Practice-Changing Innovations in the Management of Osteoradionecrosis

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology-head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm excited to speak with Dr. Michael Fritz, Section Head of Facial Plastic and Microvascular Reconstructive Surgery at Cleveland Clinic. Dr. Fritz, welcome to the podcast.

Michael Fritz: It's a pleasure to be here.

Paul Bryson: Well, let's start by having you share some background on yourself for our listeners, where you're from, where you've trained, how you came to Cleveland Clinic. You know, you and I have worked together for, it's been a, a few years now, but I always learn something here. Just a few years.

Michael Fritz: It's been more than that. My friend. I went to Duke University as an undergrad student, traveled for a year and then attended Ohio State Medical School. I grew up mostly in Solon, Ohio, very originally from California, but, but basically my home is Ohio, and then I came to the Cleveland Clinic for residency. I was just kind of completely sold by the model here and the people here. And I did a six-year residency with research here, uh, mostly focusing on transplant research. And then I did a fellowship at the University of Minnesota in facial plastic and reconstructive surgery. And I was fortunate enough to be offered a job to come back here before I left. And so, I've basically stayed an employee at the Cleveland Clinic now for I think, like 26 years or something like that. So, I've been here for a long, long time. I went into facial plastic and microvascular surgery because it is the fusion point of art in medicine and also kind of ironically, because it's so imperfect and there's a lot of ground for innovation and, and improvement of outcomes for our patients as opposed to a lot of the other things we do just seem to be a place where we could really blaze some nice trails.

Paul Bryson: And you know, just as an observer for these past several years, definitely very difficult and challenging problems that, you take care of patients that have difficult problems from cancers, other surgical problems, infections and things like that. You know, part of the podcast today we were going to talk about osteoradionecrosis, and I'm not sure, you know, there's many innovations you've done in this area, but I was going to start, can you kind of set the table like what is osteoradionecrosis and, how does it manifest in the patients that you see?

Michael Fritz: Yeah, so osteoradionecrosis is one of these kinds of late blooming problems that we see after patients have mostly been through successful cancer treatment, you know, so it's kind of a kick in the pants of them where there, you know, they've been through their radiation or their chemoradiation therapy. So obviously it involves some element of radiation exposure to bone, and it's usually the mandible, but it can be the maxilla, it can be the skull, it can be basically anywhere in the head and neck region or anywhere where you've had radiation. But radiation obviously is an incredible treatment for these folks in that, you know, it's a, it's an essential part of their cure, but it comes at a price, you know, the body is taken to the edge and the tumor falls off the edge, and so this bone is still limping along, along with the tissue over the bone.

And so, it just takes a little element of some kind of problem, like a dental infection or, or a little traumatic injury to expose some of that bone. And then it doesn't have the capability to heal. So, someone has a bad tooth. You know, the oral surgeons and dentists know that we don't extract teeth in a field of radiation because it will set up this cascade, but sometimes you have no choice. You have to pull the tooth or the tooth fractures or something, and you have exposed bone, and then there's basically infection or natural contaminants in our mouth on the bone, and it just, the bone can't heal. So, it's just kind of cascade of non-healing infection, bone breakdown. In the past, there hasn't been a great solution. We’ve done things like hyperbaric oxygen, which really has been the standard of treatment around the world for many years now, but the new studies have shown kind of something which we observed here for a long time, is that there's really no good data that shows that it's effective.

It was incredibly expensive. It usually takes 30 or 40 days out of someone's life, can affect their vision either temporarily or permanently. It comes at a lot a high cost in a lot of places with a big copay for folks. But most importantly, the randomized controlled studies have not shown that it works. But that has been our standard until the bone breaks, and you have full thickness disease, and then we cut the whole thing out and we replace it with bone, with the blood supply from somewhere else in the body, like the fibula. But that's a big operation, and it usually comes with trash, a feeding tube, and often permanent compromise of the already kind of borderline function that people have because they're scared from radiation, or they had surgical resection of parts. So, it's not just the magnitude of the surgery, but it's the fact that people are never really the same. So, we did everything we could to avoid this big operation on folks, but there were no great solutions. And so that's where these new techniques kind of came into play.

Paul Bryson: Yeah, I mean, there's been a lot of excitement about your recent publication on the anterolateral thigh fascia lata rescue flap surgery to address this. It was recently published in JAMA Otolaryngology, and it really sounds like a game changer for patients. As you said earlier, you know, people get through treatment. We really focus on survivorship and quality of life and survivorship. So, this is a really meaningful development. Can you talk a little bit for the listener about your findings, how this helps patients, what the approach is like?

Michael Fritz: Yeah, I think, I think to start with, you have to talk about the foundation of this operation. We at the Cleveland Clinic have developed these minimal access techniques to access blood vessels, not by making big incisions like we used to, but basically making small incisions right over where the artery and the vein would be. So, a facelift incision in front of the ear, a very small, you know, two, three-centimeter incision over the edge of the mandible where the facial vessels cross, or we access the angular vessels right through the nasolabial fold. These things heal invisibly, and all you need is a little Penrose drain there. You don't need, you know, a, a big recovery. So, with that, giving us blood supply, we combine that with the anterolateral thigh flap. This flap is unique in that people can walk the next day. It actually hurts less than a skin graft.

I mean, there have been studies that have shown that, but the morbidity is less than a skin graft. And so, you've got a very low morbidity donor site and a really easy way with low morbidity to access blood vessels and deliver blood supply. So, with that, as a foundation, we can now deliver basically blood supply wherever we want in the head and neck region at a very low cost. You know, this is a three- or four-hour operation. People typically stay about two days in the hospital, but some people have gone home the same day, and many of them have gone home post-up day one. So, it's an order of magnitude dipper in operation than the segmental resection and a fibula free flap. So, with that in mind, you know, when we had people with partial thickness destruction of the jaw, we're like, well, why don't we try and just cover this up with something with a really robust blood supply and see what happens, because it doesn't burn any bridges for the bigger operation, so why not?

And it was, it worked, it worked time and time again, and then when we had borderline candidates, we would start to supplement that bone. So, say the bone is two thirds gone or three quarters gone, but the jaw is still in continuity. It still has strength and stability. We take a little bit of iliac crest bone from the hip, and then we wrap that with this, you know, super highly vascularized tissue after we've drilled out all the bad bone and, you know, put them on culture, culture directed antibiotics. And even in this very hostile milieu, we've gotten the bone grafts to heal, gotten people, you know, through this and this publication that you just mentioned, we have 96 percent control in partial thickness mandibular disease, but not just superficial partial thickness - like subtotal, mandibular destruction. It works for all levels and actually at the same rate of control. It's by far and away not the sexiest operation I've ever done. You know, I love the fusion of art and medicine. I love total nose reconstruction and orbital maxillary reconstruction with layered techniques. All these really highly technical operations. This one's pretty simple once you know how to do a minimal access perforator flap, but it works on everybody, and it's totally a game changer.

Paul Bryson: Yeah, I mean, I congratulate you and the team on this for, you know, identifying the problem, taking, you know, a calculated or educated risk with little downside and, and then, you know, sparing people that bigger operation, like it's, it's a big deal to get bone harvested from somewhere and moved.

Michael Fritz: Yeah. And there's nobody who will be more in line with trying something different than someone who's had a fibula reconstruction on the other side. And that's where you really kind of get the perspective of the patients themselves. They'll look at you and say, I'll do anything to avoid going through that operation again. Now, if that's the operation you need, we'll get you through it and you, you do okay with it, but it's such a big difficult recovery. And so it was, it wasn't hard to talk to people honestly, that, look, we've done this technique in many other, you know, formats, many other iterations. This isn't super established. And we, the first person we did it on actually had a retinal detachment in the hyperbaric oxygen chamber, so he couldn't go back in there. He'd go blind and he had about half thickness disease and needed teeth extracted.

So, we knew there was going to be a big hole. And we said, well, this has worked in a lot of other situations. We think this is a good idea. And he was like, a hundred percent I'm in, and he's 13 years out. He stayed overnight, went home the next day and never looked back. So that's where we were like, okay, there's something to this. But it took us years and years to accumulate the 50 or so patients that we've had long-term follow-up because, you know, just as well as I do, surgeons are like the slowest to buy into change and to innovation sometimes, you know, doctors in general, were all kind of guilty of that. And so, getting people that were good candidates that didn't have full thickness disease, was difficult. But now, you know, people are coming from all over because why wouldn't you try something smaller? Right. It makes total sense to everybody, not just physicians and surgeons to lay people. It makes sense.

Paul Bryson: Yeah. So, what's next? What’s on the horizon? You'd mentioned, you know, very specific access to get the blood vessels, things with very minimal evidence of, you know, ever being there to do this. What happens next with this research?

Michael Fritz: Oh, and that's a really good point you bring up. The other strength of this operation is we don't disrupt any of the structures around the jaw. We just lift enough of the lining to get the bad bone out. So, you're not changing the way that someone functions from a speech or swallowing standpoint, you know? So that's a really important concept that I don't think we emphasize quite enough that the downside for these folks is so little. So, with that in mind, how about those folks that have full thickness disease that goes all the way through. Now, this is a little bit more of a stretch, right? If you've got a full break in the jaw, the standard is definitely the fibula, and that's what we talk to folks about. But we know that when we drill out that bad bone, a lot of times it's a gap of about a centimeter or two at most.

So why can't we put a plate across so that we know we can get graft to heal, and why can't we start repairing these full thickness defects with the same technique, keeping in mind that if it fails, we're still going to do a fibula. When we're not burning any bridges, we're not even using the blood vessels we normally use to do that operation. So we're, we're burning zero bridges, and so we're starting to look into that and then, okay, we can wrap graft in this hostile milieu and get it to heal. Well, complex reconstruction, are we still, do we still need to take bones from other part of the body and, and move them from one place to another and try and cut them into the shape? Or can we get surface eroding polymers, populate them with patient's own cells, and then wrap it with this vascularized tissue and rebuild things like eye sockets and noses and, and other, you know, other structures.

I mean, we're basically doing a lot of similar operations to what we did back in the 1980s. You know, I think it's time to try and turn that page. So, we have to do that in a very careful way. But again, I think the most important thing is to keep the morbidity incredibly low for people, the downside low, and make sure that we can still do the standard of care on them, you know, without any complication. I think that's the next level is, is fusing tissue engineering, you know, scaffolding, and then these wrapped low morbidity flaps and try and avoid some of these big, huge operations on folks.

Paul Bryson: Well, I really appreciate your time talking about this today. It's very exciting. I mean, it's, it's huge for patients. You know, it's really awesome to see people get that function back, have, you know, function preserving surgery before having another massive surgery.

Any take home messages for our listeners today?

Michael Fritz: You know, I'm a believer, obviously, so if you have osteoradionecrosis and it's not responding there, there are some medical therapies for very small focal disease, Pentoxifylline and tocopherol in defects under, you know, two, two and a half centimeters that are just combined to the teeth. It's worth trying. Obviously, it's always worth trying to avoid surgery, but if you're going down the road where you're not getting better, where things keep, you know, you keep getting infections, it seems like it's creeping along, don't sit on this because we can do this very low morbidity operation until we can. And so, you know, time is bone basically. And so, you know, look into this. We are training other people around the country. We're going to start having courses on this. Again, good surgeons who can do small perforator flap surgery and these minimal access techniques. This isn't an operation that only we can do, but it is an operation that we designed, and we really know how to do the right way. So hopefully we can, we can distribute this to everybody else and, and start really helping folks around the country.

Paul Bryson: Well, for more information on our osteoradionecrosis research, visit our Consult QD website at ConsultQD.ClevelandClinic.org. That's ConsultQD.ClevelandClinic.org. And to speak with one of our facial plastic and reconstructive surgeons, or submit a referral, please call 216.444.8500. That's 216.444.8500. Dr. Fritz, thanks for joining Head and Neck Innovations.

Michael Fritz: A pleasure as always, my friend.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access real-time updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.