Impact of preoperative and intraoperative management on outcomes in osteoradionecrosis requiring free flap reconstruction

Abstract

Background Perioperative management of advanced osteoradionecrosis of the head and neck requiring free flap (FF) reconstruction varies. Our objectives included assessment of practice patterns and outcomes. Methods Multi‐institutional, retrospective review of FF reconstruction for head and neck osteoradionecrosis (n = 260). Results Administration of preoperative antibiotics did not correlate with reduction in postoperative complications. Preoperative alcohol use correlated with higher rates of hardware exposure (p = 0.03) and 30‐day readmission (p = 0.04). Patients with FF compromise had higher TSH (p = 0.04) and lower albumin levels (p = 0.005). Prealbumin levels were lower in patients who required neck washouts (p = 0.02) or a second FF (p = 0.03). TSH levels were higher in patients undergoing postoperative debridement (p = 0.03) or local flap procedures (p = 0.04). Conclusion Malnutrition, hypothyroidism, and substance abuse correlated with a higher incidence of postoperative wound complications in patients undergoing FF reconstruction for advanced osteoradionecrosis. Preoperative antibiotics use did not correlate with a reduction in postoperative wound complications.

Outcomes after definitive surgery for mandibular osteoradionecrosis

“…19 A large multi-institutional sample found lower albumin, higher TSH, and substance abuse to be associated with higher rates of complications. 26 Our rates of partial and total flap failure (8%) for ORN were comparable to prior studies, ranging from 6% to 16%. 19,20 Longer time intervals between radiation and surgery and between diagnosis and surgery were found to be associated with increased risk of complications.…”

“…One study evaluating free tissue reconstruction in a matched sample of patients with and without ORN, found higher rates of local complications (47%) and the need for removal of hardware (45%) in the ORN cohort 19 . A large multi‐institutional sample found lower albumin, higher TSH, and substance abuse to be associated with higher rates of complications 26 . Our rates of partial and total flap failure (8%) for ORN were comparable to prior studies, ranging from 6% to 16% 19,20 …”

Risk factors for pathological fracture in patients with mandibular osteoradionecrosis

“…However, clinicians who treat ORN know that not all patients with ORN have serious symptoms. When ORN worsens, aggressive surgery such as mandibular resection and reconstruction with a vascularized free flap is often necessary 16 . The most common indication for aggressive surgery is a pathological fracture.…”

“…When ORN develops, patients suffer from severe pain, trismus and deterioration of esthetics such as oral cutaneous fistula. This further delays the rehabilitation of patients who have completed long-term cancer treatment 15 , 16 . In addition, mandibular ORN often results in pathological fractures as it progresses.…”

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

“…Malnutrition, hypothyroidism, anemia, vitamin deficiency, and substance abuse should be addressed to maximize healing and to minimize the development of more complications. 13 14 Speech-language pathology should be consulted to assist with oral intake and communication strategies. The ensuing priority is to biopsy any concerning lesions to exclude persistent or recurrent disease; however, occult recurrences can still occur.…”