Assessment of bone microcirculation by contrast-enhanced ultrasound (CEUS) and [18F]-positron emission tomography/computed tomography in free osseous and osseocutaneus flaps for mandibular reconstruction: Preliminary results

PURPOSE: Postsurgical evaluation of bone microcirculation in osseous and osseocutaneus free flaps by contrast enhanced ultrasound (CEUS) with time intensity curve (TIC) analysis and [18F]-positron emission tomography/computed tomography (Fluoride-PET/CT). PATIENTS AND METHODS: 10 patients with osseous or osseocutaneus microvascular flaps were evaluated with CEUS. Ultrasound was carried out by an experienced examiner with a high resolution linear probe (6-9 MHz, LOGIQ E9, GE) after intravenous bolus injection of 2.4 ml SonoVue® (BRACCO, Germany). Time intensity curves (TIC) in selected regions of interest (ROI) were analyzed and compared with the evaluation of [18F]-positron emission tomography/computed tomography and the clinical course for at least 2 month. RESULTS: 9/10 patients showed evidence for soft tissue and osseous microcirculation of the transplants in CEUS correlating with the clinical course. The soft tissue parts of the transplant showed a mean value of 84% (range 51-98%) and the bone parts a mean value of 39% (range 11-75%) for the Area under the curve (AuC) compared with the AuC for the anastomotic vessel region. Mean values for time to peak (TTP) were 27,1 sec (range 8.7-52.0 sec) for the anastomotic vessels, 29.3 sec (range 7.9-62.0 sec) for the soft tissue of and 32.0 sec (range 7.4-69.0 sec) for the transplant bone. In 1/10 patients flap failure occurred, after denudation the bone was left as an avascular transplant. AuC showed a mean value of 0.5 % for the bone region compared with the vessel region. Fluoride-PET/CT assessed bone vitality in 7 patients as "good" in 1 patient as "uncertain" and in 1 patient as "poor". CEUS assessment was corresponding with Fluoride-PET/CT in 4 patients, clinical assessment in 6 patients. CONCLUSION: Fluoride-PET/CT is a valuable tool to make an indirect statement about the perfusion of the transplanted bone and was used as control in this study. CEUS is a new and promising method for the evaluation of microcirculation of buried free microvascular bone grafts and the osseous part of osseocutaneous flaps and may be used for a steady monitoring in the first postoperative days.