Management of Pathologic Fractures of the Mandible Secondary to Osteoradionecrosis (original) (raw)
Related papers
SADJ: journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging
The 30/10 protocol is employed in the treatment of established osteoradionecrosis. No surgery should be attempted before the first 30 HBO treatments have provided sufficient angiogenesis to support surgical wounding. After 30 treatments surgical management can be staged according to the extent of improvement achieved after HBO and the size of sequestrum or area of osteolysis. If the ORN extends to the inferior border of the mandible or if it manifests as an orocutaneous fistula or pathological fracture, discontinuity resection of the necrotic bone and soft tissue will be required to resolve the disease. Unless HBO and surgery are combined in the management of ORN, the results are not long lasting or satisfactory. Even though resection of stage three ORN seems unduly aggressive, it has stood the test of time. By using the Marx protocols in the treatment of ORN, more than 95 per cent of patients can be successfully cured of their disease with predictable, functional and aesthetically ...
Paradigm shifts in the management of osteoradionecrosis of the mandible
Oral Oncology, 2010
s u m m a r y Osteoradionecrosis (ORN) of the mandible is a significant complication of radiation therapy for head and neck cancer. In this condition, bone within the radiation field becomes devitalized and exposed through the overlying skin or mucosa, persisting as a non-healing wound for three months or more. In 1926, Ewing first recognized the bone changes associated with radiation therapy and described them as ''radiation osteitis". In 1983, Marx proposed the first staging system for ORN that also served as a treatment protocol. This protocol advocated that patients whose disease progressed following conservative therapy (hyperbaric oxygen (HBO), local wound care, debridement) were advanced to a radical resection with a staged reconstruction utilizing a non-vascularized bone graft. Since the introduction of Marx's protocol, there have been advances in surgical techniques (i.e. microvascular surgery), as well as in imaging techniques, which have significantly impacted on the diagnosis and management of ORN. High resolution CT scans and orthopantamograms have become a key component in evaluating and staging ORN, prior to formulating a treatment plan. Patients can now be stratified based on imaging and clinical findings, and treatment can be determined based on the stage of disease, rather than determining the stage of disease based on a patient's response to a standardized treatment protocol. Reconstructions are now routinely performed immediately after resection of the diseased tissue rather than in a staged fashion. Furthermore, the transfer of well-vascularized hard and soft tissue using microvascular surgery have brought the utility of HBO treatment in advanced ORN into question.
Dentistry, 2014
Osteoradionecrosis is a severe and devastating late complication of radiotherapy in patients with head and neck cancer. The diagnosis of Osteoradionecrosis is established by clinical and radiographic evidence of bone necrosis after irradiation. The current article reports a case of osteoradionecrosis in an irradiated patient (male; 62-year-old), which evolved into pathological fracture of the jaw, 2 years after the end of radiotherapy for oral cancer treatment. The patient was rehabilitated in other service, with reconstruction plates, without adjuvant hyperbaric oxygen therapy, progressing to a fistula formation and bone exposure. The patient was referred to our service, with an extensive bone and plate exposure, with signs of severe osteoradionecrosis. After the adequacy of the oral environment, the patient underwent surgery for necrotic bone and reconstruction plate resection, with a primary closure of the skin and intraoral mucosa. The post-operative clinical and radiographic examinations performed after 12 month showed no signal of recurrence. Pathologic fracture in conjunction with osteoradionecrosis has a relatively high treatment complication rate. The incorrect diagnosis of mandibular fracture associated with osteoradionecrosis leads to inadequate treatment, with irreversible consequences to the patient, as described in the related case.
Management of pathologic fractures
Cancer, 1972
The principles of management of pathologic fractures in the long bones are reviewed, and a series of 45 fractures treated by internal fixation is compared with 26 fractures treated by other nonsurgical procedures. Internal fixation and radiation therapy provide better and longer lasting palliative results in these patients, provided clear indications for this method of management are carefully evaluated. Relief of pain is observed in over 80% of the patients and satisfactory healing and functional results in about 75%. The value of prophylactic fixation and irradiation of large osteolytic lesions in weight-bearing bones with a high risk of fracture is emphasized.
Clinical Orthobiologic Approach to Failure or Delay in Bone Healing
2017
Great part of the fractures heal spontaneously in the expected timing, if correctly treated, but approximately 5–10% don’t, with an incidence of 19 per 100,000. [1] Delayed unions and non-unions of long bone fractures, the latter defined by the Food and Drug Administration as fractures for which a minimum of 9 months has elapsed since the injury and for which there have been no signs of healing for 3 months, represent an important therapeutic challenge for the orthopaedic surgeons, but also an important social economic burden due to the morbidity, the costs and the disability to work that these conditions cause. Already in 1995, Einhorn and co-workers reported that, in the United States, of about 5.6 millions fractures treated, up to 10% do not heal completely [2] and this requires several complex and long-lasting type of treatments. Looking to what this means in terms of costs, in the UK, Dahabreh, Dimitriou and Giannoudis, in 2011 [3], reported that the treatment of one single cas...
Nonoperative Fracture Treatment in the Modern Era
Journal of Trauma-injury Infection and Critical Care, 2010
Background: Nonoperative fracture treatment has been used for millennia, but there has been no demographic study of its use for half a century. In the last 50 to 60 years, there has been an increased interest in operative fracture fixation and in many specialized Trauma hospitals nonoperative management is less frequently used. However, these specialized hospitals do not reflect fracture treatment in the whole community, and we have undertaken a study to investigate the current prevalence of nonoperative fracture treatment. Methods: A retrospective analysis of 7,863 consecutive fractures in a defined population was undertaken. The use of nonoperative management in different fractures was assessed as was the influence of fracture severity, mode of injury, multiple fractures and social deprivation in the choice of treatment. A comparison of current treatment with that of the 1940s and 1950s was undertaken. Results: The prevalence of nonoperative treatment was 74.6% with 91.6% of children and 67.6% of adults being treated nonoperatively. There were significant differences in upper and lower limb fractures in both children and adults. The major determinant of nonoperative management was age, although the severity of fracture, mode of injury, and presence of multiple fractures were also important. Social deprivation was not a significant factor except in adult metacarpal fractures. Conclusions: Nonoperative treatment remains the most widely used method of fracture management. Its prevalence decreases with age, particularly in lower limb fractures. In children, there is a bimodal operative treatment distribution and an increasing prevalence of operative treatment. In some adult fractures, the prevalence of surgery is increasing, but in others, we operate no more frequently than in the 1950s, despite improved operative techniques.
Treatment of Pathological Fractures
Acta Orthopaedica, 1979
The treatment of 30 patients with 34 pathological fractures is reported. Twenty-six femoral fractures and one ulnar fracture were fixed internally, whereas five fractures of the humerus, one of the radius, and one of the clavicle were treated non-operatively. Twenty-two of the patients were discharged from hospital (21 were mobilized) and eight died in the postoperative period. All patients became free of pain, and bony union occurred in 12 of the fractures. Thirteen per cent of the patients lived less than 1 month whereas 20 per cent lived more than 24 months after fracture. Previously published figures and our results indicate the place of prophylactic nailing of certain femoral metastases, perhaps also in connection with local irradiation of the metastases.
Trauma Surgery, 2018
Open fractures are common and their prevalence is increasing in elderly people. The burden of open fractures is high because of economic and social costs. Most open fractures occur in lower limbs. The use of validated protocols, will optimize our outcomes when treating open fractures. The first step began with the proper identification of the fracture characteristics and the hidden soft tissue injury. The use of an adequate and early antibiotic prophylaxis is mandatory and then, we have to perform adequate irrigation and debridement. Finally, we have to decide to temporally fix the fracture or proceed with the definitive fixation method. Recently, the creation of dedicated "orthoplastic" units has increased the outcomes in high-energy tibial fractures. These fractures should be managed in adequate trauma centers that should be used to face all the complications that will appear during the reconstruction procedure because complications can be as high as 50% in high-energy open fractures.
CROOMA, complication rates of operatively treated mandibular fractures, paramedian and body
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology, 2011
Introduction. This retrospective study comprises an exploratory analysis of 10 years of surgical treatment of symphysis (S) and parasymphysis/body (P/B). Correlations of complications, as well as dependencies of surgical concepts, are investigated. Materials and methods. All surgically treated patients in the period of 1995 to 2005 with at least one mandibular fracture mesial to the mandibular angle were included in this study. A total of 63 patients (46 men, 17 women) with 63 symphysis fractures were included and 497 patients (369 men, 128 women) with 553 P/B were included; 99.27% (549) of these fractures were included in the study, 4 had to be dismissed because of inconclusive documentation. Results. Of patients with P/B, 96.04% were successfully treated with 1 open reduction, 3.76% had 2, and 0.20% had 3 surgeries. Of the surgically treated patients, 75.77% (416) were completely free of complications, whereas the other 24.23% of the P/B showed 1 or more complications. The main complication was mild nerve damage (24.8%). Osteosynthesis failure rate (OFR) was 2.4% (7 of 298) for 2 miniplates, 5.7% (3 of 53) for 1 tension screw, and 8.4% (9 of 107) for 1 miniplate. Regarding OFR, 2 miniplates showed to be superior in a Fisher exact test (P ϭ .018, adjusted P ϭ .132). Symphysis fractures were completely free of complications in 81.8% and showed 2 major complications, i.e., 1 severe nerve damage and 1 osteosynthesis failure. Discussion. This study has the limitations of a retrospective study. Conclusion. A high success rate of open reduction and osteosynthesis with 2 miniplates can be guaranteed.