lateral approach, performing marrow decompression to the femoral head necrosis area, using curettes and other tools to remove necrotic bone, and then grafting bone or using other bone substitute materials to fill the defect, providing subchondral support to prevent cartilage collapse. Compared with other surgical techniques, the major advantage of femoral head decompression and bone grafting is its minimally invasive nature and ease of operation. However, complete removal of the necrotic area during the procedure is challenging. Some studies suggest that the effect of the window decompression and bone grafting technique for treating non-collapsed femoral head necrosis is generally satisfactory, but it is less effective for collapsed femoral heads\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. For this reason, it is currently believed that window decompression and bone grafting should be used cautiously for patients with collapsed femoral heads, large necrosis areas, and severe involvement of the femoral head lateral pillar\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. This study also confirmed that the treatment effect is poor for patients with ARCO III stage and cumulative weight-bearing areas of bone necrosis.\u003c/p\u003e \u003cp\u003eAmong the various factors causing femoral head necrosis, the lack of blood supply to the necrotic area is widely recognized as the pathological basis. Therefore, there has been a push to restore vitality to the previously necrotic regions by reintroducing blood supply. In 1979, Hori et al.\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e proposed the use of vascular bundle implantation, introducing the ascending branch of the lateral femoral circumflex artery for the treatment of femoral head necrosis. Although this technique has become less commonly used due to its insufficient mechanical support and weak osteoinductive capacity, a variety of vascularized bone flap transplantation techniques have been developed and applied in the treatment of femoral head necrosis. For specific populations, particularly young patients, vascularized bone flap transplantation may be a more cost-effective option compared to direct joint replacement\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Through postoperative SPECT/CT, we can assess the bone vitality of the femoral head and subchondral bone\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. We found that the modified MFCA deep branch trochanteric bone flap transplantation technique effectively restores the metabolic activity of both the bone flap and the surrounding former necrotic region. Therefore, theoretically, this technique could improve the success rate of hip preservation. However, due to limitations in surgical design and technology at the time, the original technique was relatively complex and did not yield optimal results. Building upon the original method, this study simplified the surgical operation and improved the precision of the procedure by designing and using specialized surgical tools and refining standardized surgical processes. The research group has previously verified the biomechanical stability of the modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation through finite element analysis\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, showing promising clinical outcomes. The modified MFCVBG procedure seems to offer superior hip preservation results in ARCO stage II patients. For ARCO IIIA patients, increasing the precision of decompression and bone flap placement based on the current modified MFCVBG procedure is expected to more thoroughly remove necrotic bone tissue and restore femoral head mechanical stability, which should theoretically improve the success rate of hip preservation. However, when comparing different hip preservation techniques, aside from the procedure's inherent effectiveness, other factors such as patient characteristics, the surgeon's experience, surgical trauma, difficulty of the operation, and potential impacts on future joint replacement surgery must also be considered, making comparisons and selections of surgical techniques a challenging issue in the treatment and research of osteonecrosis of the femoral head (ONFH)\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe commonly used vascularized bone flap transplantation techniques in clinical practice can be mainly divided into vascularized fibula transplantation and hip circumferential bone flap transplantation. Vascularized fibula transplantation is usually performed by placing a free fibula through the femoral trochanteric decompression channel, with the fibula's blood vessels typically anastomosed to the ascending branches of the lateral femoral circumflex artery and its accompanying vein\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Due to the need for microvascular anastomosis in vascularized fibula transplantation, the procedure becomes more complex and time-consuming. Cao et al.\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e designed a randomized controlled trial involving bilateral femoral head necrosis patients, in which one side underwent vascularized fibula transplantation, and the other side received core decompression combined with autologous bone grafting. They demonstrated that vascularized fibula transplantation had superior short-term results. The modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation used in this study is also a form of vascularized bone flap transplantation. Vascularized hip circumferential bone flap transplantation often uses vascularized iliac bone flaps, anterior and posterior greater trochanteric bone flaps, or corresponding musculocutaneous bone flaps, with femoral head repair performed via the bulbous-shaped decompression channel of the femoral head neck\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Generally speaking, compared with vascularized fibula transplantation, the greatest advantage of circumferential hip bone flap transplantation is the single surgical incision, no need to sacrifice fibular function, and no vascular anastomosis. Furthermore, the cancellous bone of the bone flap directly contacts the original cancellous bone of the femoral head, which facilitates better healing compared to the cortical-cancellous bone contact in fibula transplantation\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. The modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation used in this study significantly reduced blood loss and surgical time compared to Cao's vascularized fibula transplantation cohort, demonstrating that the procedure's difficulty and hip preservation efficacy are superior to that of vascularized fibula transplantation.\u003c/p\u003e \u003cp\u003eLimitations:\u003c/p\u003e \u003cp\u003eThis study is a single-center, single-cohort study with a limited sample size, and it has not compared the results with other hip preservation techniques. Therefore, the findings need to be validated in larger-scale follow-up cohorts and controlled studies. The modified medial femoral circumflex artery vascularized greater trochanteric bone flap transplantation requires a learning curve, and achieving optimal surgical results requires a certain amount of experience.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe modified MFCA deep branch greater trochanteric bone flap grafting is based on well-defined anatomical principles and is enhanced by customized surgical tools, allowing for the maximal removal of necrotic bone and precise placement of the bone flap deep into the subchondral bone. This provides optimal biomechanical stability and offers an improved solution for hip preservation in ONFH. However, the study also indicates that hip preservation outcomes are less favorable in cases where the necrosis involves the weight-bearing region, progresses to ARCO stage III, or is associated with lower preoperative Harris scores. Therefore, the application of this technique requires individualized assessment to optimize patient selection and improve treatment success rates.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis clinical study was approved by Zhongshan Hospital Fudan University’s institutional review board (B2019-135R). This study was conducted in accordance with the Declaration of Helsinki.\u0026nbsp;All the patients consented to participate in this study, and informed consents were signed by themselves in all instances.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets of the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by National Natural Science Foundation of China (82172413 and 82372393), Shanghai Shenkang Hospital Development Center Clinical Research Plan (SHDC12023111) and the Jinshan District Fifth Cycle Excellent Youth Training Program (JSYQ-2023-05). The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZYK, MTL and JC involved in making the conception and design of research and carried out drafting of the article. YZQ and CL had the conception and design of the study, and made a final approval and guarantor of the manuscript. YZQ and ZYK carried out the acquisition of data and made a final approval. HBX and JC contributed on collecting parents’ information. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all the reviewers who participated in the review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhao DW, Yu M, Hu K, et al. Prevalence of Nontraumatic Osteonecrosis of the Femoral Head and its Associated Risk Factors in the Chinese Population: Results from a Nationally Representative Survey. Chin Med J (Engl). 2015;128(21):2843\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMont MA, Zywiel MG, Marker DR, McGrath MS, Delanois RE. The natural history of untreated asymptomatic osteonecrosis of the femoral head: a systematic literature review. J Bone Joint Surg Am. 2010;92(12):2165\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu N, Zheng C, Wang Q, Huang Z. Treatment of non-traumatic avascular necrosis of the femoral head (Review). Exp Ther Med. 2022;23(5):321.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePierce TP, Elmallah RK, Jauregui JJ, Poola S, Mont MA, Delanois RE. A current review of non-vascularized bone grafting in osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015;8(3):240\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEbad Ali SM, Razak S, Khan WF, et al. Outcomes Of Reconstruction With Vascularized Vs Non Vascularized Bone Graft After Resection Of Bone Tumours- A Systematic Review And Meta-Analysis. J Ayub Med Coll Abbottabad. 2023;35(2):307\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTesta G, Lucenti L, D'Amato S, et al. Comparison between Vascular and Non-Vascular Bone Grafting in Scaphoid Nonunion: A Systematic Review. J Clin Med. 2022;11(12):3402.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi B, Yang M, Yu L. Vascular bundle transplantation combined with porous bone substituted scaffold for the treatment of early-stage avascular necrosis of femoral head. Med Hypotheses. 2019;132:109374.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan SP, Wooster B, Jiranek W, Wellman S, Bolognesi M, Seyler T. Outcomes of Conversion Total Hip Arthroplasty From Free Vascularized Fibular Grafting. J Arthroplasty. 2019;34(1):88\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Q, Guo W, Li R, Lee JH. Efficacy of various core decompression techniques versus non-operative treatment for osteonecrosis of the femoral head: a systemic review and network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2021;22(1):948.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHori Y, Tamai S, Okuda H, Sakamoto H, Takita T, Masuhara K. Blood vessel transplantation to bone. J Hand Surg Am. 1979;4(1):23\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi D, Li M, Liu P, Zhang Y, Ma L, Xu F. Core decompression or quadratus femoris muscle pedicle bone grafting for nontraumatic osteonecrosis of the femoral head: A randomized control study. Indian J Orthop. 2016;50(6):629\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Wang X, Jiang C, Hua B, Yan Z. Biomechanical research of medial femoral circumflex vascularized bone-grafting in the treatment of early-to-mid osteonecrosis of the femoral head: a finite element analysis. J Orthop Surg Res. 2022;17(1):441.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoon BH, Mont MA, Koo KH, et al. The 2019 Revised Version of Association Research Circulation Osseous Staging System of Osteonecrosis of the Femoral Head. J Arthroplasty. 2020;35(4):933\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMigliorini F, La Padula G, Oliva F, Torsiello E, Hildebrand F, Maffulli N. Operative Management of Avascular Necrosis of the Femoral Head in Skeletally Immature Patients: A Systematic Review. Life (Basel). 2022. 12(2): 179.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalekar G. Hip Preservation With Autologous Osteoblast Cell-Based Treatment in Osteonecrosis of the Femoral Head. Orthopedics. 2021;44(2):e183\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePHEMISTER DB. Treatment of the necrotic head of the femur in adults. J Bone Joint Surg Am. 1949;31A(1):55\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWatters TS, Browne JA, Orlando LA, Wellman SS, Urbaniak JR, Bolognesi MP. Cost-effectiveness analysis of free vascularized fibular grafting for osteonecrosis of the femoral head. J Surg Orthop Adv. 2011;20(3):158\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichard MJ, DiPrinzio EV, Lorenzana DJ, Whitlock KG, Hein RE, Urbaniak JR. Outcomes of free vascularized fibular graft for post-traumatic osteonecrosis of the femoral head. Injury. 2021;52(12):3653\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi J, Chen J, Wu J, et al. Evaluation of the 3D finite element method using a tantalum rod for osteonecrosis of the femoral head. Med Sci Monit. 2014;20:2556\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePierce TP, Jauregui JJ, Elmallah RK, Lavernia CJ, Mont MA, Nace J. A current review of core decompression in the treatment of osteonecrosis of the femoral head. Curr Rev Musculoskelet Med. 2015;8(3):228\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao L, Liao Y, Song C, et al. Quantitative Characterization of Bone Viability of Femoral Head and Subchondral Bone by Using Single Photon Emission Computerized Tomography/Computerized Tomography (SPECT/CT). Med Sci Monit. 2020;26:e922624.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang ZQ, Fu FY, Li WL, et al. Current Treatment Modalities for Osteonecrosis of Femoral Head in Mainland China: A Cross-Sectional Study. Orthop Surg. 2020;12(6):1776\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;zt\u0026uuml;rk K, Baydar M, Alpay Y, Şencan A, Orman O, Aykut S. Clinical results of free vascularized fibula graft in the management of precollapse osteonecrosis of the femoral head: A retrospective clinical study. Acta Orthop Traumatol Turc. 2022;56(2):105\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCao L, Guo C, Chen J, Chen Z, Yan Z. Free Vascularized Fibular Grafting Improves Vascularity Compared With Core Decompression in Femoral Head Osteonecrosis: A Randomized Clinical Trial. Clin Orthop Relat Res. 2017;475(9):2230\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho KJ, Park KS, Yoon TR. Muscle pedicle bone grafting using the anterior one-third of the gluteus medius attached to the greater trochanter for treatment of Association Research Circulation Osseous stage II osteonecrosis of the femoral head. Int Orthop. 2018;42(10):2335\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaus U, Roth A, Tingart M, et al. [S3 Guideline. Part 3: Non-Traumatic Avascular Necrosis in Adults - Surgical Treatment of Atraumatic Avascular Femoral Head Necrosis in Adults]. Z Orthop Unfall. 2015;153(5):498\u0026ndash;507.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of Factors Related to Hip Preservation Outcomes of Modified MFCVBG Surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHip preservation outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003egood\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003efair\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003epoor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of hips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Side (Left/Right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.2\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29\u0026thinsp;\u0026plusmn;\u0026thinsp;12.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Body Mass Index)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Necrosis (Hormonal Alcoholic/Idiopathic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/2/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARCO Staging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.05*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage II (A/B/C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/3/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/2/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative HHS Score (Harris Hip Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal Follow-up HHS Score (Harris Hip Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.1\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Bone Graft Malposition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Bone Graft Healing Delay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Bone Graft Downward Displacement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.05*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative Bone Graft Hypometabolic State\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, statistically significant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Hip Preservation Outcomes in Different ARCO Stages\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eARCO Staging\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage II (A/B/C)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStage IIIA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of hips\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9/3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Side (Left/Right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (Body Mass Index)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Necrosis (Hormonal Alcoholic/Idiopathic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/3/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/3/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative HHS Score (Harris Hip Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.2\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal Follow-up HHS Score (Harris Hip Score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69.5\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHip preservation outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.01*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTHA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, statistically significant.\u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Osteonecrosis of the femoral head, Medial femoral circumflex vascularized bonegrafting, Hip-preserving surgery","lastPublishedDoi":"10.21203/rs.3.rs-6848458/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6848458/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground​\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOsteonecrosis of the femoral head (ONFH) is a challenging orthopedic condition that often leads to progressive joint destruction and disability. This study aims to simplfy the surgical tehniques and idealize the position of bone grafting for the repair of ONFH, and its preliminary clinical results were reported.​\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods​\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnatomical studies were first conducted on four fresh frozen cadaveric specimens (8 hips). Arterial perfusion was performed to precisely investigate the medial femoral circumferential vessels supplying to the posterior greater intertrochanter. Based on the anatomical findings, vascularised posterior inter-trochanteric bone graft and the corresponding surgical instruments were meticulously designed to ensure accurate creation of the decompression tunnel and precise fitting of the bone graft​From August 2018 to August 2021, a total of 20 patients (24 hips) underwent the medial femoral circumferential vascularized posterior intertrochanteric bone grafting procedure at our institution. Clinical data, imaging findings, ARCO staging, and Harris hip scores were systematically collected. Intraoperative parameters, including operative time and blood loss, were also recorded. Postoperatively, patients were followed up for at least two years. Hip preservation failure was defined as a decrease in the Harris score, radiographic progression of ONFH, or the necessity for THA.​\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults​\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe cadaveric study revealed that the deep branch of the medial femoral circumflex artery (MFCA) consistently gave rise to 2–3 branches supplying the posterior intertrochanteric bone. The first branch originated from the superior margin of the quadratus femoris attachment, and the remaining two branches were located beneath the quadratus femoris. The branches supplying the posterior intertrochanteric bone are carefully dissected and preserved, a 4-5cm long, 1.5-16 cm thick and deep bone graft is cut, which is used to improve the vascularization and mechanical stability within the osteonecrosis.​There are 20 patients (24 hips) prospectively enrolled, including 15 male patients (19 hips). The average postoperative followup duration was 24.2 ± 5.6 months. Four patients had to undergo THA due to disease progression, while the remaining 20 hips continued to be monitored. The final mean postoperative Harris hip score (HHS) was 75.1 ± 13.7. Among the 24 hips, 20 did not require THA, resulting in a hip preservation rate of 83%. Based on comprehensive evaluations of clinical function, symptoms, and radiographic findings, 71% of the hips were considered to have achieved successful hip preservation.​\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions​\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe modified vascularized posterior intertrochanteric bone grafting is a simple yet effective hip - preserving surgical technique. It enables precise placement of the vascularized bone graft directly under the subchondral bone, and the good blood supply of the graft significantly promotes bone repair. This technique provides a simple，reliable and ideal graft position to repair the ONFH, the clinical outcomes seem to be related to the degree of femoral head collapse, with less favorable results associated with more severe collapse, its long term efficacy needs studied further.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable (Retrospective Study).\u003c/p\u003e","manuscriptTitle":"Modified Vascularised Posterior Inter-trochanteric Bone Grafting Technique for the Treatment of Femoral Head Necrosis: A Technical Note Based on Cadaveric Models","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-29 14:46:37","doi":"10.21203/rs.3.rs-6848458/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-16T11:14:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-15T17:30:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"61767127243045725002775380942455303247","date":"2025-09-15T12:59:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-29T00:13:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280968860660944145319956382958540250563","date":"2025-08-22T22:38:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T03:02:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-23T16:50:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-20T04:18:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-20T04:16:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-06-08T15:58:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13349d6f-e55b-45ac-9b46-8e10bc680f08","owner":[],"postedDate":"June 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:03:40+00:00","versionOfRecord":{"articleIdentity":"rs-6848458","link":"https://doi.org/10.1186/s12893-025-03313-w","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2025-12-02 15:58:14","publishedOnDateReadable":"December 2nd, 2025"},"versionCreatedAt":"2025-06-29 14:46:37","video":"","vorDoi":"10.1186/s12893-025-03313-w","vorDoiUrl":"https://doi.org/10.1186/s12893-025-03313-w","workflowStages":[]},"version":"v1","identity":"rs-6848458","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6848458","identity":"rs-6848458","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}