title: Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: 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.
authors.forename: Shih-Heng
authors.initials: SH
authors.lastname: Chen
authors.forename: Hung-Chi
authors.initials: HC
authors.lastname: Chen
authors.forename: Shyue-Yih
authors.initials: SY
authors.lastname: Horng
authors.forename: Hao-Chih
authors.initials: HC
authors.lastname: Tai
authors.forename: Jung-Hsien
authors.initials: JH
authors.lastname: Hsieh
authors.forename: Eng-Kean
authors.initials: EK
authors.lastname: Yeong
authors.forename: Nai-Chen
authors.initials: NC
authors.lastname: Cheng
authors.forename: Thomas Mon-Hsian
authors.initials: TM
authors.lastname: Hsieh
authors.forename: Hsiung-Fei
authors.initials: HF
authors.lastname: Chien
authors.forename: Yueh-Bih
authors.initials: YB
authors.lastname: Tang
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005360:Fibula / Q000637:transplantation*; D058752:Free Tissue Flaps; D006801:Humans; D007085:Ilium / Q000637:transplantation*; D007239:Infections / Q000453:epidemiology; D008297:Male; D008336:Mandibular Diseases / Q000601:surgery*; D008875:Middle Aged; D010025:Osteoradionecrosis / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology; D019651:Plastic Surgery Procedures; D014945:Wound Healing