Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction

BACKGROUND:  Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. METHODS:  This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. RESULTS:  Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). CONCLUSION:  Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.

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Among 85 irradiated head and neck reconstructions with free fibula flaps, adding flexor hallucis longus muscle (osteomyocutaneous, n=70) significantly reduced osteoradionecrosis or osteomyelitis versus osteocutaneous flaps (18.6% vs 46.7%, p=0.020), attributed to better vascularized coverage.

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