A retrospective study to compare the treatment outcomes with and without surgical navigation for fracture of the orbital wall

Intraoperative Image Guidance in Orbital and Lacrimal Surgery: A Report by the American Academy of Ophthalmology

PURPOSE

To review the efficacy and safety of the use of intraoperative image guidance (IIG) in orbital and lacrimal surgery.

METHODS

A literature search of the PubMed database was last conducted in November 2023 for English-language original research that assessed the use of any image guidance system in orbital and lacrimal surgery that included at least 5 patients. The search identified 524 articles; 94 were selected for full-text analysis by the panel. A total of 32 studies met inclusion criteria. The panel methodologist assigned a level II rating to 2 studies and a level III rating to 30 studies. No study met the criteria for level I evidence.

RESULTS

Procedures reported on were as follows: fracture repair (n = 14), neoplasm and infiltrate biopsy or excision (n = 6), orbital decompression for Graves ophthalmopathy (n = 3), dacryocystorhinostomy (n = 1), and mixed etiology and procedures (n = 8). Four studies used more than one IIG system. One study that met level II evidence criteria compared the outcomes of orbital fracture repair with IIG (n = 29) and without IIG (n = 29). Borderline better outcomes were reported in the IIG group: 2% versus 10% with diplopia (P = 0.039) and 3% versus 10% with enophthalmos (P = 0.065). The other level II study compared the repair of fractures with navigation (n = 20) and without (n = 20). The group in which navigation was used had a measured mean volume reduction of 3.82 cm3 compared with 3.33 cm3 (P = 0.02), and there was a greater measured reduction in enophthalmos in the navigation group of 0.72 mm (P = 0.001). Although the remaining 30 assessed articles failed to meet level II criteria, all alleged a benefit from IIG. No complications were reported.

CONCLUSIONS

A small number of comparative studies suggest that there are improved outcomes when IIG is used in orbital fracture repair, but each study suffers from various limitations. No high-quality comparative studies exist for the management of lacrimal surgery, neoplastic disease, or decompression. Complications attributable to the use of IIG have not been identified, and IIG has not been analyzed for cost savings.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Does a Point-of-Care 3-Dimensional Printer Result in a Decreased Length of Surgery for Orbital Fractures?

BACKGROUND

Utilization of point-of-care 3-dimensional printing (3DP) has decreased length of surgery in facial trauma. Little is known regarding 3DP's impact on length of surgery in orbital fracture.

PURPOSE

The purpose of this study was to compare length of surgery between 3DP/preadapted (3DPPA) orbital plates and intraoperative adapted plates (IOAP) for orbital fracture reconstruction.

STUDY DESIGN, SETTING, SAMPLE

This was a prospective, non-blinded, randomized clinical study of consecutive subjects with orbital fractures presented to Grady Memorial Hospital in Atlanta, Georgia, between January 2018 and June 2021. Subjects ≥ 18 years, unilateral fracture, no previous orbital surgery, and/or congenital craniofacial anomaly were included. We excluded subjects <18 years and bilateral fractures.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Primary predictor variable was the treatment approach. Randomization software was used, and subjects were randomized to 3DPPA or IOAP groups.

MAIN OUTCOME VARIABLE(S)

Primary outcome variable was length of surgery in minutes. Secondary outcomes were the time required for plate insertion and fixation in minutes, operating room (OR) charges, and orbital volume (OV) calculation.

COVARIATES

Age, sex, race, etiology, laterality, location, dimension, indication for surgery, postoperative enophthalmos, and diplopia.

ANALYSES

Univariate and bivariate analyses were calculated. Statistical significance was P < .05.

RESULTS

Twenty-five subjects met the inclusion criteria. Mean ages in 3DPPA and conventional IOAP groups were 41.5 (±9) and 38.2 (±10, P = .31), respectively. The mean length of surgery was 32.6 (±13.7) in 3DPPA and 53.3 (±12.8, P < .001) in conventional IOAP. The mean time required for plate insertion and fixation was 15.8n (±14.4) in 3DPPA and 41.4 (±9.4, P < .001) in conventional IOAP. The mean OR charges were $1,072.5 (±524.6) in 3DPPA and $1,757.3 (±422.6, P ≤ 0.001) in conventional IOAP. The mean calculated OV of uninjured and reconstructed orbit for the 3DPPA was 23.5 (±3.2)cm3 and 23 (±3.5, P = .37)cm3, respectively. The mean calculated OV of uninjured and reconstructed orbit for conventional IOAP was 28.6 (±3.6)cm3 and 22.8 (±2.6, P < .001)cm3, respectively.

CONCLUSION AND RELEVANCE

Using 3DP to produce a model that enables preoperative plate bending/adaptation reduces the length of surgery, decreases OR charges, and results in predictable OV.

Three-dimensional computer navigation in the reconstruction of complex unilateral orbital fractures: evaluation and review of applications

BACKGROUND

The eyes are the central aesthetic unit of the face. Maxillofacial trauma can alter facial proportions and affect visual function with varying degrees of severity. Conventional approaches to reconstruction have numerous limitations, making the process challenging. The primary objective of this study was to evaluate the application of three-dimensional (3D) navigation in complex unilateral orbital reconstruction.

METHODS

A prospective cohort study was conducted over 19 months (January 2020 to July 2021), with consecutive enrollment of 12 patients who met the inclusion criteria. Each patient was followed for a minimum period of 6 months. The principal investigator carried out a comparative analysis of several factors, including fracture morphology, orbital volume, globe projection, diplopia, facial morphic changes, lid retraction, and infraorbital nerve hypoesthesia.

RESULTS

Nine patients had impure orbital fractures, while the remainder had pure fractures. The median orbital volume on the normal side (30.12 cm3; interquartile range [IQR], 28.45-30.64) was comparable to that of the reconstructed orbit (29.67 cm3; IQR, 27.92-31.52). Diplopia improved significantly (T(10) = 2.667, p = 0.02), although there was no statistically significant improvement in globe projection. Gross symmetry of facial landmarks was achieved, with comparable facial width-to-height ratio and palpebral fissure lengths. Two patients reported infraorbital hypoesthesia at presentation, which persisted at the 6-month follow-up. Additionally, five patients developed lower lid retraction (1-2 mm), and one experienced implant impingement at the infraorbital border.

CONCLUSION

Our study provides level II evidence supporting the use of 3D navigation to improve surgical outcomes in complex orbital reconstruction.

Accuracy of surgical navigation for patient-specific reconstructions of orbital fractures: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to review the recent literature on the technical accuracy of surgical navigation for patient-specific reconstruction of orbital fractures using a patient-specific implant, and to compare surgical navigation with conventional techniques.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed (Medline), Embase, Web of Science, and Cochrane (Core Collection) databases on May 16, 2023. Literature comparing surgical navigation with a conventional method using postoperative three-dimensional computed tomography imaging was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy (angular accuracy, linear accuracy, volumetric accuracy, and degree of enophthalmos), preoperative and perioperative times, need for revision, complications, and total cost of the intervention. MINORS criteria were used to evaluate the quality of the articles.

RESULTS

After screening 3733 articles, 696 patients from 27 studies were included. A meta-analysis was conducted to evaluate volumetric accuracy and revision rates. Meta-analysis proved a significant better volumetric accuracy (0.93 cm3 ± 0.47 cm3) when surgical navigation was used compared with conventional surgery (2.17 cm3 ± 1.35 cm3). No meta-analysis of linear accuracy, angular accuracy, or enophthalmos was possible due to methodological heterogeneity. Surgical navigation had a revision rate of 4.9%, which was significantly lower than that of the conventional surgery (17%). Costs were increased when surgical navigation was used.

CONCLUSION

Studies with higher MINORS scores demonstrated enhanced volumetric precision compared with traditional approaches. Surgical navigation has proven effective in reducing revision rates compared to conventional approaches, despite increased costs.

The Use of Dynamic Navigation Systems as a Component of Digital Dentistry

The development of dynamic navigation system (DNS) has facilitated the development of modern digital medicine. In the field of dentistry, the cutting-edge technology is garnering widespread recognition. Based on the principles of 3-dimensional visualization, virtual design, and precise motion tracking, DNS is mainly composed of a computer, a tracking system, specialized tracer instruments, and navigation software. DNS employs a workflow that begins with preoperative data acquisition and imaging data reconstruction, followed by surgical instrument calibration and spatial registration, culminating in real-time guided operations. Currently, the system has been applied in a broad spectrum of dental procedures, encompassing dental implants, oral and maxillofacial surgery (such as tooth extraction, the treatment of maxillofacial fractures, tumors, and foreign bodies, orthognathic surgery, and temporomandibular joint ankylosis surgery), intraosseous anesthesia, and endodontic treatment (including root canal therapy and endodontic surgery). These applications benefit from its enhancements in direct visualization, treatment precision, efficiency, safety, and procedural adaptability. However, the adoption of DNS is not without substantial upfront costs, required comprehensive training, additional preparatory time, and increased radiation exposure. Despite challenges, the ongoing advancements in DNS are poised to broaden its utility and substantially strengthen digital dentistry.

Assessing the benefits of digital twins in neurosurgery: a systematic review

Digital twins are virtual replicas of their physical counterparts, and can assist in delivering personalized surgical care. This PRISMA guideline-based systematic review evaluates current literature addressing the effectiveness and role of digital twins in many stages of neurosurgical management. The aim of this review is to provide a high-quality analysis of relevant, randomized controlled trials and observational studies addressing the neurosurgical applicability of a variety of digital twin technologies. Using pre-specified criteria, we evaluated 25 randomized controlled trials and observational studies on the applications of digital twins, including navigation, robotics, and image-guided neurosurgeries. All 25 studies compared these technologies against usual surgical approaches. Risk of bias analyses using the Cochrane risk of bias tool for randomized trials (Rob 2) found "low" risk of bias in the majority of studies (23/25). Overall, this systematic review shows that digital twin applications have the potential to be more effective than conventional neurosurgical approaches when applied to brain and spinal surgery. Moreover, the application of these novel technologies may also lead to fewer post-operative complications.

Reconstruction of Medial Orbital Wall Using Autologous Perpendicular Plate of Ethmoid

The aim of this study is to investigate the feasibility of perpendicular plate of ethmoid as material for the reconstruction of medial orbital wall. The main outcome measurement was preoperative and postoperative orbital volume. The authors performed a study including 17 patients who have isolated medial orbital wall fracture (blow-out fracture). All the patients were fixed the defect using autologous perpendicular plate of ethmoid under endonasal approach. The authors compared the preoperative and postoperative orbital volume difference (unaffected orbit, affected orbit) of all the patients, and observed the improvement of diplopia or ocular motility disorders after operation. All 17 medial orbital wall reconstruction surgeries were successful with no severe postoperative ophthalmic complications. Statistically significant differences were found between the preoperative and postoperative orbital tissue volumes for the affected orbit. There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction. And postoperative computed tomography showed the implant is in place and there is no medial rectus incarceration. Autologous perpendicular plate of ethmoid proved to be safe and effective in the reconstruction of medial orbital wall under endonasal approach with cost-effectivence, low complication rate, high biocompatibility, and minimally invasion.

Applications of three-dimensional imaging techniques in craniomaxillofacial surgery: A literature review

Three-dimensional (3D) imaging technologies are increasingly used in craniomaxillofacial (CMF) surgery, especially to enable clinicians to get an effective approach and obtain better treatment results during different preoperative and postoperative phases, namely during image acquisition and diagnosis, virtual surgical planning (VSP), actual surgery, and treatment outcome assessment. The article presents an overview of 3D imaging technologies used in the aforementioned phases of the most common CMF surgery. We searched for relevant studies on 3D imaging applications in CMF surgery published over the past 10 years in the PubMed, ProQuest (Medline), Web of Science, Science Direct, Clinical Key, and Embase databases. A total of 2094 articles were found, of which 712 were relevant. An additional 26 manually searched articles were included in the analysis. The findings of the review demonstrated that 3D imaging technology is becoming increasingly popular in clinical practice and an essential tool for plastic surgeons. This review provides information that will help researchers and clinicians consider the use of 3D imaging techniques in CMF surgery to improve the quality of surgical procedures and achieve satisfactory treatment outcomes.

[Current developments in primary and secondary surgical treatment of midface and periorbital trauma]

Fractures of the periorbita and the midface are among the most common bony facial injuries. Aesthetic and functional reconstruction is a challenge in clinical routine. This article illustrates recent developments in the primary and secondary surgical treatment of midface and periorbital trauma. Resorbable patches and films increase the anatomic reconstructive capacity and enable treatment of extensive orbital fractures. Orbital fractures with involvement of supporting key structures are advantageously reconstructed using patient-specific implants (PSI), which are fabricated by computer-assisted manufacturing techniques and positioned by intraoperative navigation. If late complications such as bulbar malposition and enophthalmos have occurred after the initial procedure, they can be addressed by overcorrective restoration of orbital volume. The use of PSI for initial fracture restoration of the midface is not yet established but may be useful in re-osteotomies of misconsolidated fragments. Extensive midface defects with significant soft tissue involvement can be reconstructed using microvascular grafts. Consecutive reconstructive procedures may include orthognathic surgery and local flap reconstruction. In summary, the integration and advancement of computer-assisted techniques now offers individualized reconstruction procedures, which may be a viable alternative to conventional implants and compression miniplates. Future developments may focus on the search for innovative biomaterials, which can be integrated into computer-aided design and manufacturing processes.