Fibula free flap pedicle ossification: Experience of two centres and a review of the literature
Introduction
Mandibular integrity can be affected by a variety of causes, including infection, benign and malignant cancers, osteoradionecrosis, and trauma. Restoration of mandibular integrity after such conditions is pivotal in restoring form and function (Heyden et al., 2012).
Fibula free flap (FFF) is a routinely used free flap for oromaxillary and oromandibular bony defect reconstruction, due to its low donor site morbidities, great length of harvestable bone (while preserving the integrity of the knee and ankle joints), the possibility for implant and prosthetic rehabilitation/restoration (osteointegrated dental implants), and the potential combination of multiple skin flaps. Multiple osteotomies can be performed to shape the flap in order to achieve the best match and the best contour possible (Hidalgo, 1989, Hidalgo, 1994).
The osteogenic potential of vascularized periosteum has been studied and described in a few cases in the literature, and many different factors have been pointed out as plausible (Finley et al., 1978).
Clinically, free flap pedicle ossification is presented as trismus, hard swelling, and severe pain during movements (mastication, ipsilateral neck rotation), although the diagnosis is scarce and often fortuitous.
The purpose of this article is to review the literature in order to evaluate clinical and epidemiological aspects, pathological characteristics, and treatment of the FFF, while reporting on our recent cases of FFF pedicle ossification.
Section snippets
Materials and methods
A full, systematic literature review was carried out, to include studies published up to the end of September 2016. Pubmed was used as an electronic database. The principal keywords used were ‘pedicle ossification’ and ‘fibula free flap’.
Inclusion criteria were as follows: 1) patients had ossification of the vascular pedicle of the FFF; 2) articles were published in Italian or English. No articles were subsequently excluded.
In addition, we included three patients diagnosed and treated at
Results
Ossification of the vascular pedicle in a vascularised osseous free flap has been reported 10 times in the literature since 1997. The additional cases from our institution are outlined below.
Discussion
In 1997 Deschler et al. (Deschler and Hayden, 1997) first described a bone spur, presenting as a mass, as a sign of FFF pedicle ossification. They noticed that this consistently occurred in regions where vascularised periosteum was present (Klotch et al, 1995, Ishida et al, 1996), and that periosteal osteogenesis was also affected by the tissue in direct proximity to the osteogenic inner cambium layer of the periosteum (Ishida et al, 1996, Wlodarski, 1989).
Periosteum transferred into contact
Conclusions
Three new cases of FFF pedicle ossification were presented in this study, together with a review of literature.
Ossification of FFF pedicles is rare, but when it occurs, it has dramatic clinical consequences, so maxillofacial surgeons must be aware of this process.
Diagnosis can be fortuitous, but an X-ray study together with clinical presentations can help in confirming diagnosis.
We strongly advise surgery to be carried out only in cases when pedicle ossification is symptomatic and there is no
Declarations of interest
None.
All authors have read the Helsinki Declaration and followed the guidelines in this investigation.
Acknlowledgements
All authors contributed to the investigation; in particular:
C. Baserga: conception and design of the study; drafting of the article; final approval of the version to be submitted.
O. Massarelli: critical revision of the manuscript for important intellectual content; final approval of the version to be submitted.
A. Bolzoni: critical revision of the manuscript for important intellectual content; final approval of the version to be submitted.
D. S. Rossi: conception and design of the study; critical
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Università degli Studi di Milano-Bicocca, Piazza dell'Ateneo Nuovo, 120126 - Milano, Italy.