Efficacy of small reconstruction plates in vascularized bone graft mandibular reconstruction

Is hardware colonization associated with latent hardware complications and removal in maxillomandibular free flap reconstruction?

BACKGROUND

The relationship between hardware colonization, latent hardware complications, and hardware removal remains unclear following osteocutaneous free flap reconstruction of the jaws.

METHODS

Retrospective cohort study of all patients undergoing free flap reconstruction of the maxilla or mandible from 2016 to 2021.

RESULTS

A total of 240 subjects were included. Hardware colonization was associated with latent hardware complication in bivariate (p ≤ 0.001) and multivariate analysis (p ≤ 0.001). Time to latent hardware complication was 6.87 months earlier in colonized subjects (p ≤ 0.001). Of the 35 subjects undergoing hardware removal, 25 initiated but failed conservative therapy, and resolution of symptoms was achieved in 24 subjects after one operative intervention and 33 subjects after repeat intervention if indicated.

CONCLUSIONS

Hardware colonization increases the risk and onset of latent hardware complication. Prompt hardware removal may improve outcomes by leading to faster resolution of symptoms without the burden and cost of conservative therapies.

Titanium Alloy Implants with Lattice Structures for Mandibular Reconstruction

In recent years, the field of mandibular reconstruction has made great strides in terms of hardware innovations and their clinical applications. There has been considerable interest in using computer-aided design, finite element modelling, and additive manufacturing techniques to build patient-specific surgical implants. Moreover, lattice implants can mimic mandibular bone's mechanical and structural properties. This article reviews current approaches for mandibular reconstruction, their applications, and their drawbacks. Then, we discuss the potential of mandibular devices with lattice structures, their development and applications, and the challenges for their use in clinical settings.

Outcome of Mandibular Reconstruction with Fibula free Flaps: Retrospective Analysis of Complications

Rationale: Fibula free flap has become the workhorse for head and neck reconstruction. In this retrospective study we aimed at determining the outcomes of mandibular reconstruction with fibula free flaps. Methods: Any patient who underwent a mandibulectomy and reconstructed with vascularised fibula flap was included in the study. The predictor variables were age, sex, type of lesion, tobacco and alcohol use, tracheostomy, neck dissection, post operative radio and chemotherapy. Flap failure, fistulas, dehiscence, bone exposure and hardware complications were the outcomes. A P value of < 0.05 was considered statistically significant. Results: 242 patient records were selected for evaluation. PORT, CRT, neck dissection, no. of segments were the factors significantly associated with every complication. Malignant lesion was significantly associated with every complication except for plate fracture. Plate fracture although occurred more frequently with malignant diseases, the association was insignificant. Tobacco consumption was significantly associated with increased incidence of post -operative complications. Alcohol consumption was significantly associated with plate fracture, screw loosening, fistulas, bone exposure and flap failure. Conclusion: Overall the fibula free flap has a success rate of 90.0% with fistulas being the most significant complication.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03344-2.

Managing Oromandibular Hardware Failure after Free Flap Surgery

Hardware failure after oromandibular reconstruction using free tissue transfer can delay additional therapies directed at cancer treatment and prevent patients from returning to normal oral function. Understanding and strict adherence to principles of rigid fixation is critical in preventing complications. Early surgical intervention for hardware exposure as well as utilization of locoregional flaps may prevent the need for more extensive revision surgery.

Finite element analysis of different internal fixation methods for the treatment of atrophic mandible fractures

The aim of this study is to evaluate different plate systems and contribute to revealing the most appropriate treatment option for severe atrophic edentulous mandible fractures. A total of 8 different types of rigid internal fixation methods, which were a 4-hole miniplate on the crest, a 4-hole miniplate on the basis, a 6-hole miniplate on the crest, a 6-hole miniplate on the basis, two 4-hole mini plates on both the crest and basis, two 6-hole mini plates on both crest and basis, a 6-hole reconstruction plate on the crest and a 6-hole reconstruction plate on the basis, were simulated. Stress analysis on plates and screws and the displacement between fragments were evaluated using finite element analysis. The lowest von Mises stress was observed on the basis plate in Group 6. The highest von Mises stresses were measured on the screws closes to the fracture line. Values exceeding the boundary conditions were observed only in Groups 3 and 4 under molar loading. The highest compressive stresses were measured in Group 1, and the lowest compressive stresses were measured in Group 6. Under molar loading, the highest displacement was observed in Group 3, and the lowest displacement was observed in Group 6. When all groups are evaluated in terms of stress distributions and stability, a 1.5 mm thick six-hole reconstruction plate can be a reliable method in the treatment of severe atrophic edentulous mandible fractures.

Risk factors associated with fixation-related complications in microsurgical free flap reconstruction of the mandible

BACKGROUND

Hardware complications (loosening of screws, infection, or exposure of the plate) in mandibular reconstruction with vascularized osseous free flaps impose significant morbidity, and frequently require revision surgery. Purpose of this study was to identify possible contributing factors for hardware complications.

METHODS

This is a retrospective cohort study involving case series of patients who underwent microvascular mandible reconstructions between 2000 and 2020. Patient demographics, pathological, clinical, and treatment-related factors were analyzed in univariate and multivariate analyses.

RESULTS

Ninety-one patients were enrolled, encompassing 63 reconstructions with fibular free flaps, 26 reconstructions with scapular, and 2 reconstructions with iliac flaps. Rate of hardware complications and plate exposure was 14.3% and 7.7%, respectively, with a median follow-up time for extrusion of 29 months. In univariate analysis, preoperative radiotherapy (odds ratio [OR] = 6.57, p = .01), and secondary mandible reconstruction (OR = 4.3, p = .04) were significant predictors of hardware complications, and plate exposure was most frequently found in secondary reconstruction (37.5%, OR = 11.8, p = .04). Hypertension was the most commonly found comorbidity (24%), and it trended toward significance regarding plate exposure (p = .05). Only secondary mandible reconstruction was associated with osteosynthesis complications (OR = 12.53, p = .01) and plate exposure (OR = 23.86, p = .005) on multivariate analysis, while preoperative radiation therapy did not retain its relevance on plate exposure.

CONCLUSION

Secondary mandible reconstructions with vascularized osseous free flaps have a higher risk of osteosynthesis complications than primary reconstructions.

Benefits of Patient-Specific Reconstruction Plates in Mandibular Reconstruction Surgical Simulation and Resident Education

Poorly contoured mandibular reconstruction plates are associated with postoperative complications. Recently, a technique emerged whereby preoperative patient-specific reconstructive plates (PSRP) are developed in the hopes of eliminating errors in the plate-bending process. This study’s objective is to determine if reconstructions performed with PSRP are more accurate than manually contoured plates. Ten Otolaryngology residents each performed two ex vivo mandibular reconstructions, first using a PSRP followed by a manually contoured plate. Reconstruction time, CT scans, and accuracy measurements were collected. Paired Student’s t-test was performed. There was a significant difference between reconstructions with PSRP and manually contoured plates in: plate-mandible distance (0.39 ± 0.21 vs. 0.75 ± 0.31 mm, p = 0.0128), inter-fibular segment gap (0.90 ± 0.32 vs. 2.24 ± 1.03 mm, p = 0.0095), mandible-fibula gap (1.02 ± 0.39 vs. 2.87 ± 2.38 mm, p = 0.0260), average reconstruction deviation (1.11 ± 0.32 vs. 1.67 ± 0.47 mm, p = 0.0228), mandibular angle width difference (5.13 ± 4.32 vs. 11.79 ± 4.27 mm, p = 0.0221), and reconstruction time (16.67 ± 4.18 vs. 33.78 ± 8.45 min, p = 0.0006). Lower plate-mandible distance has been demonstrated to correlate with decreased plate extrusion rates. Similarly, improved bony apposition promotes bony union. PSRP appears to provide a more accurate scaffold to guide the surgeons in assembling donor bone segments, which could potentially improve patient outcome and reduce surgical time. Additionally, in-house PSRP can serve as a low-cost surgical simulation tool for resident education.

Unicortical Bone Necrosis of the Fibula Free Flap Associated to the Fixation with a Nonlocking 2.0-mm Reconstruction Plate and Screws

The authors present a unique case of osteonecrosis of a cortical half of a fibula free flap that has not been reported in the literature yet. This complication was associated with the impairment of the vascularization of periosteum in the cortical half of fibula that was fixated with a nonlocking reconstructive 2.0-mm plate and screws but other factors could have been involved. The patient was submitted to excision of a cemento-ossifying fibroma that resulted in a left hemimaxilectomy mesoinfrastructure defect classified as the Cordeiro type 2B. The 42-year-old female patient was submitted to reconstruction with an osteomusculocutaneous fibula free flap plus a segment of fibula graft. The two bone segments of the free flap used to reconstruct the anterior and left alveolar crest were fixated with a reconstructive 2.0-mm plate of matrixMANDIBLE system. The only reported complication was an oronasal fistula that healed with conservative treatment and the referred osteonecrosis of the external cortical half of the fibula free flap with plate exposure at 2.5 years postoperatively. Surgical excision of the osteonecrosed cortical half of the fibula with the plate and screws was performed, while the other cortical underwent bone union as corroborated by computed tomography scans.

Association of Plate Contouring With Hardware Complications Following Mandibular Reconstruction

OBJECTIVES/HYPOTHESIS

Despite considerable effort being dedicated to contouring reconstruction plates, there remains limited evidence demonstrating an association between contour and reconstructive outcomes. We sought to evaluate whether optimizing mandibular reconstruction plate contouring is associated with reduced postoperative hardware complications.

STUDY DESIGN

Retrospective cohort study.

METHODS

A cohort study was performed with adult patients (age ≥18 years) who underwent mandibulectomy and osseous free flap reconstruction following oncologic ablation at the University Health Network in Toronto, Canada, between January 1, 2003 and December 31, 2014. Patients with computed tomography scans performed within 1 year of reconstruction were included. Computer-based three-dimensional models were generated and used to calculate the mean plate-to-bone gap (mm). The primary outcome was plate exposure. Secondary outcome included a composite of plate exposure or intraoral dehiscence. Logistic regression models were fitted for each outcome accounting for other patient and surgical characteristics associated with the primary outcome.

RESULTS

Ninety-four patients met inclusion criteria, with a mean age of 60.4 (standard deviation [SD] 14.9). The mean follow-up time was 31.4 months (range 3-94). Reconstruction was performed with fibular (57%) and scapular free flaps (43%). In the multivariable model, small mean plate-to-bone gap (<1 mm) was independently associated with 86% reduced odds of plate exposure (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.02-0.55). Mean plate-to-bone gap less than 1 mm was also independently associated with reduced odds of developing a composite of plate exposure or intraoral dehiscence (OR, 0.29; 95%CI, 0.11-0.75).

CONCLUSION

Optimizing plate contouring during mandibular reconstruction may decrease the development of postoperative hardware complications.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Risk Factors for Plate Extrusion After Mandibular Reconstruction With Vascularized Free Flap

PURPOSE

Plate extrusion after mandibular reconstruction is a complication that imposes significant morbidity on the patient. The goal of this study is to estimate the incidence of plate extrusion after mandible reconstruction with a vascularized free flap and to identify the factors associated with plate extrusion.

METHODS

This was a retrospective cohort study involving patients who underwent mandibular reconstruction from October 2008 to July 2019 at LAC + USC or Keck Hospital of USC. Inclusion criteria were age ≥ 18 years, single-stage mandibular reconstruction with vascularized free flap, and follow-up of at least 12 months. Relevant demographic, intraoperative, and postoperative data were collected. The primary outcome was postoperative plate extrusion within the 12-month follow-up. Descriptive, univariate, and multivariate analyses were performed. Statistical significance was set at P ≤ .05.

RESULTS

A total of 102 patients were included in this study. The majority received a fibula free flap (90%) for a malignant neoplasm (76%). All patients had at least 12 months of follow-up. The rate of plate extrusion was 16%, with the majority of those patients undergoing plate removal (69%). After adjusting for postoperative fistula, soft tissue, and length of hospitalization, we found that any history of smoking (odds ratio = 12.8; confidence interval, 1.57 to 104.2), number of osteotomies (odds ratio 3.07; confidence interval, 1.09 to 8.6), flap nonviability (odds ratio = 18.2; confidence interval, 2.22 to 148.8) were associated with plate extrusion on multivariate analysis. Postoperative soft tissue infection approached significance.

CONCLUSIONS

This study demonstrates that smoking history, number of osteotomies, and flap nonviability are associated with plate extrusion after mandible reconstruction. Performing fewer osteotomies when possible to avoid excessively small flap bone segments and minimizing postoperative complications may improve long-term outcomes after mandibular reconstruction.

Fibula free flap in maxillomandibular reconstruction. Factors related to osteosynthesis plates' complications

The aim of this paper is to identify risk factors associated with the development of osteosynthesis plates' related complications in fibula free flap reconstructions. This is a case series study of consecutive fibula free flaps. Clinical and radiological variables were recorded. Patient outcomes were evaluated with special attention to osteosynthesis plates' related complications; these included plate exposure, plate fracture, loosening of screws, non-union, bone resorption, oro-cutaneous fistulas, and bone exposure. We have done a descriptive analysis, univariate analysis, and multivariate logistic regression model to explore possible risk factors for osteosynthesis plates' related complications. Data analysis was performed using R software (version 3.5.0). 111 fibula free flaps were studied. 29 patients (26.1%) developed osteosynthesis plates' related complications. The mean time to osteosynthesis plates' related complications was 22 months; range (1-120); the median and mode were 12 months. Patients with preoperative radiotherapy (34% vs 14%, p = 0.021), and secondary reconstruction (31% vs 15%, p = 0.053) had a higher incidence of osteosynthesis plates' related complications. In the univariate analysis, "preoperative radiotherapy" (OR 3.07, 95%CI = 1.139-8.242, p = 0.025) and "extraoral soft-tissue defect" (OR 2.907, 95%CI = 1.032-8.088, p = 0.042) were risk factors for osteosynthesis plates' related complications. We have observed an interaction effect: patients with mandibular Brown's classes III + IV and "secondary reconstruction" have a higher risk for osteosynthesis plates' related complications; more than 47.30 times compared to Brown's class I and "primary reconstruction" (p = 0.026). Different factors may contribute to the development of osteosynthesis plates' related complications. Our study adds important information about these. Patients with higher risk of developing complications should be informed that a second intervention to remove the plates might be necessary.

Evaluation of a novel osteosynthesis plate system for mandibular defects

Continuity defects of the jaw can be reconstructed with titanium plates or microvascular bone flaps; osteosynthesis plates are necessary for both. In this study we performed a retrospective review of patients treated with Medartis MODUS® Mandible Trauma/Reco 2.0-2.5, TriLock bridging plates, mandibulectomy and soft tissue free flap or reconstruction with a bony free flap and TriLock mandibular plates from the same system from January 2015 to August 2019. The variables recorded were sex, age, diagnosis, radiotherapy, date of implantation, date of explantation or death of patient, size of mandibular defect, Jewer classification of defect, number of screws used, segments of bony reconstruction, screws per segment, plate exposure, plate breakage, and pseudarthrosis. The bridging plate group consisted of 41 patients, while the mandibular plate group consisted of 24 patients. The percentage of plate exposure was 17.07% for the bridging plate group and 4.17% for the mandibular plate group. Plate breakage was 0 in both groups. Pseudarthrosis was 4.17% in the mandibular plate group. In the bridging plate group, an anterolateral thigh flap covered all exposures. Of 7 plate exposures, 4 were found in a C defect. The complication rate of the investigated plates was lower than the complication rates of other plate systems.

Miniplates Versus Reconstruction Bars for Oncologic Free Fibula Flap Mandible Reconstruction

PURPOSE

The free fibula is the flap of choice for reconstructing most segmental mandibular defects resulting from head and neck resections. The use of miniplates or reconstruction bars for fixation has been described in the literature. We wanted to compare outcomes between the 2 methods of fixation in head and neck cancer patients.

PATIENTS AND METHODS

An IRB approved retrospective review of 25 consecutive patients undergoing free fibula flap reconstruction of the mandible for head and neck cancer over a period of 5 years was performed. Patient demographics, risk factors, number of fibula osteotomies, defect length, and clinical outcomes were noted. Fourteen patients were reconstructed with miniplates and 12 with reconstruction bars. The choice of plate fixation was determined by the individual reconstructive surgeon. Wound complications requiring surgery and hardware removal rate were recorded.

RESULTS

Average follow-up was 27 months. There was no significant difference with regard to age (P = 0.67), sex (P = 0.77), smoking (P = 0.63), neoadjuvant radiation (P = 0.47), number of osteotomies (P = 0.99), or defect length (P = 0.95) between the 2 groups. Of the 4 patients requiring hardware removal for infection or persistent symptoms, all were in the miniplate group (P = 0.05). Other clinical outcomes, such as hematoma, wound dehiscence, infection, fistula formation, and osteoradionecrosis were comparable between the 2 groups without significant differences. The overall complication rate was similar as well (P = 0.25).

DISCUSSION

Different from other reports in the literature, we show that miniplate use resulted in more hardware removal for infection or persistent symptoms, and this was statistically significant while controlling for patient demographics, risk factors, number of osteotomies, and defect length. Much like other reports in the literature, however, there is no statistically significant difference in overall complication rates, and all other specific complications, when using miniplates versus reconstruction bars. The decision to use miniplates versus reconstruction bars remains a clinical one. In our experience, for 0 to 1 osteotomy, a reconstruction bar suffices. For multiple osteotomies, however, miniplates allow for more customization.

Surgical site infections following oral cavity cancer resection and reconstruction is a risk factor for plate exposure

Background

Plate-related complications following head and neck cancer ablation and reconstruction remains a challenging problem often requiring further management and reconstructive surgeries. We aim to identify an association between surgical site infections (SSI) and plate exposure.

Methods

A retrospective study between 1997 and 2014 was performed to study the association between postoperative SSI and plate exposures. Eligible patients included those with a history of oral squamous cell carcinoma who underwent surgical resection, neck dissection, and free tissue reconstruction. Demographic and treatment related information was collected. SSI were classified based on CDC definition and previously published literature. Univariable analysis on demographic factors, smoking history, diabetes, radiation, surgical and hardware related factors; while multivariable analysis on SSI, plate height, segmental mandibulectomy defects and radiation were conducted such as using cox proportional hazard models.

Results

Three hundred sixty-five patients were identified and included in our study. The mean age of the study group was 59.2 (+/−13.8), with a predominance of male patients (61.9%). 10.7% of our patient cohort had diabetes, and another 63.8% had post-operative radiation therapy. Patients with SSI were more likely to have plate exposure (25 vs. 6.4%, p <0.001). Post-operative SSI, mandibulectomy defects, and plate profile/thickness were associated with plate exposure on univariable analysis (OR = 5.72, p < 0.001; OR = 2.56, p = 0.014; OR = 1.44, p = 0.003 respectively) and multivariable analysis (OR = 5.13, p < 0.001; OR = 1.36, p = 0.017; OR = 2.58, p = 0.02 respectively).

Conclusion

Surgical site infections are associated with higher rates of plate exposure. Plate exposure may require multiple procedures to manage and occasionally free flap reconstruction.

Evaluation of plate-related complications and efficacy in fibula free flap mandibular reconstruction

AIM

The objective of this study was to evaluate the incidence of plate-related complications after vascularized bony reconstruction of the mandible, comparing the plate type used.

PATIENTS AND METHODS

Between 2004 and December 2012, a total of 41 free osteocutaneous fibula flaps have been used in an equal number of patients for reconstruction of the mandible, at the Division of Maxillofacial surgery, San Giovanni Battista Hospital, University of Turin. Malignant pathology was the most common indication for segmental mandibulectomy.Patient outcomes were retrospectively evaluated with special attention to plate complications such as plate fracture, exposure, infection, and bony nonunion.The types of reconstruction plates used were mandible plates 2.0, locking plates 2.0, miniplates (<2.0), and locking 2.4 plates.

RESULTS

Mandible plates 2.0 were used in 14 patients, locking plates 2.0 in 12 patients, and locking 2.4 plates in 4 patients. The most commonly used plates were miniplates, which were used in 86 patients.A total of 5 plate complications occurred after 41 procedures in an equal number of patients.Two complications occurred in patients receiving 2.0 mandible plates (2/14). One complication occurred in patients receiving 2.0 locking plates (1/12). Two complications occurred in patients receiving miniplates (2/86).

CONCLUSIONS

In our experience, miniplates are not associated to a high rate of complications comparing to other plates. The advantage of these plates and the low rate of complications make them our first choice for mandibular reconstructions.

Surgical Management of Edentulous Atrophic Mandible Fractures in the Elderly

Fractures of the mandible occur with a greater frequency in the elderly. This study reports three cases of edentulous atrophic mandible fracture in elderly patients treated with open reduction technique. Three patients who presented with edentulous atrophic mandible fractures underwent surgical management using open reduction and internal fixation. After treatment, clinical evaluations and postoperative complications were examined with postoperative x-ray. Patients were followed with clinical and radiographic examinations. In the postoperative clinical evaluation, two male patients healed well, but one female patient complained of pain and swelling. In radiographic examinations, no union delay or lack of fusion was observed in the edentulous area. Open reduction technique is a viable treatment option for the edentulous atrophic mandible fractures in geriatric patients.

Hardware removal after osseous free flap reconstruction

OBJECTIVE

Identifying risk factors for hardware removal in patients undergoing mandibular reconstruction with vascularized osseous free flaps remains a challenge. The purpose of this study is to identify potential risk factors, including osteocutaneous radial forearm versus fibular flap, for need for removal and to describe the fate of implanted hardware.

STUDY DESIGN

Case series with chart review Setting Academic tertiary care medical center.

SUBJECTS AND METHODS

Two hundred thirteen patients undergoing 227 vascularized osseous mandibular reconstructions between the years 2004 and 2012. Data were compiled through a manual chart review, and patients incurring hardware removals were identified.

RESULTS

Thirty-four of 213 evaluable vascularized osseous free flaps (16%) underwent surgical removal of hardware. The average length of time to removal was 16.2 months (median 10 months), with the majority of removals occurring within the first year. Osteocutaneous radial forearm free flaps (OCRFFF) incurred a slightly higher percentage of hardware removals (9.9%) compared to fibula flaps (6.1%). Partial removal was performed in 8 of 34 cases, and approximately 38% of these required additional surgery for removal.

CONCLUSION

Hardware removal was associated with continued tobacco use after mandibular reconstruction (P = .03). Removal of the supporting hardware most commonly occurs from infection or exposure in the first year. In the majority of cases the bone is well healed and the problem resolves with removal.

Multidisciplinary approach to cancer treatment: focus on head and neck cancer

This article focuses on squamous cell carcinoma of the head and neck (SCCHN), the most common malignancy of the head and neck area. Early detection limits morbidity of treatment and increases the chances of a cure. The treatment of SCCHN is often multidisciplinary in nature and provides a model for how multimodality therapy may be applied for optimal patient management. The role of surgery in SCCHN is continually undergoing evolution, and the surgeon's role in the multidisciplinary treatment of head and neck cancers has changed as more cancers are being treated by chemoradiotherapy. Salvage surgery has become more common, and with it the increased challenges in managing metastatic disease to neck nodes as well as managing failure of organ preservation treatments. Surgeons continue to develop and refine reconstruction techniques to optimize cosmetic and functional outcomes.