Osteoradionecrosis in osseous free flap reconstruction: Risk factors and treatment

Peter T Dziegielewski; Stewart Bernard; William M Mendenhall; Kathryn E Hitchock; Charles Parker Gibbs; Joy Wang; Robert J Amdur; Natalie L Silver; John Hardeman; Hadi Seikaly; William J Reschly; Deepa Danan; Raja Sawhney

doi:10.1002/hed.26118

Osteoradionecrosis in osseous free flap reconstruction: Risk factors and treatment

Head Neck. 2020 Aug;42(8):1928-1938. doi: 10.1002/hed.26118. Epub 2020 Mar 5.

Authors

Peter T Dziegielewski^{1

2

3}, Stewart Bernard^{1

3}, William M Mendenhall^{2

4

3}, Kathryn E Hitchock^{2

4

3}, Charles Parker Gibbs^{5

3}, Joy Wang^{6

3}, Robert J Amdur^{2

4

3}, Natalie L Silver^{1

2

3}, John Hardeman^{7

3}, Hadi Seikaly^{7

3}, William J Reschly^{1

3}, Deepa Danan^{1

3}, Raja Sawhney^{1

3}

Affiliations

¹ Department of Otolaryngology, University of Florida, Gainesville, Florida.
² University of Florida Health Cancer Center, Gainesville, Florida.
³ Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada.
⁴ Department of Radiation Oncology, University of Florida, Gainesville, Florida.
⁵ Department of Orthopedic Surgery, University of Florida, Gainesville, Florida.
⁶ Department of Restorative Dentistry, University of Florida, Gainesville, Florida.
⁷ Department of Oral and Maxillofacial Surgery, University of Florida, Gainesville, Florida.

PMID: 32134160
DOI: 10.1002/hed.26118

Abstract

Objective: To determine the rate and risk factors for osteoradionecrosis (ORN) in osseous free flaps after postoperative radiation therapy (PORT). To describe the treatment of free flap ORN.

Methods: Seventy-four patients undergoing osseous free flap reconstruction were analyzed. Thirty-eight completed PORT. Patients were followed for ≥6 months.

Results: The rate of ORN was 34% overall; 0% with 50 to 59.9 Gy; 8% with 60 Gy; 40% with 66 Gy; 56% with 70 to 74.4 Gy. Mean time to ORN was 13.1 months. 0/28 patients without PORT developed free flap osteonecrosis. Multivariate analysis found the only factor predicting ORN: PORT >60 Gy, which increased the risk 21-fold. Treatment included PENTACLO, hyperbaric oxygen, and surgical debridement with 75% within 2 years.

Conclusion: PORT >60 Gy is significantly associated with free flap ORN. As the dose of adjuvant RT increases beyond 60 Gy, the risk of ORN in free flaps rises. Consideration should be given to lower PORT doses or delaying free flap reconstruction when feasible.

Keywords: fibula free flap; free flap; head and neck cancer; osteoradionecrosis; radiation therapy.

MeSH terms

Free Tissue Flaps*
Humans
Mandibular Diseases* / surgery
Osteoradionecrosis* / etiology
Osteoradionecrosis* / surgery
Plastic Surgery Procedures*
Retrospective Studies
Risk Factors