Management of pathologic fractures of the mandible secondary to osteoradionecrosis.

OBJECTIVE To review our experience with late Marx stage III osteoradionecrosis (ORN) of the mandible in patients who present with pathologic fracture. STUDY DESIGN Case series with chart review. SETTING Tertiary care center. SUBJECTS AND METHODS Thirty-seven patients were identified from June 1998 to August 2010 who underwent treatment of Marx grade III osteoradionecrosis with pathologic fracture of the mandible. All patients underwent reconstruction with osteocutaneous free tissue transfer and when possible underwent hyperbaric oxygen therapy Marx protocol. RESULTS The average time between completion of radiation therapy and presentation of ORN-induced pathologic fracture was 3.2 years. Sixteen patients developed ORN following tooth extraction. Sixteen patients had no previous documented ORN prior to presenting with pathologic fracture. Follow-up after surgery averaged 4.5 years with no recurrence of disease. The overall complication rate was 24% with no total flap loss. Of the patients, 95% returned to prefracture dietary intake. Twenty-six patients underwent a staged protocol, in which after resection and plate reconstruction, they underwent 20 hyperbaric oxygen (HBO) dives. They then underwent free tissue transfer followed by a further 10 HBO dives. There were no flaps lost or nonbony unions. Eleven patients did not receive HBO therapy as part of their surgical treatment plan. Again, there was no total flap loss, but 2 skin paddles were lost and 4 bony nonunions occurred. CONCLUSIONS Pathologic fracture in conjunction with ORN has a relatively high treatment complication rate. Free tissue transfer and HBO are the treatment of choice for this population.