Early-onset osteoradionecrosis following adjuvant volumetric-modulated arc therapy to an osteocutaneous free fibula flap with customized titanium plate - 25/12/21

Doi : 10.1016/j.jormas.2021.12.004

David A. Daar ^a, David J. Byun ^b, Karl Spuhler ^b, Lavinia Anzai ^a, Lukasz Witek ^c, David Barbee ^b, Kenneth S. Hu ^b, Jamie P. Levine ^a, Adam S. Jacobson ^d,^⁎
^a Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 222 East 41st Street, New York, NY 10017, United States
^b Department of Radiation Oncology, New York University Langone Health, 160 E 34th St. 2nd floor, New York, NY 10016, United States
^c Department of Biomaterials, New York University College of Dentistry, 433 First Ave., Room 842, New York, NY 10010, United States
^d Department of Otolaryngology-Head and Neck Surgery, New York University Langone Health, 160 E 34th St. 7th floor, New York, NY 10016, United States

^⁎Corresponding author.

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Abstract

Background

Computerized surgical planning (CSP) in osseous reconstruction of head and neck cancer defects has become a mainstay of treatment. However, the consequences of CSP-designed titanium plating systems on planning adjuvant radiation remains unclear.

Methods

Two patients underwent head and neck cancer resection and maxillomandibular free fibula flap reconstruction with CSP-designed plates and immediate placement of osseointegrated dental implants. Surgical treatment was followed by adjuvant intensity modulated radiation therapy (IMRT).

Results

Both patients developed osteoradionecrosis (ORN), and one patient had local recurrence. The locations of disease occurred at the areas of highest titanium plate burden, possibly attributed to IMRT dosing inaccuracy caused by the CSP-designed plating system.

Conclusion

Despite proven benefits of CSP-designed plates in osseous free flap reconstruction, there may be an underreported risk to adjuvant IMRT treatment planning leading to ORN and/or local recurrence. Future study should investigate alternative plating methods and materials to mitigate this debilitating outcome.

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Keywords : Computerized surgical planning, Radiation, Fibula flap, Osteoradionecrosis