Use of intraoperative computed tomography during repair of orbitozygomatic fractures

Intraoperative Computed Tomography in the Surgical Treatment of Zygomatic Complex Fracture: A Retrospective Cohort Study

This study aimed to assess the effectiveness of intraoperative computed tomography (ICT) in managing zygomatic complex (ZMC) fractures surgically. A total of 143 patients (84 men, 59 women; average age 37.13 y) undergoing surgical treatment for ZMC fractures participated in this retrospective cohort study, with 72 in the ICT group and 71 in the control group. There were no notable differences in gender, age, time from injury to surgery, and surgical duration between the two groups. The ICT group exhibited significantly fewer surgical approaches than the control group (1.39±0.519 vs. 2.07±0.617, P<0.001). Fixation points in the ICT group (1-point: 42, 2-point: 14, 3-point: 16) significantly differed from the control group (1-point: 15, 2-point: 17, 3-point: 39), P<0.001. Symmetry of reduction was assessed through immediate postoperative images, and stability was compared between immediate postoperative images and those taken at least 3 months later. Both assessments revealed no significant differences between the 2 groups. This study indicates that ICT facilitates prompt evaluation of ZMC reduction, minimizing the necessity for incisions and internal fixation, while achieving comparable reduction efficacy and long-term stability to conventional approaches.

The Application of Cone Beam Computed Tomography (CBCT) on the Diagnosis and Management of Maxillofacial Trauma

The assessment and management of facial trauma in an acute setting is one of the core services provided by oral and maxillofacial units in the United Kingdom. Imaging is a pre-requisite for appropriate diagnosis and treatment planning, with a combination of plain radiographs and medical-grade CT being the mainstay. However, the emergence of cone beam CT in recent years has led to its wider applications, including facial trauma assessment. It can offer multi-planar reformats and three-dimensional reconstruction at a much lower radiation dose and financial cost than conventional CT. The purpose of this review is to appraise its potential indications in all anatomical areas of maxillofacial trauma and provide our experience at a level 1 trauma centre.

Intraoperative computed tomography for orbital reconstruction: a systematic review

Orbital reconstruction is a common procedure with inherent challenges and important consequences. Intraoperative use of computed tomography (CT) is an emerging application that facilitates accurate intraoperative evaluation to improve clinical outcomes. This review aims to investigate the intraoperative and postoperative outcomes of intraoperative CT use in orbital reconstruction. PubMed and Scopus databases were systematically searched. Inclusion criteria were: clinical studies investigating intraoperative CT use in orbital reconstruction. Exclusion criteria were: duplicates; non-English publications; non-full-text publications; studies with insufficient data. Of the 1022 articles identified, seven eligible articles representing 256 cases were included. The mean age was 39 years. Most cases were male (69.9%). With regards to intraoperative outcomes, the mean revision rate was 34.1%, with plate repositioning being the most common type (51.1%). Intraoperative time was variably reported. With regards to postoperative outcomes, there were no revisions, and only one case that had a complication (transient exophthalmos). Mean volumetric difference between the repaired and contralateral orbits was reported in two studies. The findings of this review present an updated evidence-based summary of the intraoperative and postoperative outcomes of intraoperative CT use in orbital reconstruction. Robust longitudinal comparisons of clinical outcomes between intraoperative and non-intraoperative CT cases are required.

Predictors of Intraoperative Difficulty and Postoperative Examination Abnormalities in 164 Orbital Operations

BACKGROUND

Although orbital fractures are common, prediction of outcomes in orbital surgery can be quite challenging.

PURPOSE

We aim to identify predictors of intraoperative difficulty, operating time, and postoperative examination abnormalities in subjects undergoing post-traumatic orbital reconstructions.

STUDY DESIGN, SETTING, AND SAMPLE

This is a retrospective cohort study of all consecutive orbital operations performed at a private, Level 1 trauma center in Portland, Oregon, USA over an 82-month period. All subjects that underwent exploration of the internal orbit for traumatic indications during the study period were included in the cohort.

PREDICTOR VARIABLES

Four plating styles, surgical approach (transorbital vs transantral), days from injury to first surgery, fracture size (approximated as a rectangle using linear measurements from computed tomography scans), anteroposterior fracture position, and medial wall involvement were examined.

OUTCOME VARIABLES

The primary outcome variable was intraoperative difficulty (defined as requiring revision after intraoperative imaging or return to the operating room). Secondary outcome variables included operating time and postoperative examination abnormalities.

COVARIATES

Age and sex were included.

ANALYSES

χ2 and Regression analyses were performed using a significance level of P < .05.

RESULTS

One hundred and sixty four orbital operations were performed (90 isolated injuries and 74 combined orbital/midface injuries) on 155 subjects (73% male, mean age 39.8 years, standard deviation 16.7). In subjects with isolated orbital fractures, medial wall involvement was associated with intraoperative difficulty (P = .01). When using a transantral approach, intraoperative difficulty was more likely in more anterior fractures (P = .02). Plating style was associated with operating time (P = .03), with median times from 81 to 105 minutes (range 21 to 248 minutes). Postoperative examination abnormalities were more likely in the transorbital approach group (P = .01). Neither days to first surgery nor intraoperative difficulty were associated with postoperative examination abnormalities. Postoperative eyelid changes were seen in 13.6% of transorbital approaches and 0% of transantral approaches. Correction of gaze restriction and enophthalmos were more likely than correction of diplopia (P < .01).

CONCLUSIONS AND RELEVANCE

Medial wall involvement is associated with intraoperative difficulty in orbital surgery. Anteriorly positioned fractures are better treated transorbitally, while posterior fractures may be amenable to transantral repair, thus avoiding risk of lower eyelid changes.

Intraoperative Computed Tomography Use in Orbital Fracture Repair: A Systematic Review and Meta-Analysis

Background: Intraoperative computed tomography (CT) allows surgeons to make adjustments during orbital fracture repair that may impact postoperative outcomes. Learning/Study Objectives: To determine the impact of intraoperative CT use on intraoperative revision and surgical outcomes for orbital fracture repair. Methods: A systematic review was performed in concordance with the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines: the population was patients undergoing orbital fracture repair; intervention was use of intraoperative CT; comparison was patients not undergoing intraoperative CT; and outcomes were intraoperative revision rate, postoperative complications, and secondary revision surgeries. Meta-analysis was performed on the rate of intraoperative revision. Results: The search criteria yielded 790 articles, 377 were eligible for review, and 20 articles met criteria for analysis. In 19, intraoperative imaging led to immediate surgical corrections, with a random pooled effect size of 0.27 (0.20-0.35). Six studies reported secondary revision surgery rates (range 0-10.5%), and six studies reported postoperative complication rates (range 10-30%). Conclusions: Intraoperative imaging helps surgeons make precise, real-time adjustments in 27% of orbital fracture repair cases, which may improve surgical outcomes; however, more research is needed to investigate its impact on health care costs, operating time, and radiation exposure.

The Value of Intraoperative Computed Tomography in the Treatment of Zygomatic Complex Fractures

BACKGROUND

Due to the complex anatomical morphology and lack of anatomic markers on the surface of zygomatic complex (ZMC), the treatment results of ZMC fractures are often suboptimal.

PURPOSE

The study aimed to evaluate the effectiveness of intraoperative computed tomography (ICT) in the treatment of unilateral ZMC fractures, and further study the feasibility of ICT to replace early postoperative Computed Tomography (CT).

STUDY DESIGN, SETTING, AND SAMPLE

The investigators designed a retrospective cohort study. Adult patients who underwent surgery with unilateral ZMC fractures were enrolled.

PREDICTOR VARIABLE

According to whether intraoperative CT was used, the subjects were divided into the ICT group and the control group (without ICT).

MAIN OUTCOME VARIABLES

Five distances and 3 angles representing bilateral ZMC symmetry were main outcome variables. The differences of outcome variables were compared between the 2 groups and the indices of ICT group were further compared with their postoperative indices.

COVARIATES

Demographics (eg age), etiology (eg traffic injury), dysfunction (eg diplopia), and surgical approach (eg vestibular incision) were collected as covariates while we conducted clinical investigation, examination, and implementation.

ANALYSES

The data were analyzed using independent-samples t test, paired-samples t test, Mann-Whitney U test, and χ2 test. P value < .05 was considered statistically significant.

RESULTS

A total of 60 patients (18 to 59 years) were enrolled in this study. All median values of the measurements in the ICT group were smaller than those in the control group, and the differences of horizontal displacement distance (0.56 vs 1.02 mm), anteroposterior displacement distance (1.69 vs 2.34 mm, 0.90 vs 2.35 mm), horizontal angle of bilateral zygomatic arch (2.31 vs 4.19°), and horizontal angle of bilateral zygomatic process (1.77 vs 2.94°) were significantly different between the 2 groups with P value < .05. Moreover, there was no statistically significant difference in all indices between the intraoperatively and postoperatively injured sides in the ICT group.

CONCLUSIONS

ICT can improve the treatment outcomes of ZMC fractures by evaluating the fracture reduction adequacy during surgery. Moreover, ICT can replace early postoperative CT.

Justifying the implementation of intraoperative computed tomography for midface fracture treatment in improving outcomes

Intraoperative CT scanning is the international standard for treating midface fractures as it allows intraoperative assessment of reduction and fixation. To our knowledge, no NHS hospital in the UK has this facility yet due to the financial and logistical burden of its implementation. The aim of this study was to determine if complications including the requirement for a return to theatre (RTT) could have been predicted from the post-fixation CT scan. All treated midface fractures that had presented to a regionalised major trauma centre within two years (01 January 2020 - 31 December 2021) were identified. Those developing complications including RTT were determined. All postoperative CT scans (including those without complication or RTT) were re-analysed with the clinicians blinded to the outcomes to determine the positive predictive value (PPV) and negative predictive value (NPV) of requiring RTT to alter plate position intraoperatively based on CT scan alone. In all, there were eight episodes of unplanned return to theatre, resulting in an overall RTT rate of 8/119 (6.7%). When only analysing patients treated for orbital fractures this RTT rises to 8/40 (20%). Of those eight patients who had a postoperative CT and required RTT, this could have been predicted in 7/8 (87.5%). A total of 16/44 (36.4%) patients that did not have RTT would have additionally been recommended to have the plate position altered based on CT alone. Based upon those that had a CT, the PPV of CT alone being able to predict those requiring RTT was 40.6% and the NPV 96.2%. Our results would suggest intraoperative CT would likely have prevented eight patients requiring RTT in two years and could have improved outcomes in 16 cases. In preventing RTT as well as potentially improving the outcomes of a further 16 cases in maxillofacial surgery, the purchase of an intraoperative CT scanner could yield net savings of £75534-£114990 over two years.

Secondary Correction of Posttraumatic Enophthalmos

Posttraumatic enophthalmos (PE) arises when the ocular globe is displaced posteriorly and inferiorly in the orbital cavity due to a mismatch in orbital volume and orbital content. This most commonly happens after orbital fractures. The resulting disruptions to aesthetic form and ocular functions often necessitate surgical correction for reconstruction and restoration. The purpose of surgical management of PE is to reconstruct orbital shape and volume as well as to restore any herniated orbital content. This can be particularly challenging in cases involving large defects that require complex orbital reconstruction. Recent advancements in computer-aided surgery have introduced innovative and important tools to assist surgeons with these difficult cases. The ability to create customized, patient-specific implants can facilitate reconstruction involving complicated anatomy. Additionally, intraoperative imaging and intraoperative navigation can serve as useful guides for surgeons to more accurately place implants, especially in cases with limited visualization, in order to achieve optimal outcomes.

Three-dimensional intraoperative computed tomography imaging for zygomatic fracture repair

Objectives

Zygomatic complex (ZMC) fractures comprise up to 40% of all facial fractures. Misaligned bone fragments and misplaced fixation hardware traditionally detected postoperatively on plain radiographs of the skull might require re-operation. The intraoperative O-Arm (Medtronic, USA) is a three-dimensional (3D) computed tomographic imaging system.

Materials and Methods

This retrospective single-center study evaluated the utility of O-Arm scanning during corrective surgeries for ZMC and zygomatic arch (ZA) fractures from 2018 to 2020. Three females and 16 males (mean age, 31.52 years; range, 22-48 years) were included. Fracture instability (n=6) and facial deformity (n=15) were the most frequent indications for intraoperative 3D O-Arm scan.

Results

The images demonstrated that all fracture lines were properly reduced and fixed. Another scan performed at the end of the fixation or reduction stage, however, revealed suboptimal results in five of the 19 cases, and further reduction and fixation of the fracture lines were required.

Conclusion

Implementation of an intraoperative O-Arm system in ZMC and ZA fracture surgeries assists in obtaining predictable and accurate results and obviates the need for revision surgeries. The device should be considered for precise operations such as ZMC fracture repairs.

Rubber Bullet Induced Traumatic Brain Injury

ABSTRACT

Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

Implications of Applying New Technology in Cosmetic and Reconstructive Facial Plastic Surgery

The field of facial plastic and reconstructive surgery is privy to a myriad of technological advancements. As innovation in areas such as imaging, computer applications, and biomaterials progresses at breakneck speed, the potential for clinical application is endless. This review of recent progress in the implementation of new technologies in facial plastic surgery highlights some of the most innovative and impactful developments in the past few years of literature. Patient-specific surgical modeling has become the gold standard for oncologic and posttraumatic reconstructive surgery, with demonstrated improvements in operative times, restoration of anatomical structure, and patient satisfaction. Similarly, reductions in revision rates with improvements in learner technical proficiency have been noted with the use of patient-specific models in free flap reconstruction. In the cosmetic realm, simulation-based rhinoplasty implants have drastically reduced operative times while concurrently raising patient postoperative ratings of cosmetic appearance. Intraoperative imaging has also seen recent expansion in its adoption driven largely by reports of eradication of postoperative imaging and secondary-often complicated-revision reconstructions. A burgeoning area likely to deliver many advances in years to come is the integration of bioprinting into reconstructive surgery. Although yet to clearly make the translational leap, the implications of easily generatable induced pluripotent stem cells in replacing autologous, cadaveric, or synthetic tissues in surgical reconstruction are remarkable.

Impact of intraoperative cone beam computed tomography in the management of zygomatic fractures

AIM

To evaluate the impact of intraoperative cone beam computed tomography (CBCT) assessment for the surgical management of zygomatic bone fracture (ZF).

METHODS

A prospective study was conducted on patients operated on for unilateral ZF during a two-year period. Repositioning of the fractured zygoma was assessed intraoperatively by measuring the position of malar eminences in three dimensions on CBCT. A difference of more than 2 mm between both sides was considered significant and the reduction was judged inadequate. Surgical procedure was adapted to intraoperative imaging findings.

RESULTS

The surgical procedures of 47 patients treated for ZF were analyzed. In 15% of the cases (7 patients), the intraoperative CBCT showed an inadequate reduction while the morphological results seemed correct. Those patients benefited from an immediate correction of the reduction. From these 7 patients, reduction was optimized further without the need of osteosynthesis in one case, additional osteosynthesis was performed in 4 cases and 2 patients required both reduction and osteosynthesis revision.

CONCLUSION

Intraoperative CBCT control helps to achieve anatomic repositioning in case of ZF. It may reduce the risk of under-treatment and possible reoperation, and of over-treatment meaning systematic ORIF in all fractures.

Does Intraoperative Computed Tomography Scanning in Maxillofacial Trauma Surgery Affect the Revision Rate?

PURPOSE

The purpose of this study was to determine how intraoperative computed tomography affects the intraoperative revision rate and consequently the post-operative, secondary corrective surgery in maxillofacial trauma surgeries.

PATIENTS AND METHODS

A retrospective study composed of patients with facial fractures was conducted in Prince Sultan Military Medical City in Riyadh, Saudi Arabia. The predictor variables were age, gender, site of facial fracture, type of treatment, number of scans per patient, and discharge time. The primary outcome variable was immediate intraoperative revision rate. Secondary outcome variable was total scanning time (recorded from the moment surgery was halted until it was resumed after image acquisition). Descriptive statistics were used; numerical data presented as mean ± SD and categorical variables as frequency (%).

RESULTS

A total of 22 patients underwent 25 intraoperative scans while undergoing different maxillofacial surgeries. Eleven (50%) required intraoperative revisions after the scans, and 3 (13.6%) cases had another intraoperative scan after revision. Eighteen were men and 4 were women. The mean age was 30 years and age range was 19 to 76. Cases were categorized by fracture location and treatment preformed. The mean scanning time was 18.9 ± 4.6 minutes. The highest rate of revisions was seen in zygomaticomaxillary complex fractures (63.6%), they were also the only cases that required a second intraoperative scan after revision to confirm final reduction. No complications were seen postoperatively, and all patients recovered uneventfully. None of the patients required a secondary corrective surgery. All patients were discharged on the following day, except 1 case which was admitted under another service.

CONCLUSIONS

The use of intraoperative computed tomography imaging in treating maxillofacial fractures results in a higher rate of intraoperative revisions, which in turn leads to more accurate fracture reduction and consequently reduces the possibility of a postoperative, secondary corrective surgery.

Management of Zygomaticomaxillary Complex Fractures Utilizing Intraoperative 3-Dimensional Imaging: The ZYGOMAS Protocol

PURPOSE

Utilization of technology to aid in the assessment, planning, and management of complex craniomaxillofacial injuries is increasingly common. Limited data exist regarding the implication of intraoperative CT/3-Dimensional imaging on decision making in the management of zygomaticomaxillary complex (ZMC) fractures. This study characterizes the utilization of the intraoperative CT scanner for ZMC fracture surgery and analyzes the impact of the intraoperative CT scanner on fracture management. Using these findings, we sought to propose an algorithm to guide the appropriate utilization of intraoperative 3-Dimensional imaging in ZMC fracture surgery.

METHODS

This retrospective case series evaluates the use of the intraoperative CT scanner for orbitozygomatic trauma surgery at a level 1 trauma center from February 2011 to September 2016. We evaluated the preoperative CT images assessing for the number of displaced sutures, the presence of adjacent fractures requiring fixation, the presence of comminution of the zygomaticomaxillary buttress or body of the zygoma, as well as the number of axes displaced ≥ 5 mm. This information was evaluated to provide guidance on the appropriate utilization of the intraoperative scanner in ZMC fracture management.

RESULTS

A total of 71 patients were identified to have intraoperative facial CT scans and surgery for ZMC fractures over the study time period. There was a 23.9% (17/71) CT directed revision rate. There was a significantly increased likelihood of CT directed revision for fractures with adjacent fractures requiring fixation, and those with ≥ 2 axes displaced ≥ 5 mm. Using these findings, we proposed the ZYGOMAS algorithm outlining the indications for use of intraoperative CT in management of ZMC fractures.

CONCLUSIONS

If available, intraoperative CT/3-Dimensional imaging should be utilized in the management of ZMC fractures with the requirement for orbital floor reconstruction, where adjacent fractures require fixation and/or when ≥ 2 axes are displaced ≥ 5 mm.

Clinical outcome following intraoperative computed tomography-assisted secondary orbital reconstruction

BACKGROUND

Secondary post-traumatic orbital reconstructions are challenging. Portable computed tomography (CT) provides the option to acquire real-time, intraoperative images that help to detect the insufficient reconstruction of the orbit immediately. We retrospectively analyzed patients who received intraoperative CT imaging and analyzed the effect of intraoperative CT scans on revision rates and orbital volume changes before, during, and after surgery.

METHODS

From August 2014 to September 2016, eleven patients received intraoperative cone-beam CT scans to evaluate the results of secondary orbit reconstruction using Medpor + titanium implants. Patient demographics, surgical details, CT scanning protocol, and follow-up results were analyzed. 3D CT volumetry was used to analyze the orbital volume based on OsiriX MD software.

RESULTS

Based on intraoperative CT findings, seven cases required intraoperative revision to further augment the orbital cavity or adjust implants. The mean preoperative measured enophthalmos was 3.41±1.4 mm (range: 2-6 mm), which decreased to 0.73±0.4 mm (range: 0-1 mm) at postop assessment (p<0.0001). On the fracture side, there was a significant difference between preoperative vs. intraoperative and preoperative vs. postoperative volume measurements (p<0.01 for both subsets), but no significant difference between intraoperative vs. postoperative measurements.

CONCLUSION

Intraoperative CT is a valuable tool in secondary orbital reconstruction cases based on clinical enophthalmos evaluation and 3D CT volumetry. For these patients, the avoidance of another revision surgery may outweigh the disadvantage of increased operation time and additional radiation exposure.

Evaluation of Open Reduction and Internal Fixation of Mandibular Condyle Fracture by Intraoperative Cone-Beam Computed Tomography in a Hybrid Operating Room

Condylar fractures are the most common fractures of the mandible, and treatment of mandibular condylar fractures by maxillofacial surgeons is a very important procedure. However, the surgical approaches have anatomical limitations. Therefore, it is difficult to evaluate the reduction achieved in open reduction and internal fixation because of the uncertainty in securing a sufficient operative field. As a potential solution, the authors evaluated the benefits of intraoperative cone-beam computed tomography (CBCT) with high image quality performed in a hybrid operating room. Intraoperative CBCT is easy to perform in a hybrid operating room, and it is possible to quickly evaluate high-quality CT images, including 3D images. Because the state of reduction of mandibular condylar fractures also affects the prognosis of treatment, more precise reduction and fixation should improve prognoses. The use of CBCT in a hybrid operating room also avoids re-operation, and patients benefit from minimum invasive surgery. Intraoperative CBCT is a very useful strategy for evaluation of mandibular condylar fracture surgical treatment.

Intraoperative imaging and navigation with mobile cone-beam CT in maxillofacial surgery

INTRODUCTION

Intraoperative mobile Cone-Beam Computed Tomography (CBCT) trends to develop for the management of complex facial fractures. It allows a real-time imaging and surgical navigation.

AIM

Through the presentation of two clinical cases, we aimed at presenting the procedure of intra-operative CBCT and new applications in maxillofacial surgery.

RESULTS

A young patient with extended orbito-frontal fibrous dysplasia, and a child with the recurrence of a temporomandibular joint ankylosis secondary to mastoïditis, were operated using a intra-operative imaging control. In both cases, the intraoperative CBCT increased precision and safety of the bone resection. No surgical complication was noted and a good healing was obtained.

CONCLUSION

Intraoperative CBCT raises the problems of radiation exposure and increased operating time. However, it represents a useful imaging tool and a navigation system in complex situations as osseous dysplasia and surgery of the temporo-mandibular joint.

A study protocol for a randomised controlled trial evaluating the effects of intraoperative computed tomography on the outcomes of zygomatic fractures

Background

Zygomaticomaxillary complex (ZMC) and zygomatic arch (ZA) fractures are common injuries resulting from facial trauma and frequently require surgical management (Huang et al., Craniomaxillofac Trauma Reconstr 8(4):271-6, 2015). A substantial number of post-operative functional and cosmetic complications can arise from the surgical management of these fractures. These include scarring, inadequate facial profile restoration, facial asymmetries and diplopia (Ellis et al. J Oral Maxillofac Surg 54(4):386-400, 1996; Yang et al. Oral Maxillofac Surg Clin North Am 23(1):31-45, 2011; Kloss et al. Int J Oral Maxillofac Surg 40(1):33-7, 2011). Intuitively, most of these aforementioned complications arise as a result of inadequate fracture reduction; however, current standard practice is to assess reduction post-operatively through plain radiographs or computed tomography (CT) scans. The role of intra-operative CT scanning to assess the reduction of ZMC/ZA fractures and the potential impact on complications, has thus far not been established.

Methods

This is a prospective randomised controlled trial currently being undertaken at the Royal Brisbane and Women’s Hospital. All patients who require operative management of their ZMC or ZA fractures are offered enrollment in the trial. The patients are randomised into two groups: interventional (intra-operative CT) and control (no intra-operative CT). All patients in each group will have post-operative radiographs taken. From these radiographs, the reduction of the ZMC and/or ZA fracture is graded by a blinded assessor. Patients will be reviewed in clinic at 1 week and 6 weeks post-surgery. During these consultations, all patients will be assessed for scarring, diplopia, facial profile restoration and need for revision surgery.

Discussion

Many complications associated with surgical management of ZMC and ZA fractures involve poor aesthetic results as a direct consequence of inadequate fracture reduction. Inadequate fracture reduction is predictable given that small incisions are used and only limited visualisation of the fractures is possible during the procedure. This is due to a desire to limit scarring and reduce the risk of damage to vital structures in an aesthetically sensitive region of the body. It follows that an intraoperative adjunctive tool such as a CT scan, which can assist in visualisation of the fractures and the subsequent reduction, could potentially improve reduction and reduce complications.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12616000693426. Registered on 26 May 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3625-8) contains supplementary material, which is available to authorized users.

Intraoperative Computed Tomography Scan for Orbital Fracture Reconstruction

Orbital fractures pose specific challenge in its surgical management. One of the greatest challenges is to obtain satisfactory reconstruction by correct positioning of orbital implant. Intraoperative computed tomography (CT) scan may facilitate this procedure. The aim of this study was to describe the early use of intraoperative CT in orbital fractures repair in our center. The authors assessed the revision types and rates that have occurred with this technique. With the use of pre-surgical planning, optical intraoperative navigation, and intraoperative CT, the impact of intraoperative CT on the management of 5 cases involving a total number of 14 orbital wall fractures were described. There were 6 pure orbital blowout wall fractures reconstructed, involving both medial and inferior wall of the orbit fracturing the transition zone and 8 impure orbital wall fractures in orbitozygomaticomaxillary complex fracture. 4 patients underwent primary and 1 had delayed orbital reconstruction. Intraoperative CT resulted in intraoperative orbital implant revision, following final navigation planning position, in 40% (2/5) of patients or 14% (2/14) of the fractures. In revised cases, both implant repositioning was conducted at posterior ledge of orbit. Intraoperative CT confirmed true to original reconstruction of medial wall, inferior wall and transition zone of the orbit. Two selected cases were illustrated. In conclusion, intraoperative CT allows real-time assessment of fracture reduction and immediate orbital implant revision, especially at posterior ledge. As a result, no postoperative imaging was indicated in any of the patients. Long-term follow-ups for orbital fracture patients managed with intraoperative CT is suggested.

New and emerging patient-centered CT imaging and image-guided treatment paradigms for maxillofacial trauma

This article reviews the conceptual framework, available evidence, and practical considerations pertaining to nascent and emerging advances in patient-centered CT-imaging and CT-guided surgery for maxillofacial trauma. These include cinematic rendering-a novel method for advanced 3D visualization, incorporation of quantitative CT imaging into the assessment of orbital fractures, low-dose CT imaging protocols made possible with contemporary scanners and reconstruction techniques, the rapidly growing use of cone-beam CT, virtual fracture reduction with design software for surgical pre-planning, the use of 3D printing for fabricating models and implants, and new avenues in CT-guided computer-aided surgery.

Management of Zygomaticomaxillary Complex Fractures

Zygomaticomaxillary fractures account for approximately 25% of all facial fractures. They can be grouped into high-velocity and low-velocity injuries. A complete head and neck examination is critical for accurate clinical diagnosis. A thin-cut axial CT scan with sagittal, coronal, and 3-D reconstruction is important for accurate diagnosis and treatment planning. A thorough understanding of bony tetrapod anatomy and fracture mechanics is critical to treatment planning. Treatment options include closed and open reduction with internal fixation. Computer-aided applications can reduce the need for open reduction and improve the accuracy of both closed and open repairs.

Use of a Balloon Catheter With Intraoperative C-Arm Fluoroscan for Reduction of Zygomatic Arch Fractures

BACKGROUND AND OBJECTIVES

The purpose of this study was to evaluate the usefulness of C-arm fluoroscan with a balloon catheter in patients undergoing closed reduction of zygomatic arch fractures.

SUBJECTS AND METHODS

All patients who had zygomatic arch reduction surgery between 2006 and 2015 were identified and classified into 2 groups. Group A included those patients who underwent closed reduction of zygomatic arch fractures. Group B included those who underwent zygomatic arch reduction surgery with a C-arm fluoroscan and supporting balloon. A balloon catheter was used to stabilize the zygomatic bone after reduction. Results were scored from 1 (poor) to 3 (good) to assess surgical outcomes based on 3 criteria: alignment of the zygomatic arch on a postoperative computed tomography scan, facial asymmetry in photography, and the patient's subjective satisfaction.

RESULTS

The authors enrolled 32 patients with zygomatic arch fractures. 18 patients underwent closed reduction for zygomatic arch fractures (group A), while 14 patients underwent closed reduction with C-arm fluoroscan and balloon support (group B). The average score for group A was 2.00 for alignment, 2.56 for facial asymmetry, and 2.67 for subjective satisfaction compared with 2.64 for alignment, 2.86 for facial asymmetry, and 2.79 for subjective satisfaction in group B. There were statistically significant differences in the alignment and facial asymmetry scores between the 2 groups.

CONCLUSION

The authors suggest that C-arm fluoroscan with balloon support is a useful modality for reduction of zygomatic arch fractures that provides better surgical outcomes than conventional closed reduction surgery.

Management of Zygomatic Fractures: A National Survey

INTRODUCTION

Repair of zygomatic fractures can be classified into the early closed reduction or the more recent open reduction and rigid internal fixation (ORIF) methods. Surgical training and literature advocate ORIF, but the actual frequency of the different techniques in clinical practice is unknown. The purpose of this study was to determine the current trends in the management of zygomatic fractures among US surgeons and elucidate their influences.

METHODS

A 10-question survey was developed and distributed to over 16,000 practicing US facial trauma surgeons, including plastic surgeons (PS), oral and maxillofacial surgeons (OMFS), and otorhinolaryngologists (ENT). The survey queried training background, zygoma fracture treatment preferences, and rationale. Responses were tabulated and both univariate and bivariate statistical analyses completed.

RESULTS

One thousand six hundred eleven (10%) total responses were received. Zygomatic fractures are treated most commonly by OMFS (61%), then PS (20%) and ENT (19%), with 71% of repairs being performed in private practice. Open reduction and rigid internal fixation is the most common treatment modality (81%), with most surgeons using 2 to 3 sites for exposure, reduction, and fixation with titanium miniplates (70%). Thirty-five percent of surgeons perform routine orbital floor exploration. Forty-three percent quoted training and 32% reported accuracy of repair as the primary reason for choosing ORIF.

CONCLUSIONS

This is the largest reported survey on the repair of zygoma fractures. The response rate suggests dominance of OMFS in zygoma fracture care, an area pioneered by PS. Evolution of technique is also evident by predominance of ORIF with emphasis of multiple points of exposure, reduction, and fixation with rigid hardware.

Current Management of Zygomaticomaxillary Complex Fractures: A Multidisciplinary Survey and Literature Review

Despite the prevalence of zygomaticomaxillary complex (ZMC) fractures, there is no consensus regarding the best approach to management. The aim of this study is to determine differences in ZMC fracture treatment among various surgical specialties. A survey was conducted regarding treatment of patients with different ZMC fractures that included a minimally displaced fracture (Case 1), a displaced fracture without diplopia (Case 2), a displaced fracture with diplopia (Case 3), and a complex comminuted fracture (Case 4). The survey was distributed to members of plastic surgery, oral maxillofacial surgery, and otolaryngology societies. The rates of surgical treatment, exploration of the orbital floor, and plating three or more buttresses were analyzed among the specialties. A total of 173 surgeons participated (46 plastic and reconstructive surgeons, 25 oral and maxillofacial surgeons, and 102 otolaryngologists). In Case 1, a significantly higher percentage of plastic surgeons recommend an operation (p < 0.01) compared with other specialties. More than 90% of surgeons would perform an operation on Case 2. Plastic surgeons explored the orbital floor (p < 0.01) and also fixated three or more buttresses more frequently (p < 0.01). More than 93% of surgeons would operate on Case 3, with plastic surgeons having the greatest proportion who fixed three or more buttresses (p < 0.01). In Case 4, there was no difference in treatment patterns between specialties. Across the specialties, more fixation was placed by surgeons with fewer years in practice (<10 years). Conclusion There is no consensus on standard treatment of ZMC fractures, as made evident by the survey. Significant variability in fracture type warrants an individualized approach to management. A thorough review on ZMC fracture management is provided.

[Intraoperative quality management modalities in head and neck surgery]

Immediate intraoperative control via suitable imaging techniques is necessary to achieve the best possible surgical outcome. Intraoperative imaging increases patient safety, offers the surgeon direct support in challenging anatomic regions, and affords the possibility of direct correction with a reduced rate of corrective surgery. The procedures are based on cone beam computed tomography (CBCT), endoscopy, or navigation-assisted surgery. This article describes available intraoperative quality management modalities for fracture management and tumor treatment in the field of head and neck surgery.

Controversies in the Management of the Trauma Patient

Facial trauma is a significant cause of morbidity in the United States. Despite the large volume of trauma surgeries at most academic institutions, there is still controversy regarding management of many traumatic injuries. The literature lacks clear-cut best practices for most fractures. In orbital trauma, there is debate about the optimal timing of repair, preferred biomaterial to be used, and the utility of evaluation afterward with intraoperative computed tomographic scan. In repair of mandible fractures, there is debate regarding open versus closed reduction of subcondylar fractures, or alternatively, endoscopic repair.

Use of Intraoperative Computed Tomography for Revisional Procedures in Patients with Complex Maxillofacial Trauma

Background:

In patients with panfacial fractures and distorted anatomic landmarks of zygomatic and orbital complex, there is a risk of zygomaticomaxillary complex (ZMC) malpositioning even with the best efforts for surgical repair. This results in increased number of additional procedures to achieve accurate positioning.

Methods:

We describe the usage of intraoperative C-arm cone-beam computed tomographic (CT) scan for ZMC malpositioning in a representative patient with panfacial fractures.

Results:

We have successfully used intraoperative CT scan for ZMC malpositioning in 3 patients. The representative patient had ZMC malposition after the initial attempt of surgical repair without any intraoperative imaging. On using intraoperative CT scan during the next attempt, we were able to reposition the ZMC accurately.

Conclusions:

Intraoperative CT scan might improve the accuracy of ZMC positioning and decrease the chances of potential additional surgeries. In patients with distorted anatomical landmarks and panfacial fractures, it can be especially helpful toward correcting ZMC malposition.

C-arm assisted zygoma fracture repair: a critical analysis of the first 20 cases

PURPOSE

Currently used open reduction and internal fixation techniques of zygoma fracture repair are not optimal. Surgical exposure of those sites needed to allow for accurate reduction and for rigid fixation has a high possibility of negative consequences. The objective of the present study was to present a single-incision, single-fixation site zygoma fracture repair technique using a single zygoma c-arm view to quantitatively determine its accuracy, complication rate, and practical aspects in a clinical series.

MATERIALS AND METHODS

In a prospective study, consecutive patients with isolated, unilateral, displaced zygoma fractures not requiring orbital floor exploration treated using a c-arm-assisted repair technique at the author's institution from 2009 to 2011 were included. Objective outcomes assessed included accuracy of zygoma realignment (on postoperative computed tomogram), ocular globe projection symmetry (using a Naugle exophthalmometer), complication rate, and operative duration. Statistical analysis was performed using the Student t test.

RESULTS

Twenty patients were included. Differences in zygoma projection, width, and height between the uninjured and repaired sides of the face were clinically noteworthy (>3 mm) in the first patient only. Average differences of these parameters for all 20 patients were clinically and statistically insignificant. Differences in ocular globe projection between the uninjured and repaired sides of the face for each patient were no greater than 2 mm. The average difference in globe projection for all 20 patients was also clinically and statistically insignificant. No major complications occurred, and the average operative duration was 76 minutes.

CONCLUSIONS

The present study shows that the c-arm-assisted zygoma fracture repair technique is accurate, has a low complication rate, can be performed quickly, and has a relatively low level of difficulty.

Use of intraoperative computed tomography in complex craniofacial trauma: an example of on-table change in management

The primary goals in repairing complex craniofacial fractures are restoration of occlusion and mastication, and anatomic reconstruction of a symmetric facial skeleton. Failure to accomplish these goals may result in the need for secondary operations. Recognition of malreduction may not be appreciated until review of a postoperative computed tomographic (CT) scan. Intraoperative CT scanning enables immediate on-table assessment of reduction and fixation, allowing alteration of the surgical plan as needed. We report using intraoperative CT scanning while repairing a panfacial injury in which malreduction was appreciated intraoperatively and corrected. Intraoperative CT can be used to improve outcomes and quality of complex facial fracture repair.

Ratio of Simple versus Comminuted Lateral Wall Fractures of the Orbit

Reduction of a fracture may be relatively easy with a simple, noncomminuted fracture along the zygomaticofrontal suture, zygomaticomaxillary buttress, or the inferior rim of the orbit. When one or more of these key landmarks is comminuted, it becomes more important to confirm that the fracture commonly seen between the greater wing of the sphenoid and the zygoma is properly repositioned. The zygomaticosphenoidal suture is an excellent landmark with a simple lateral orbital wall fracture (LOWF), but it may not be reliable in patients with a comminuted fracture. The purpose of this study is to determine the frequency that the lateral orbital wall (LOW) is a reliable landmark in the reduction of a zygoma fracture by determining the ratio between simple versus comminuted LOWF. To identify 100 patients with a LOWF, the authors reviewed consecutive midface computed tomography images of 877 patients performed over a 25-month period from one of our city's primary Level I trauma and teaching hospitals. A total of 121 LOWF were identified in 100 patients. In 60.3% of cases the facture was a simple, noncomminuted LOWF. In 39.7% of cases the fracture was comminuted (p = 0.023). Simple LOWF are significantly more common than comminuted fractures. In 39.7% of fractures the LOW is comminuted. This suggests that there are many fractures in which other modalities may be much more important to use to confirm the proper reduction of the zygoma.

Closed reduction of mandibular condyle fractures using C-arm fluoroscopy: a technical note

We describe a C-arm technique for mandibular condylar fractures in an anatomic study using a model skull and show its feasibility in a clinical case. The C-arm allowed posterior-anterior visualization of the condylar process. The X-ray axis was canted ∼15 degrees cranially to the Frankfort horizontal line. The skull's sagittal plane was rotated ∼15 degrees ipsilaterally to the X-ray axis. This technique facilitates clear visualization of the condylar neck with easy, flexible, and timely adjustments. In selected cases, this method would convert the clinical settings of the condylar fracture pattern to that which would not be amenable to an open approach, making possible minimally invasive surgical procedures.

C-arm-guided reduction of zygomatic fractures revisited

BACKGROUND

Anatomic reduction of the zygomatic arch, a key surgical landmark for midfacial width and projection, is essential for the treatment of combined fractures of the zygomaticomaxillary complex and zygomatic arch. Reduction control in surgery for this common facial fracture would be facilitated by intraoperative real-time assessment using widely available and reliable equipment. Although C-arm fluoroscopy is routinely used in the repair of orthopedic fractures, its use in the maxillofacial region, particularly for combined zygomatic fractures, has been scarcely reported.

METHODS

We prospectively evaluated C-arm-guided reduction in 38 patients of combined zygomatic fracture without concurrent craniofacial fractures. Patients were classified according to the presence or absence of bone contact in the displaced zygomatic arch, namely as conserved (C) and loss (L) types, respectively. Reduction status was determined by the degree of recovery of the malar prominence and arch shape.

RESULTS

In all cases, C-arm imaging clearly displayed the displaced zygomatic arch and body in a single image. Cumulative fluoroscopic time was a few minutes in all cases. Total reduction status was excellent in 21 patients and good in 17. No case was classified as fair or poor. Repair was significantly more favorable in type C than in type L cases (p = 0.0016).

CONCLUSIONS

In combined zygomatic fractures, the C-arm technique provides easy, flexible, and time-efficient adjustment. Its comprehensive imaging for zygomatic arch shape and body contour markedly facilitates the control of fracture reduction and protects against unexpected, unsatisfactory outcomes.

Three-dimensional analysis of zygomatic-maxillary complex fracture patterns

Zygomatic-maxillary (ZMC) complex fractures are a common consequence of facial trauma. In this retrospective study, we present a novel method of ZMC fracture pattern analysis, utilizing three-dimensional visualization of computed tomography (CT) images to record displacement of the malar eminence in a three-dimensional coordinate plane. The pattern of fracture was then correlated with treatment outcome. Facial CT scans were obtained from 29 patients with unilateral ZMC fractures and 30 subjects without fractures and analyzed. Briefly, displacement of the malar eminence (ME) on the fractured side was measured in medial-lateral (x), superior-inferior (y), and anterior-posterior (z) dimensions, as well as Euclidean distance, by comparison to ME location on the unfractured side. Baseline natural variance in asymmetry was accounted for by comparing ME location on the left and right sides in subjects without fractures. Patients who required open reduction and internal fixation (ORIF) to repair the ZMC fracture alone had significantly greater cumulative ME displacements than patients who did not require ORIF (p = 0.02). Additionally, patients with a high fracture score of 3, 4, or 5 (assigned based on severity displacement in each dimension) had significantly higher rates of ORIF than patients with a low fracture score of 0, 1, or 2 (p = 0.05). Severe displacement in one or more dimensions was associated with higher rates of ORIF than seen in patients with only neutral or mild displacements in all dimensions (p = 0.05). Severe x displacement was most strongly correlated with surgical intervention (p = 0.02). Overall, orbital floor repair was less strongly associated with most displacement measures than ZMC repair alone; however, patients requiring orbital floor repair had greater Euclidean ME displacements than patients who did not require orbital floor repair (p = 0.02). Fracture severity, as determined by multiple parameters in this novel evaluation system, is associated with higher rates of ORIF in patients with unilateral ZMC fractures. Determination of ZMC fracture pattern may thus be informative when considering treatment options.

Mirror imaging and preshaped titanium plates in the treatment of unilateral malar and zygomatic arch fractures

OBJECTIVE

The aim of this study is to discuss the application of mirror imaging and preshaped titanium plates in the treatment of unilateral malar and zygomatic arch fractures.

STUDY DESIGN

Four patients with unilateral malar and zygomatic arch fractures were included in this study. All patients underwent preoperative CT scan. CT data were processed with Surgicase. Two 3D skull models were reconstructed using a rapid prototyping device. The first model was the original model obtained from CT scanning; the other model was obtained by mirroring the unaffected side onto the fractured side. Simulation surgery was performed on the first model. For the second model, titanium plates were shaped in advance and a resinous guide plate was created to guide surgical reduction. When using the resinous guide plates, 4 patients' fractures were reduced and fixed with preshaped titanium plates. The pre- and postoperative displacement of zygomatic markers were analyzed in Surgicase.

RESULTS

According to the measurement of fracture displacements, the facial asymmetry of all 4 patients was greatly improved at the 1-month follow-up.

CONCLUSIONS

Mirror imaging and preshaped titanium plates are viable choices for the treatment of unilateral malar and zygomatic arch fractures. Combined use of these techniques can improve facial symmetry.

Portable head computed tomography scanner--technology and applications: experience with 3421 scans

OBJECTIVE

The use of head computed tomography (CT) is standard in the management of acute brain injury; however, there are inherent risks of transport of critically ill patients. Portable CT can be brought to the patient at any location.

METHODS

We describe the clinical use of a portable head CT scanner (CereTom: NeuroLogica: Danvers, MA) that can be brought to the patient's bedside or to other locations such as the operating room or angiography suite.

RESULTS

Between June of 2006 and December of 2009, a total of 3421 portable CTs were performed. A total of 3278 (95.8%) were performed in the neuroscience intensive care unit (ICU) for an average of 2.6 neuroscience ICU CT scans per day. Other locations where CTs were performed included other ICUs (n = 97), the operating room (n = 53), the emergency department (n = 1), and the angiography suite (n = 2). Most studies were non-contrasted head CT, though other modalities including xenon/CT, contrasted CT, and CT angiography were performed.

CONCLUSION

Portable head CT can reliably and consistently be performed at the patient's bedside. This should lead to decreased transportation-related morbidity and improved rapid decision making in the ICU, OR, and other locations. Further studies to confirm this clinical advantage are needed.