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

1. Militsakh ON, Wallace DI, Kriet JD, Girod DA, Olvera MS, Tsue TT. Use of the 2.0-mm

locking reconstruction plate in primary oromandibular reconstruction after composite

resection. Otolaryngol--Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg.

2004;131(5):660-665.

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).