minimally invasive mandibular hardware removal post ... · minimally invasive mandibular hardware...
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Minimally Invasive Mandibular Hardware Removal Post Reconstruction Neerav Goyal MD MPH1,2 Daniel G. Deschler MD1 1Harvard Medical School, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts 2Penn State Milton S. Hershey Medical Center, Division of Otolaryngology Head and Neck Surgery, Hershey, Pennsylvania
Abstract
Outcome Objective: To evaluate a minimally invasive
technique for hardware removal in patients status post
osseous reconstruction of the mandible
Methods: A retrospective review was performed of all
patients with a history of head and neck cancer requiring
resection with osseous free flap reconstruction that later
had mandibular hardware removed between June 2013
and June 2014 were included. Each patient underwent
hardware removal via 1-2cm percutaneous incisions
directly over the hardware allowing for screw removal
and hardware extraction. For each patient relevant
demographic and cancer information was recorded as
well as time of symptom onset, type of hardware
removed, length of hospital stay and last follow up.
Results: A total of 6 patients were identified since this
technique was employed. All patients had received prior
radiation and had evidence of recurrent infections at the
reconstruction site. The average time between
reconstruction and hardware removal was 47.8 months.
Follow up after hardware averaged 8.3 months. All
patients had resolution of their infections, and there were
no complications from the surgery. One patient had
persistent bone exposure that was asymptomatic.
Conclusion: Removing exposed mandibular hardware
in the setting of prior radiation and active infection can
present a technical challenge. This technique uses small
incisions to allow for percutaneous removal of the
screws and removal of the mandibular hardware without
the need for extensive dissection over the native and
reconstructed mandible. All patients demonstrated
resolution of their infections and healing of any open or
draining wounds during the follow up period.
Introduction With the advent of osseous free tissue transfer and rigid
internal fixation, patients undergoing segmental
mandibulectomy for head and neck cancer can obtain
acceptable form and function1,2. Most patients undergo
adjuvant radiation therapy with our without chemotherapy
and many develop osteoradionecrosis with fistula
formation as well as exposure of the bone and previously
placed hardware. Despite prolonged antibiotics and
bacteriostatic mandibular plates, some patients face
recurrent infections and chronic drainage from their
reconstruction site where the hardware is a nidus of
infection and requires removal.
Surgical approaches to hardware removal may require
using the large prior incisions from the resection and
dealing with a radiated operative bed with significant
scarring. Coupled with patient co-morbidities, surgery to
remove the hardware can be challenging and involve long
hospital stays with increased risk for complications
including infection, wound breakdown, and cranial nerve
injury. We present a minimally invasive technique utilizing
the fistula site as well as strategically placed small incisions
to remove infected hardware in an efficient and safe
manner.
Methods From July 2013 through July 2014, patients who
underwent removal of mandibular hardware using the
described method were reviewed. Data regarding the
pathology, surgery (resection and reconstruction), interval
to removal, the type of hardware placed, prior
chemotherapy or radiation treatment, the presence of
osteoradionecrosis, wound cultures and prior use of
hyperbaric oxygen were recorded. This review was
approved by the Massachusetts Eye and Ear Infirmary
Institutional Board Review.
Surgical Technique Prior to hardware removal, radiographic studies were
reviewed. In addition to the available computed
tomography (CT) imaging, scout plain X-ray films were
also used to identify the position and number of screws
requiring removal (Figures 1 and 2).
Under general anesthesia, the hardware at the frank fistula
sites was explored and the accessible screws removed.
Figure 1. Scout
x-ray imaging
demonstrating
the hardware
and screw
position.
(A) lateral view
(B) anterior
view
A
B
Figure 2. Sagittal (left) and axial (right) CTs
visualizing screw and plate placement.
Small stab incisions (1-3mm) were made through the skin
overlying the location of the screws placed at other
locations along the plate. Blunt dissection was taken down
to the hardware dividing any fibrous attachments present
around the hardware. Efforts were made to place the
stab incisions so that 2 or 3 screws could be removed
through a single stab site. In later cases, a plate template
from the plating set was bent to mimic the patient’s
hardware and assist with incisions planning (Figure 3A).
A locking screwdriver engaged the screw under direct
vision or by palpation, to remove the screw. After all the
screws are removed, blunt dissection with a periosteal
elevator was utilized to dissect any fibrous attachments off
the remainder of the hardware. The hardware was
removed through the fistula which afforded the largest
opening or a more convenient stab incision. If necessary
to assist delivery, the plates could be cut with a sagittal saw
through the fistula. This was more common for plates
crossing the symphysis to the contralateral body or
further.
After removal
of the
hardware,
wound
cultures were
sent and the
wound was
irrigated. All
stab incisions
were closed
with
absorbable
suture. The
fistula tracts
were excised
and closed
with local
tissue
advancement
(Figure 3B).
Patients were
discharged
home with
analgesics and
oral
antibiotics.
All patients were treated with multiple courses of
antibiotics prior to hardware removal. The average interval
between hardware placement and removal was 47.8
months (range 6.8-113.7 months). The removed plates
were 2.0mm and 2.5mm locking titanium plates between
8-18 holes in length with between 5-15 screws. One
patient also had 2 mini plates that were removed.
Intraoperative cultures demonstrated a variety of flora
including Staphylococcus aureus (MRSA and MSSA),
coagulase negative Staphylococcus species, Corynebacterium,
Fusobacterium, and Actinomyces. Patients were placed on
antibiotics following the hardware removal. All patients
were discharged the same day following surgery.
Patient follow up ranged from 3.1-12.6 months (average
of 8.25 months). Within the cohort, 5 out of 6 patients
demonstrated complete healing of the prior infected
region with closure of sites of exposed bone and or
fistulae (Figure 3C,D). One patient had an
asymptomatic residual area of dry exposed bone less
Results Six cases were identified, 3 men and 3 women with an
average age of 57 years (range 46-67). All were treated for
squamous cell carcinoma of the oral cavity or oropharynx
and underwent surgical resection with segmental
mandibulectomy and fibula free flap for osseous
reconstruction. All patients received radiation therapy
prior to necessitating hardware removal (either adjuvant or
prior to surgery).
Five patients had osteoradionecrosis prior to hardware
removal, and 4 underwent hyperbaric oxygen treatment.
Other treatments included drainage of abscesses (2
patients), debridement of exposed bone (2 patients), or
placement of vascularized tissue (2 patients).
than 5 mm without
evidence of infection or
fistula. No patient had
iatrogenic facial nerve
palsy secondary to the
hardware removal.
Discussion Hardware related
complications
necessitating removal in
this patient population
has been previously
reported at
approximately 15%, with
tobacco use, radiation
therapy, cancer
recurrence and prior
hyperbaric oxygen
treatment noted as
associated factors3,4. In
patients who have a
chronic infection and/or
fistula, the social and
economic impact of a
draining wound, with
repeated clinic visits and hospital admissions, can be
significant. This technique forgoes a large skin flap
elevation and dissection in a scarred operative bed without
increasing risk to the facial nerve or causing cosmetic
deformity. All patients were discharged the same day after
the surgery, and all patients had resolution of their
infections. The technique presented provides a safe and
efficient method to remove large mandibular plates
without significant patient morbidity or hospital stay.
References
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locking reconstruction plate in primary oromandibular reconstruction after composite
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2. Futran ND, Urken ML, Buchbinder D, Moscoso JF, Biller HF. Rigid fixation of vascularized
bone grafts in mandibular reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121(1):70-
76.
3. Knott PD, Suh JD, Nabili V, et al. Evaluation of Hardware-Related Complications in
Vascularized Bone Grafts With Locking Mandibular Reconstruction Plate Fixation. Arch
Otolaryngol Neck Surg. 2007;133(12):1302.
4. Day KE, Desmond R, Magnuson JS, Carroll WR, Rosenthal EL. Hardware Removal after
Osseous Free Flap Reconstruction. Otolaryngol -- Head Neck Surg. 2014;150(1):40-46.
Figure 3. Intraoperative (A), immediate post operative
(B), and 2 week follow up photographs (C, D).