Advancing Education, Research, and Quality of Care for the Head and Neck oncology patient.
Background: Osteoradionecrosis (ORN) is a complication of radiation therapy (RT) which can lead to compromised mandibular and/or maxillary bone in head and neck cancer (HNC) patients. For severe disease, including pathologic fracture, surgical resection of the involved bone with reconstruction is often warranted. This study aimed to evaluate outcomes of patients who underwent free or local flap reconstruction for ORN of the mandible or maxilla and preoperative factors that may impact postoperative healing.
Methods: This single-institution study retrospectively reviewed patients who underwent primary surgery and adjuvant RT for HNC, and subsequently developed ORN requiring mandibular or maxillary reconstruction between 2014 and 2020. Variables of interest included prior management of ORN (vitamin E, trental, and HBO), smoking status, comorbidities including osteopenia/osteoporosis, diabetes, and hypothyroidism, RT dosing, time from RT to development of ORN, reconstructive tissue used for ORN resection (soft tissue vs bony reconstruction), and length of ischemia time during reconstruction. The primary outcomes were recurrence of ORN following reconstruction, fistula formation, and flap failure. Uni- and multivariate logistic regression were used for data analysis.
Results: 44 patients including 29 (65.9%) men underwent local (4.5%) or free flap (95.5%) reconstruction for ORN. 90.9% of patients underwent reconstruction of the mandible, while 9.1% underwent reconstruction of the maxilla. The mean follow up time was 6.8 years (SD 3.5). 29.1% underwent oncologic segmental or marginal mandibulectomy. Most patients (84.1%) did not require bony reconstruction following initial oncologic resections. The average time from adjuvant RT to ORN diagnosis was 5.22 years (SD 4.9), while time from ORN diagnosis to definitive surgical intervention was 1.37 years (SD 2.2). Surgical reconstruction for ORN included 24 fibular, 11 scapular, 5 anterolateral thigh, 2 radial forearm free flaps, and 2 pectoralis major rotational flaps. 16 patients (36.4%) developed recurrence of ORN, 8 (18.2%) developed a fistula and 6 (13.6%) experienced free flap failure. There was no association (p>0.05) between any preoperative comorbidity, operative reconstructive choice, or time from RT to ORN and rates of ORN recurrence, fistula formation, or flap failure.
Conclusion: Our cohort demonstrates the heterogenous clinical course of ORN with no specific factor leading to a statistically significant impact on recurrence of ORN, fistula formation, or flap failure. Despite the evolution of complex reconstructive surgeries for patients with ORN, the optimal treatment option continues to be challenging and requires unique planning for each individual patient. Larger cohort studies are needed to understand the best long-term reconstructive paradigm for patients with ORN.