Mandible Vascularized Bone Graft Reconstruction Successful in BRONJ

Does vascularized bone reconstruction provide optimum reconstruction among patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ)?

Background: Bisphosphonates, a commonly prescribed class of medications used in the treatment of multiple myeloma and metabolic and metastatic bone disease, decrease bone resorption via inhibition of enzyme activity within osteoclasts. Remaining in the bone for several years, bisphosphonates can cause an avascular osteonecrosis, loss of bone matrix and accumulation of nonviable osteocytes.

Study design: Multi-institutional retrospective review

Setting: Head and Neck Institute at Cleveland Clinic; the Department of Otolaryngology-Head and Neck Surgery at the University of Washington Medical Center, Seattle

Synopsis: The researchers evaluated 11 patients undergoing mandible reconstruction with vascularized bone grafts after segmental mandible resection with BRONJ. The majority of patients had been treated with IV bisphosphonate. Two had intractable pain, four had a preoperative fistula and eight had BRONJ-related pathologic mandible fraction. A reconstruction plate was used in all cases, with two to three screws used per fibula segment and one to three osteosyntheses. A skin paddle was used in all cases, and there were no flap failures. Radiographic evidence of union suggested viable bone at the margin of resection with clearance and nonrecurrence of BRONJ. All patients had resolution of symptoms. There was a high rate of fistula and chronic infection, however.

Bottom line: The use of fibula free flap microsurgical mandibular reconstruction is feasible and effective in the resolution of advanced, refractory BRONJ and its complications.

Citation: Seth R, Futran ND, Alam DS, et al. Outcomes of vascularized bone graft reconstruction of the mandible in bisphosphonate-related osteonecrosis of the jaws. Laryngoscope. 2010;120(11):2165-2171.

—Reviewed by Sue Pondrom