Osteoradionecrosis of the calvarium: a systematic review of management and patient outcomes

Background: Osteoradionecrosis (ORN) of the calvarium is a complex reconstructive problem that can have severe consequences if not identified and managed appropriately. This is a systematic review of the risk factors and treatment modalities for ORN of the calvarium and the associated patient outcomes. Methods: Two independent researchers conducted a computerised search via Ovid of MEDLINE, Embase and the Cochrane Library for studies relevant to ORN of the calvarium published up to and including 1 June 2024. The researchers extracted information including patient population, treatment modality, patient outcomes and study design. All study designs and patient populations were eligible to be included in the review. Results: Of a total of 1050 screened studies, 20 met criteria to be included in the systematic review. These studies involved a total of 79 patients with a mean age of 52.9 years. Risk factors for calvarial ORN included higher radiotherapy fractions, cumulative radiotherapy dose and skin grafting. Approximately half of the patients required surgical intervention (49%), including cranioplasty and soft tissue reconstruction, 32 per cent of patients were treated conservatively with debridement and dressings, and 24 per cent received hyperbaric oxygen therapy (HBOT) as part of their treatment. Surgical management was complicated by wound dehiscence, infection or failed reconstructions requiring revisions in 10 patients. Conservative management appeared to yield low rates of intracranial infection, but was also resource intensive with prolonged healing times. Conclusion: There is a paucity of high-quality evidence to inform the management of ORN of the calvarium, and both surgical and conservative strategies may be effective. Robust soft tissue reconstruction should be considered in patients undergoing adjuvant radiotherapy to mitigate the risk of ORN, and long-term follow-up is required to ensure early identification and intervention in patients who develop ORN of the calvarium.