Caso Clínico

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Colgajo libre osteoseptocutáneo de peroné en la reconstrucción primaria
de la radionecrosis masiva mandibular
Fibular osteoseptocutaneous free flap in the primary reconstruction after massive radionecrosis
of the mandible

 

P. Infante Cossío¹, A. García-Perla García¹, R. Belmonte Caro¹, D. Sicilia Castro², J.D. González Padilla¹, J.L. Gutiérrez Pérez¹

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Abstract: Osteoradionecrosis is one of the most serious complications after radiation therapy of squamous carcinoma of the oral cavity. In this article, we report four cases of massive osteoradionecrosis of the mandible, all of whom had failed initial conservative management and treated with radical resection and primary reconstructed with fibular osteoseptocutaneous free flap. Mandible defects after radical resection were around 10 cm long and included intraoral mucosa, skin or both. A doubled-paddle peroneal tissue transfer was used in two cases for reconstruction of an extensive extra- or intraoral defects. The vascularized fibular flap was osteotomized in all cases to permit contouring the mandibular defect. All the flaps survived completely. Three patients healed primarily with good aesthetic and functional results. One patient died one month after the operation due to an acute pancreatitis and renal failure. One patient had placement of osseointegrated implants. In our experience, the fibular osteoseptocutaneous free flap can be an ideal option for one stage reconstruction of complex, composite mandibular defects in patients with massive osteoradionecrosis. Key words: Osteoradionecrosis; Mandible; Microvascular surgery; Fibular free plap.

Resumen: Una de las complicaciones más serias del uso de la radioterapia en el tratamiento del carcinoma epidermoide de la cavidad oral, es la osteorradionecrosis. En este trabajo, presentamos cuatro pacientes afectos de osteorradionecrosis masiva de la mandíbula que habían fracasado inicialmente con medidas conservadoras y que fueron tratados con resección radical y reconstrucción primaria con un colgajo libre osteoseptocutáneo de peroné. El defecto mandibular tras la resección ósea midió una media de 10 cm e incluyó mucosa intraoral, piel o ambos. En dos casos de reconstrucción, se empleó el colgajo libre de peroné con doble paleta para reconstruir defectos extensos intra y extraorales. Se realizaron osteotomías en el peroné vascularizado en todos los casos para recrear el contorno mandibular. Todos los colgajos sobrevivieron completamente. Tres pacientes curaron primariamente con buenos resultados estéticos y funcionales. Una paciente falleció en el primer mes tras la operación por una pancreatitis aguda y fallo renal. En un paciente se han insertado implantes osteointegrados. En nuestra experiencia, el colgajo libre osteoseptocutáneo de peroné puede ser una opción ideal para la reconstrucción en un solo tiempo de defectos complejos mandibulares compuestos en pacientes afectos de osteorradionecrosis masiva. Palabras clave: Osteorradionecrosis; Mandíbula; Microcirugía; Colgajo libre de peroné.

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1 Servicio de Cirugía Oral y Maxiofacial
2 Servicio de Cirugía Plástica y Quemados
Hospitales Universitarios Virgen del Rocío, Sevilla, España

Correspondencia:
Pedro Infante Cossio
Servicio de Cirugía Oral y Maxilofacial
Hospitales Universitarios Virgen del Rocío, Sevilla, España
Avda. Manuel Siurot s/n
41013 Sevilla, España

Introduction

Radiotherapy is one of the therapeutic tools used in the treatment of squamous carcinoma of the oral cavity, and the complication most feared is osteoradionecrosis (ORN). It is usually slow to appear in the mandible and it results in a significant decrease in the quality of life of the patient. ORN of the mandible has been defined as exposed irradiated bone that has failed to heal over a three-month period in the absence of a localized tumor.¹ The average incidence in patients is 2-10%.^2,3 The management of ORN of the mandible represents a therapeutic challenge. When it is in a limited area it can be treated with conservative therapy, but if there is massive necrosis of the bone and soft tissues, an aggressive approach is needed which includes the resection of necrotic bone and soft tissue and primary reconstruction of the defect. Among the different reconstructive options, the fibular osteoseptocutaneous flap has proved to be of great utility, as it provides a large area of tissue for the reconstruction of complex, tri-dimensional defects.

The object of this article is to present our experiences with the use of the fibular osteoseptocutaneous flap in primary type reconstruction following massive radionecrosis of the mandible.

Material and method

Between 2000-2001, four patients with massive radionecrosis of the mandible underwent primary reconstruction with fibular osteoseptocutaneous flaps at the Maxillofacial Service of the Hospital Virgen del Rocío of Seville. The patient sample consisted of two male patients and two female patients, with ages ranging between 52 and 68 (the average age was 60,2). Three patients (cases 1,2 and 4) with squamous carcinoma of mandibular gums had been treated initially by our Service with surgical resection and postoperative complementary radiotherapy; one patient (case 3) had been treated exclusively with radiotherapy for a carcinoma on the floor of her mouth and she had been referred to us by another hospital. All patients had undergone external radiotherapy of the tumor bed and on the cervical lymphatic chains. The dose varied between 60 and 70 Gy, with an average dose of 65 Gy. The time span between the end of the radiotherapy to the onset of ORN sequelae varied between 6 and 16 months. Clinical manifestations of osteoradionecrosis in all patients included pain, infection, cutaneous fistulization, intra- and extraoral exposure and mucosal necrosis (Figs. 1 and 4). In one patient (case 3) a pathological fracture of the mandibular body was observed. All patients were initially treated conservatively with hygienic measures, antibiotherapy (Amoxicilina-Clavulanic acid) and intraoral curettage or removal of small intraoral sequesters under local anesthetic. In two patients (case 2 and 4) the osteosynthesis plates were removed under local anesthetic/sedation which had been placed during initial surgery. None of the patients had been given hyperbaric oxygen before reconstructive treatment, although the patient in case 3 received 30 sessions of hyperbaric oxygen previous to the placement of osseointegrated implants.

Results

In all patients surgical treatment of the mandibular radionecrosis was carried out with aggressive resection of the necrotic bone by means of a segmental mandibulectomy which varied between 8 and 12 cm (average length 10 cm) (Table 1), together with intraoral mucosa, skin or both. The extension of the resection was determined by radiological studies and intraoperative findings until healthy bone was reached. All patients were reconstructed with a fibular osteoseptocutaneous free flap, composed of one or two skin paddles. An osteotomy of the fibula was then performed to create a mandibular contour for the flaps, in three segments in one patient (case 3) and two segments in three patients. All flaps were fixed with mini-plates, and with two patients Krenkel^® type reconstruction plates were used. An intraoral cutaneous paddle was used in two patients, and in two cases a cutaneous double-paddle was used in order to line intraand extra-orally. The donor site was primary closed in one patient (case 3) and in the remainder free skin grafts were used. Microsurgical anastomosis was performed on the homolateral facial vessels. All flaps were viable. In three of the patients there were no postoperative complications worth noting. One patient (case 2) died a month after surgery of metabolic shock as a result of acute pancreatitis with renal failure. In cases 1,3, and 4 clinical following showed bone healing, (minimum follow-up of two years) symptoms of pain and infection disappeared, and deglutition was resumed. They are to date free of tumors. The fibula of patient in case 3 has been fitted with osseointegrated implants.

 

Discussion

Technical advances in radiotherapy have minimized the effects of tissue radiation although not completely eliminated it. Bone lesions can appear within a 3-month to 6-year time span.^4,5 Generally necrosis of the bone is accompanied by soft tissue necrosis which results in the exposure of the irradiated bone to intra- and extraoral conditions, contamination and infection.⁶ As a result of this, tissue healing becomes more complicated taking months or years, or it may never be achieved at all.⁷

Radionecrosis takes place typically in the jaw, due to its terminal type vascularization. The horizontal branch is where it is most frequently located and it is usually associated with necrosis of soft tissue areas, either skin or mucosa.⁸ Clinical presentation will consist principally in continuous and intense pain, together with suppuration, hemorrhage, trismus and pathologic fractures, especially if during the previous surgical intervention, a bone resection has been performed, osteosynthesis material placed, or if a considerable amount of the periosteum of the mandible has been removed.⁹ In our group marginal mandibulectomies had been carried out in two patients (cases 2 and 4) and osteosynthesis material had been placed in three patients (cases 1,2 and 4). Other factors related to etiopatogeny are the presence of teeth, repetitive infection of the periodontium, xerostomy, bad oral hygiene, and cigarette and alcohol abuse.⁶ Images of osteolysis were observed in the radiographic study. It normally extends further than the affected area, as it is only visible in radiological images when the bone has lost 30% of its mineralization.¹⁰

The best therapy with regard mandibular radionecrosis is prevention. In order to do this, there has to be a strict patient following, and rapid diagnosis of any bone exposure or necrosis of those patients undergoing radiotherapy. In this respect, an important role is played by the dentist in the care of these patients. A oral/dental program before and after radiotherapy can reduce complications. It should include, the extraction two weeks previously of any unhealthy teeth in the radiation area, oral hygiene, fluorization, and dental prostheses should not be placed nor should tooth extractions be made until a year later.^11,12

In the management of established ORN, hygienic measures should be intensified, local irritants avoided, and treatment given using a wide spectrum of long-term systematic antibiotics and strong, conventional analgesics/anti-inflammatory painkillers. Morphine derivatives should be used if necessary. However, this conservative treatment is ineffective in massive and progressive ORN, as occurred with the patients in our case study. Surgery is indicated when conservative measures have not produced results or when there are progressive and symptomatic lesions. At the time of carrying out surgical treatment (curettage, sequestrectomies, mandibular resections) there should be a minimum waiting period of three months following the last session.7 One has to take into account that bone vascularization is delicate and that any surgery, however limited, can result in a larger area of exposed or necrotic bone, and new micro-organisms can penetrate through this route, giving rise to progressive ORN. Therefore, conservative treatment of radionecrosis is usually advisable initially, providing there is patient collaboration, as treatment can be prolonged for months or even years.^5,13

Treatment can be attempted with a hyperbaric oxygen chamber, which serves to increase the concentration of oxygen in the bone, limiting necrosis. Although in specialized literature the benefits of its use have been demonstrated,^4,5,15 in our area this recourse is very limited due of difficulties regarding accessibility, cost and time. Nevertheless, in progressive and extensive ORN, as in the cases presented, the possibility of revitalizing necrotic bone and soft tissue is low.¹⁶ In massive ORN the need for carrying out some type of bone resection after completing conservative treatment including hyperbaric oxygen chamber, is situated in between 70 and 83% of cases.¹⁷ It is also indicated before the placement of osseointegrated implants,¹⁸ as occurred in case 3.

Surgical treatment of advanced ORN with massive necrosis of bone and soft tissue consists in mandibular resection, extirpation of adjacent skin or mucosa and reconstruction micro-vascularized free grafts.¹⁹ This requires an approach that allows for extensive resection of the mandible, a key issue for ensuring the desired surgical outcome. Radical surgical treatment includes the elimination of bony sequesters, resection of all necrotic bone up to apparently healthy bone and immediate reconstruction. If additionally ORN coexists with a fracture of the mandible, radical surgery and reconstruction with a vascularized flap²⁰ is a primary indication. Following these procedures is, however, not possible in all centers due to complexity, despite acceptance in the literature. Shaha and cols.¹³ uphold that microvascular reconstruction appears to accelerate bone healing due to vascular contribution and thus progress of ORN to the rest of the mandible is limited.

The advantages of the fibular osteoseptocutaneous free flap for the reconstruction of total or subtotal defects of the mandible, following resection after massive osteoradionecrosis, are numerous. These days, the superiority of vascularized micro-surgical flaps over other reconstruction systems, ^22,23,24 has been well established. And of all of them, the fibular osteoseptocutaneous flap has come out on top when associated with soft tissue defects.²¹ It allows for the inclusion of one or two skin paddles, if filling is needed for soft tissue so as to overlie intra- and/or extra orally.²⁵ Some authors have used a combination of two consecutive free flaps in large defects.^7,26 Recently we have published a new variant of the fibular osteoseptocutaneous flap together with a lateral supramalleolar skin paddle, ideal for composite defects where a large covering of soft tissue is required.²⁷ A good length of bone can be used (up to 25 cms) which has great resistance to the forces of mastication and multiple osteotomies can de carried out for tri-dimensional contouring. This allows the resected bone and soft tissue to be extended as far as is necessary. The fibular vessels have in addition suitable length and diameter for microsurgical anastomosis. Two teams can be used simultaneously and, despite needing skin grafts in the donor site in three of our cases, morbidity is minimal and leg function is not affected. In addition, there is enough bone for inserting osseointegrated implants and for rehabilitation with dental prostheses, as these patients are tumor free. In this group, our experience is limited to just one patient, as even though there was a possibility for the other two patients, they did not wish to undergo further surgery for reasons of age and good adaptation.

In short, ORN of the mandible entails considerable morbidity and the direction that therapy should take continues being a challenge. Although preventative measures are fundamental, the results of our group indicate that aggressive surgical treatment with extensive resection of necrotic bone, skin, or mucosa, and the immediate reconstruction with a fibular osteoseptocutaneous free flap, is a satisfactory alternative therapy in a few selected patients affected with massive ORN of the mandible. This flap allows including in its design one or two cutaneous paddles and for multiple osteotomies of the fibula in order to obtain a tri-dimensional shape. It also offers a sufficient quantity of bone that allows for the insertion of osseointegrated implants.

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