血管化骨组织瓣在下颌骨放射性骨坏死临床治疗中的应用研究

Clinical application of free vascularized bone flaps for reconstruction for osteoradionecrosis of the mandible

目的：探讨血管化骨组织瓣在治疗下颌骨放射性骨坏死中的应用。方法：对2003 年1 月到 2015 年1 月上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科采用血管化骨组织瓣修复下颌骨放射性骨坏死术后缺损的53 例患者临床资料进行回顾性分析。结果：在53 例下颌骨放射性骨坏死血管化骨组织瓣修复中，血管化腓骨瓣应用48 例（90 .57 %），血管化髂骨瓣5 例（9.43 %）。术后5 例（10 .42 %）腓骨瓣出现并发症（4 例静脉栓塞，1 例动脉危象），经探查后 3 例皮瓣恢复正常，2 例改用胸大肌皮瓣修复创面。而髂骨瓣 2 例（40 .00 %）出现术后并发症（1 例静脉栓塞，1 例动脉危象），最后植入髂骨因坏死被取出，局部清创缝合。皮瓣供区均未出现明显并发症。平均随访时间28 （5～60 ）个月，经过血管化骨组织瓣治疗后88 .57 % 患者骨坏死得到有效控制，85 .71 % 患者张口度在 2～3 指，85 .72 %的患者能进软食或半流质，80 .00 %的患者言语可识别度较好。另外，在随访时还发现，通过术中牵引钉或术后斜面导板等使用，髁状突保留与否与患者术后张口、面型等关系不大，但髁状突保留的患者颞下颌关节区不适感明显比髁状突去除者少。结论：血管化骨组织瓣应用于下颌骨放射性骨坏死术后缺损的修复，虽然存在一定的风险，但只要适应证选择恰当、术中操作精细及术后并发症控制良好，仍是目前手术治疗下颌骨放射性骨坏死最好的方法。血管化骨组织瓣首推血管化腓骨瓣。

Objective： To assess the effectiveness of free vascularized bone flap transfer for treatment of advanced osteoradionecrosis of the mandible （ORNM）. Methods： We reviewed 53 patients who were treated for ORNM by radical resection and reconstruction with free vascularized bone flaps in our institute between January 2003 and January 2015. Results： Among the 53 vascularized bone flap patients, 48 （90.57%） had fibula osteocutaneous and 5 （9.43%） had deep circumflex iliac artery （DCIA）. Postoperative complications occurred in 5 （10.42%） of the 48 fibula osteocutaneous patients （4 cases of vein thrombosis and 1 case of arterial crisis）. In three of these patients, flap was salvaged back to normal in a timely manner by vascular exploratory surgery. However, pectoralis major myocutaneous flap was conducted as a second procedure for the other two patients. Meanwhile, complications occurred in 2 （40%） of the 5 DCIA transfer patients （1 case of vein thrombosis and 1 case of arterial crisis）. None of these two flaps was salvaged back. Necrosis transfer bone was finally removed. No obvious donor site complications were noted. The mean follow-up time was 28 months. Our results showed that 88.57% of the patients with ORNM were stable, 85.71% of the patients can open their mouth at 2-3 figures, 85.72% of the patients can eat soft or semi-liquid food, and 80% patients can speak clearly and can be understood by others around them. No significant difference was found in mouth opening and face type of the patients with or without the intact condyle. However, the temporomandibular joint area discomfort of the patients with intact condyle was obviously less than that of patients with removed condyle. Conclusion： Radical resection, followed by vascularized bone flaps, especially fibula osteocutaneous, is still the best way to treat ORNM, as long as the indications are chosen appropriately, intraoperative work is conducted properly, and postoperative complications are controlled.