Failure of salvage therapies in radiation-induced necrosis of a free fibula flap: a case report.

INTRODUCTION AND

IMPORTANCE

Osteoradionecrosis (ORN) of a free fibula flap following mandibular reconstruction is a rare but severe complication in head and neck cancer survivors. Despite advances in microvascular reconstruction and radiotherapy protocols, late-onset ORN remains a therapeutic challenge with limited evidence guiding management.

CASE PRESENTATION: A 53-year-old male smoker presented 2 years post-resection of pT4aN1M0 (Stage IVA) oral floor squamous cell carcinoma, having undergone mandibular reconstruction with a free fibula flap and adjuvant radiotherapy (66 Gy). Routine CT surveillance at 1 year revealed asymptomatic radiation-induced changes in the flap. By 2 years, he developed pain, trismus, swelling, titanium bar extrusion, and large sequestra. Biopsy confirmed ORN. Initial conservative therapy - including antibiotics, NSAIDs, and pentoxifylline with α-tocopherol - failed. Subsequent sequestrectomy provided only transient relief, with recurrent sequestra and persistent symptoms. Ultimately, the fibula flap was completely removed, and the patient declined a second free flap; reconstruction was completed with a pectoralis major myocutaneous flap, resulting in an uneventful recovery.

CLINICAL DISCUSSION: This case underscores the aggressive nature of ORN in vascularized bone flaps and the limitations of conventional salvage therapies.

CONCLUSIONS

When conservative and surgical salvage fail, prompt flap excision and alternative reconstruction may be necessary. This case provides longitudinal, image-supported documentation of sequential treatment failure and patient-driven deviation from standard free flap salvage.