Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

Introduction. The vascularized periosteal free flap transposes a non-irradiated soft tissue with neo-angiogenesis, bone induction, and osteogenesis qualities. Its technique and interest are studied for early osteoradionecrosis.Material and method. A retrospective study was made between 1992 and 2002. Thirty-four patients were selected among the 59 cases operated for osteoradionecrosis; all patients were classified stage II and I on the Epstein scale. Twenty-six patients were reconstructed using a non-periosteum free flap (bone, muscular or cutaneous flap), and eight patients were reconstructed using a "periosteum free flap". The study was clinical, radiological, and histological.Results. Osteoradionecrosis evolved for two of the eight patients having undergone periosteum free flap surgery. Operative morbidity and the number of reoperation were less important than for the rest of the series. The reconstruction was satisfactory on a functional and esthetic level. A bone production was noted for two patients of the "periosteum" group.Discussion. Periosteum free flap surgery is an alternative for early osteoradionecrosis. The periosteum brings osteo-induction and osteogenesis, and revascularization recorded clinically, radiologically, and histologically, even on an irradiated area. (C) 2008 Elsevier Masson SAS. All rights reserved.

Introduction. The severe evolution for some patient presenting with osteoradionecrosis, even if classified in the same stages as other patients, suggests that there are aggravating factors. Material and method. A retrospective study was made between 1992 and 2002 on all patient operated for mandibular osteoradionecrosis. Fifty-nine patients were included and the mandibular defects were reconstructed with a bone or a composite free flap (fibula 21%, iliac crest 49%, scapula 6%, antebrachial 3%), and with a periosteal free flap (13%). Results. The study included severe eases (87% of stage II or III) operated on several times without success. Free flap reconstruction was successful in 90% of the cases. However, complications were present in 60% of cases (24% minor complications, 48% major complications), and were more frequent with a higher stage. The analysis allowed identifying morbidity factors. Discussion. Studying the morbidity allowed identifying severity factors of osteoradionecrosis; spontaneous onset, important irradiation (important dose, bone proximity of the tumor, bilateral damage), vascular damage (symphyseal localization, lack of sequestrum, facial artery ligature, active tobacco addiction), actinomycosis colonization, non-observance of medical treatment. Understanding aggravating factors should allow us to offer more efficient surgery on an early osteoradionecrosis stage, also decreasing the morbidity linked to reconstructive surgery. (C) 2007 Elsevier Masson SAS. All rights reserved.

La médiatisation d'un événement scientifique n'est ni contrôlable, ni contrôlée. L'expérience vécue lors de la première allotransplantation de tissus composites au niveau de la face le confirme: les acteurs d'une innovation chirurgicale n'en sont pas les propriétaires. Car il n'y a ni confidentialité, ni brevetisation possible. Curieusement, le monde scientifique, nourri d'une éthique de partage, qui privilégie justement la diffusion gratuite du savoir afin d'en faire profiter le plus grand nombre, sans renier cependant la controverse, à seule fin de vérité, rejoint le monde des médias, affichant une éthique propre du devoir d'information, mais nourri de préoccupations mercantiles, prompt à cultiver la controverse non pas tant pour éclairer cette vérité que pour mieux vendre image ou papier. Ne reste alors à l'auteur qu'à subir cette instrumentation qui, certes, le flatte et dont il pourrait user, mais qui en réalité le paralyse quelque peu à poursuivre sereinement son cheminement de travailleur de l'ombre, qu'il revendique.

Mediatisation of a scientific event could be neither controlled, nor verifiable. The experience which has been lived through the first worldwide allotransplantation of composite tissues of the face confirms that the actors of a surgical innovation are not the owners. Because there is neither confidentiality nor possible patent. Curiously the scientific world, providing with a sharing ethic, which rightly privileges the free spreading of knowledge in the way that most people could benefit of it. Obviously it is made without denied controversy, for truth as purpose. This scientific word that way joins the media one, with a specific ethic of the duty of information, but also interested in mercantile preoccupations quick to cultivate controversy not to enlighten this truth but to better sell pictures or papers. Than the author should only sustain this instrumentation which could certainly flatter him, and from which he could used, but in reality that paralysed him a little to go on in serenity with his shadow worker way.

INTRODUCTION:The severe evolution for some patient presenting with osteoradionecrosis, even if classified in the same stages as other patients, suggests that there are aggravating factors.MATERIAL AND METHOD:A retrospective study was made between 1992 and 2002 on all patient operated for mandibular osteoradionecrosis. Fifty-nine patients were included and the mandibular defects were reconstructed with a bone or a composite free flap (fibula 21%, iliac crest 49%, scapula 6%, antebrachial 3%), and with a periosteal free flap (13%).RESULTS:The study included severe cases (87% of stage II or III) operated on several times without success. Free flap reconstruction was successful in 90% of the cases. However, complications were present in 60% of cases (24% minor complications, 48% major complications), and were more frequent with a higher stage. The analysis allowed identifying morbidity factors.DISCUSSION:Studying the morbidity allowed identifying severity factors of osteoradionecrosis; spontaneous onset, important irradiation (important dose, bone proximity of the tumor, bilateral damage), vascular damage (symphyseal localization, lack of sequestrum, facial artery ligature, active tobacco addiction), actinomycosis colonization, non-observance of medical treatment. Understanding aggravating factors should allow us to offer more efficient surgery on an early osteoradionecrosis stage, also decreasing the morbidity linked to reconstructive surgery.

Quarante-six victimes d'accidents par projectiles ou explosions ont été traitées de 1984 à 1989. Trois catégories sont séparables : les plaies par projectile unique (12 cas), n'entraînant que des dégâts osseux graves et, en dehors de 3 amputations immédiates, le résultat final a été satisfaisant au moins sur le plan fonctionnel. Les plaies par projectiles dispersés (11 cas), moins graves dans leurs lésions initiales n'ont pas nécessité d'amputation mais n'ont évolué sans problèmes que pour 8 d'entre elles. Les plaies par explosion (23 cas) où l'effet de souffle entraîne des dégâts initiaux considérables ayant conduit à une amputation de main et à 33 amputations digitales ; l'association de lésions squelettiques et des parties molles pose le problème d'une excision et d'une couverture primitive faisant appel à des lambeaux larges. L'évolution est longue et sur 26 mains, 8 ont de graves séquelles et pour les autres la reconstitution d'une pince élémentaire peut être considérée comme un résultat acceptable.46 victims of projectile accidents or explosions were treated over a 5 years period between 1984 and 1989. 3 categories were distinguished : injuries due to a single projectile (12 cases), only inducing serious bone damage and, apart from 3 immediate amputations, the final result was satisfactory. Injuries due to multiple scattered projectiles (11 cases), less severe in terms of the initial lesions, not requiring any amputations, with good results in 8 cases. Explosion injuries (23 cases) in which the effect of the explosion induced considerable initial lesions leading to one hand amputation and 33 finger amputations ; the association of skeletal and soft tissue lesions raises the problem of excision and primary cover, requiring large flaps. The course is long and 8 out of 26 hands had serious sequelae, while the reconstruction of an elementary pinch can be considered to be an acceptable result in the other cases.Cuarenta y seis víctimas de accidente por proyectil o explosión fueron tratados de 1984 a 1989. Se distinguen tres categorías : las heridas por proyectil único (12 casos) las cuales ocasionan sólo daños óseos graves y, fuera de 3 amputaciones immediatas, el resultado final fue satisfactorio. Las heridas por proyectiles múltiples diseminados (11 casos), menos graves en su estado inicial, no requirieron amputación y evolucionaron sin complicaciones en 9 casos. Las haridas por explosión (23 casos) en la cual la onda de choque ocasiona un daño inicial considerable conduciendo a una amputación de la mano y a 33 amputaciones digitales, la asociación de lesiones esqueléticas y de tejidos blandos ilustra el problema de la excisión y la cobertura primitiva debiéndose recurrir a grandes colgajos. La evolución es larga y sobre 26 manos, 8 presentan secuelas graves y para el resto la reconstitución de una pinza elemental puede ser considerado como un resultado aceptable.