Chen Shih-Heng, Chen Hung-Chi, Horng Shyue-Yih, Tai Hao-Chih, Hsieh Jung-Hsien, Yeong Eng-Kean, Cheng Nai-Chen, Hsieh Thomas Mon-Hsian, Chien Hsiung-Fei, Tang Yueh-Bih
From the *Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY; †Department of Plastic Surgery, China Medical University Hospital, Taichung City; and ‡Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan.
Ann Plast Surg. 2014 Sep;73 Suppl 1:S18-26. doi: 10.1097/SAP.0000000000000270.
Osteoradionecrosis (ORN) of the mandible is not an uncommon complication after radiotherapy for head and neck cancers. Although definitive treatment has been confirmed as radical excision of the necrotic bone with simultaneous vascularized osteocutaneous flap reconstruction, it remains a unique challenge. In this study, we compare our results of reconstruction with free iliac and fibula flaps in flap survival, bony union, and postoperative complications.
From 1986 to 2011, there were 153 mandibular ORN cases in our center that were treated with radical resection of the necrotic bone and reconstruction with either vascularized iliac (n=108) or fibula flaps (n=45). Data collected for analysis included patient demographics, flap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use.
All patients healed eventually without recurrence of ORN. However, we observed difference in the complication rate between the iliac flap group and fibula flap group. In the group with iliac flap reconstruction, patients required less days of hospital stay for intravenous antibiotics treatment postoperatively. The average days required for intravenous antibiotics in the iliac flap group were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P<0.01). In the group with fibula flap reconstruction, 9 (20.0%) patients had subsequent neck infection due to healing problem, compared to 8 (7.4%) patients in the iliac flap group (P=0.04). In the iliac flap group, the nonunion and malunion rates were 4.6% and 2.8% respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (P=0.04 and 0.36, respectively).
For ORN patients, vascularized iliac bone flap provides more reliable results compared to fibula flap. The merits of vascularized iliac flap include the following: (1) its natural curve mimics the shape of mandible and does not need osteotomy; (2) it offers more volume of bone that matches better to the native mandible to allow later osteointegration as well as faster bony union, due to the nature of being a membranous bone; and (3) it carries more abundant soft tissue to obliterate possible dead space. The only disadvantages are short pedicle and requiring special management of skin paddle, which can be overcome by training in microsurgery.
下颌骨放射性骨坏死（ORN）是头颈部癌症放疗后一种并不罕见的并发症。尽管已确认确定性治疗为坏死骨的根治性切除并同时进行带血管蒂骨皮瓣重建，但这仍然是一项独特的挑战。在本研究中，我们比较了游离髂骨瓣和腓骨瓣重建在皮瓣存活、骨愈合及术后并发症方面的结果。
1986年至2011年，我院中心有153例下颌骨ORN患者接受了坏死骨的根治性切除，并用带血管蒂的髂骨瓣（n = 108）或腓骨瓣（n = 45）进行重建。收集用于分析的数据包括患者人口统计学资料、皮瓣存活率、术后感染率、骨不连/骨畸形愈合率、平均住院时间及抗生素使用情况。
所有患者最终均愈合，ORN无复发。然而，我们观察到髂骨瓣组和腓骨瓣组在并发症发生率上存在差异。在髂骨瓣重建组，患者术后静脉使用抗生素治疗的住院天数较少。髂骨瓣组静脉使用抗生素的平均天数为10.46（2.28）天，而腓骨瓣组为16.09（3.88）天（P < 0.01）。在腓骨瓣重建组，9例（20.0%）患者因愈合问题继发颈部感染，而髂骨瓣组为8例（7.4%）患者（P = 0.04）。在髂骨瓣组，骨不连和骨畸形愈合率分别为4.6%和2.8%；而在腓骨瓣组，这两个比率分别为15.5%和6.6%（分别为P = 0.04和0.36）。
对于ORN患者，带血管蒂的髂骨瓣比腓骨瓣能提供更可靠的结果。带血管蒂髂骨瓣的优点如下：（1）其天然曲线模仿下颌骨形状，无需截骨；（2）由于其为膜性骨的性质，它提供更多的骨量，与天然下颌骨更匹配，利于后期骨整合以及更快的骨愈合；（3）它携带更丰富的软组织以消除可能的死腔。唯一的缺点是蒂短以及需要对皮瓣进行特殊处理，这可通过显微外科培训来克服。
