Indicates sessions with Audience Response Systems (ARS) or Poll Everywhere available
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Indicates sessions with recordings available for purchase.Mark E. Turner DDS, Lee C. Kojanis DDS, Nimal C. Tejwani MD, Jamie Levine MD, Kenneth E. Fleisher DDS
The fibula microvascular free flap is widely used for mandible reconstruction including patients with medication-related osteonecrosis of the jaw (MRONJ) who are refractory to conservative management.1
In comparison with other free flaps used in mandible reconstruction, the fibula provides the greatest bone length and provides soft tissue replacement. While the fibula has little effect on bearing weight, it is an essential insertion for the biceps femoris muscle, one of the hamstrings, which assists in flexion of the knee as well as rotation of the leg. In addition, it is an attachment of the fibular collateral ligament, a structural component of the knee joint.2
There is a paucity of literature related to the feasibility of mandible reconstruction utilizing a microvascular free fibula flap in a patient with previous knee replacement surgery. Our patient is a 60-year-old female diagnosed with medication-related osteonecrosis of the jaw (MRONJ). She was refractory to multiple courses of antibiotic therapy and oral rinses. Upon physical examination, intraorally she has draining fistula at the right body of the mandible. Computed tomography of the mandible was significant for osteolytic bone destruction at the body of the right mandible and nearing the inferior border. Her concerning surgical history included bilateral knee replacement which was taken into consideration during surgical planning. Due to the size of the planned defect, reconstruction with a fibula microvascular free flap was planned using virtual surgical planning (Medical Modeling Inc., Golden CO) and a prefabricated reconstruction plate (Stryker, Kalamazoo, MI). The surgical procedure included a tracheostomy, segmental resection of the right body of the mandible, rigid fixation, extraction of all teeth and microvascular fibular free flap reconstruction. The patient continued physical therapy and occupational therapy and became full weight bearing 12-days postoperatively. The patient was back to her preoperative ambulatory status one month after surgery.
An English language search of three databases (PubMed, Science Direct, OvidMD) was performed to determine if a microvascular free fibula flap had been attempted in a patient with a history of knee replacement. The dearth of literature related to this concern lead to an interdisciplinary meeting between the Oral and Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery services to review the feasibility and risks for the proposed reconstruction in our patient. It was determined that as long as 10 cm of superior bone was to remain in place, the stability of the patient’s knee should not be compromised. We conclude that microvascular fibular graft reconstruction of the mandible remains an option for patients with bilateral knee replacement.
References
1. Eckardt A, Lemound J, Lindhorst D, Rana M, Gellrich N: Surgical management of bisphosphonate-related osteonecrosis of the jaw in oncologic patients: A challenging problem. Anticancer Res. 31:2313-2318, 2011
Palastanga N, Field D, Soames R: Anatomy and Human Movement. Chapter 5, The Lower Limb, Elsevier, 1994