Osteoradionecrosis in osseous free flap reconstruction: Risk factors and treatment

Abstract

ObjectiveTo 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.MethodsSeventy‐four patients undergoing osseous free flap reconstruction were analyzed. Thirty‐eight completed PORT. Patients were followed for ≥6 months.ResultsThe 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.ConclusionPORT >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.

Flap delineation guidelines in postoperative head and neck radiation therapy for head and neck cancers

“…The therapeutic implication is that if lack of or low dose irradiation to the flap body is not associated with a higher risk of local failure than when irradiating the whole flap body at a tumoricidal dose, toxicity may be decreased by irradiating the tissue-flap junction only [33]. Previous studies are limited in terms of accurate definition of flap delineation.…”

Current Role of Radiotherapy in the Management of Oral Cavity Squamous Cell Carcinoma

“…Dziegielewski et al reported on 74 patients who underwent osseous free flap reconstruction; 38 competed PORT. 10 Patients were followed for 6 months or more. The incidence of ORN was 0 for 28 patients who did not receive PORT.…”

“…27,29 A problem increasingly encountered is a patient who has undergone free flap reconstruction, such as a fibular free flap (FFF), who has very adverse prognostic factors. 10 Doses more than 60 Gy may increase the risk of ORN and doses of 60 Gy or less may increase the risk of a local-regional recurrence which would likely be fatal. The choice is to avoid complex free flap reconstructions in patients likely to require POCRT doses > 60 Gy or to accept a higher risk of ORN and/or fatal local-regional recurrence.…”

“…6 –9 More recently, the widespread use of free flap reconstruction has impacted the treatment planning of PORT/POCRT to reduce the likelihood of complications. 10 –12 Following is a review of the current role of RT in the management of oral cavity SCC.…”

Rates of osteoradionecrosis in resected oral cavity cancer reconstructed with free tissue transfer in the intensity‐modulated radiotherapy era

“…Among 74 patients with head and neck cancer undergoing osseous free flaps and postoperative RT not limited to IMRT, an ORN rate of 34% was reported. 18 Wang et al reported a 47% incidence of ORN in 15 patients treated with osteocutaneous fibula flap who underwent postoperative RT. 19 The incidence of ORN in reconstructed versus native mandibles and the identification of risk factors have not been formally evaluated.…”