Fractures of the orbital floor: indications for exploration and for the use of a floor implant

Orbital floor fractures: a retrospective review of 45 cases at a tertiary health care center

The purpose of this retrospective study was to investigate treatment options for orbital floor fractures at a Level 1 Trauma Center in Southern California. A review of 45 cases of isolated orbital floor fractures treated at the University of California at Irvine between February 2004 and April 2007 was done. Patients were retrospectively analyzed for gender, age, mechanism of injury, associated facial injuries, presenting symptoms, method of treatment, and postoperative complications. Thirty-six male patients and nine female patients were treated. Motor vehicle collision (26/45) was the most common cause of injury, and the mean age of the patients was 35.5 years (range: 15-81 years). Ecchymosis surrounding the orbital tissue was the most common presentation (38/45). Diplopia was present in 8 of 45 patients, with 1 patient requiring urgent decompression for retrobulbar hematoma. Forty-three patients underwent surgical repair; 40 underwent transconjunctival approach with lateral canthotomy; 17 underwent reconstruction with porous polyethylene Medpor (Porex Surgical, Inc., College Park, GA.); and 26 underwent reconstruction with a titanium mesh plate. Immediate postoperative complications included 12 patients with infraorbital numbness, 3 with diplopia, 1 with cellulitis, and 1 with ectropion with a subcilliary approach. Average timing of surgery of our study was 4.94 days (range, 1-20 days). Orbital floor fracture management has changed significantly over the past few decades with the introduction of new internal fixation methods and new materials for reconstructing orbital floor defects. Recommendations for surgical intervention on orbital floor fractures mostly depend on clinical examination and imaging studies. Consequences of inadequate repair of orbital floor fractures can lead to significant facial asymmetry and visual problems. Both porous polyethylene and titanium plates are effective tools for reconstructing the orbital floor. Our review demonstrates that orbital floor fractures can be repaired safely with minimal postoperative complications and confirms that transconjunctival approach to orbital floor is an effective way for exposure and prevention of ectropion that can be seen with other techniques.

Orbital floor reconstruction considering orbital floor slope

Orbital floor fractures are among the more challenging injuries faced by plastic surgeons. Enophthalmos is defined as backward, usually downward, displacement of the globe into the bony orbit. We describe reconstruction of the orbital floor slope in orbital floor fractures that prevents postoperative complications, especially posttraumatic enophthalmos. Thirty-three patients with orbital floor fractures were treated using reconstruction of the orbital floor slope between April 2009 and July 2010. The patients ranged in age from 12 to 54 years. There were 31 males and 2 females. All patients were operated on using a transconjunctival approach under general anesthesia. The orbital floor was reconstructed with poly-l/d-lactide sheets in all cases. Preoperatively, 23 [Float1]patients (69%) had enophthalmos, and 12 patients (36%) had symptomatic diplopia. The enophthalmos was corrected in 20 patients (86%), and the diplopia resolved in 10 (83%). Extrinsic ocular movement was impaired preoperatively in 1 patient (3%), but resolved after surgery. No patient had impaired visual acuity preoperatively or postoperatively. The results suggest that orbital floor reconstruction considering the orbital floor slope is a safe, reliable method with fewer complications that is more effective at preventing posttraumatic enophthalmos.

Complications related to midfacial fractures: operative versus non-surgical treatment

The treatment of midfacial fractures depends on the dislocation of the fracture and patient-related limitations. Surgical treatment risks iatrogenic complications. In 740 patients with midfacial fractures, the age, sex, fracture type, concomitant injuries, cause of accident and the decision to use operative or non-surgical treatment were recorded. Follow-up was performed 6 and 12 months after the injury. In 41% the fractures were isolated; they were multiple in 59%. Initially, hypaesthesia of the infraorbital nerve was present in 10% of the single and 16% of the multiple fracture patients. Surgical treatment was performed in 57% of the single and in 75% of the multiple fracture patients. Women underwent surgical treatment considerably less frequently than men. After 6 and 12 months, significantly more complications were present in the surgically treated cohort. Nerve disturbances and 'meteorosensitivity' were most prominent. These results, together with previous findings, indicate that there is a need for prospective clinical investigations that fulfil the criteria of evidence-based medicine to generate guidelines for decision making in trauma surgery. In the meantime, the decision to use surgical treatment for midfacial fractures has to be made carefully.

Early versus late repair of orbital blowout fractures

BACKGROUND AND OBJECTIVE

To compare early and late surgical repair of orbital blowout floor fractures.

PATIENTS AND METHODS

A retrospective, comparative interventional case series reviewed medical records of 50 consecutive patients who underwent unilateral orbital floor fracture repair in a 4-year period. Comparative analysis was performed between patients operated on within 2 weeks of injury and those operated on at a later stage.

RESULTS

Assault, motor vehicle accidents, and sports injuries were the most common causes of injury. Surgery was performed due to inferior rectus muscle entrapment and limitations in up gaze in 20 (40%) patients or to prevent enophthalmos in cases with significant bony orbital expansion in 30 (60%) patients. After surgery, enophthalmos improved an average of 0.8 mm. Limitation in ocular motility improved after surgery but was statistically significant only in up gaze. Patients who underwent early repair (within 2 weeks) achieved less improvement in enophthalmos versus patients who underwent late repair (delta enophthalmos of 0.2 +/- 1.1 vs 1.3 +/- 1.9 mm, respectively; P = .02).

CONCLUSION

In these patients, postoperative vertical ductions and postoperative enophthalmos improved after fracture repair. Surgery was associated with a low rate of postoperative complications. No apparent difference in surgical outcome was seen between early (within 2 weeks) and late surgical repair.

Reconstruction of Internal Orbital Wall Fracture with Iliac Crest Free Bone Graft: Clinical, Computed Tomography, and Magnetic Resonance Imaging Follow-Up Study

BACKGROUND

The purpose of this study was to clinically and radiologically assess the outcome of internal orbital reconstruction with an iliac bone graft.

METHODS

Twenty-four consecutive patients with unilateral orbital wall fractures were enrolled in this prospective study. A medial cortical wall from the anterior ilium was used for reconstruction. At each follow-up visit, globe posture, diplopia, and eye movements were assessed. Coronal and sagittal computed tomography and magnetic resonance imaging were used to observe graft posture, bone defects, and intraorbital soft-tissue changes.

RESULTS

Most fractures (46 percent) were pure orbital floor fractures. The mean follow-up was 7.8 months. One patient with medial wall and floor fractures required reoperation because of insufficient bone graft. At the last follow-up, this was the only patient (4 percent) with both enophthalmos (2 mm) and hypophthalmos (3 mm). Five patients (21 percent) had hypophthalmos (> 1 mm) at the end of the study. Resorption and remodeling were detected in all grafts, but no grafts were totally resorbed. Sagittal or coronal bone graft postures were assessed as good in 18 orbits (75 percent). Bone defects (> 10 mm) at reconstructed areas were detected in 13 orbits (54 percent). Scar tissue was observed only in three reconstructed orbits (13 percent). Diplopia in central field of vision was registered in seven patients preoperatively but in none at the end of the study.

CONCLUSIONS

The resorption rate was high, but most of it was advantageous remodeling. Overall outcome was good. Secondary operations led to poor outcomes. Thin computed tomography and magnetic resonance imaging sections (< or = 2 mm) are needed to evaluate accurately bone graft placement and posture and orbital volume.

Surgical Timing in Orbital Fracture Treatment: Experience with 108 Consecutive Cases

Orbital fractures can lead to esthetic deformities and functional impairments, and adequate surgical timing is considered important in obtaining good results from surgery. By means of chart review, a retrospective analysis was carried out in 108 consecutive cases of pure orbital fractures to investigate the differences in surgical timing and the correlations with patient age and clinical and radiographic findings. In this analysis, surgical timing of pure orbital fractures was strongly related to the combination of parameters such as anatomical location of the fracture, eventual exposure of the fracture, cerebrospinal fluid (CSF) leakage or penetrating wounds, age of patients, eventual functional impairments or muscle entrapment, and serious conditions of compression or ischemia. As the data confirmed, an urgent approach was considered indispensable in severe orbital apex fractures and in orbital fractures with CSF leakage, penetrating objects, or exposure. Early surgery was necessary within 3 days in children with diplopia (type IIIb) and mainly within 7 days in adults with double vision (type IIIa). Delayed surgery, within 12 days in all cases, was performed orbital wall fractures with no impairments (type II) or in orbital rim fractures (type I). Data from this retrospective analysis confirm the need for an aggressive approach to all orbital fractures. In our experience, surgery was performed within 12 days and most orbital fractures were treated during the first week after trauma, which is earlier than previously reported.

Use of Bioglass for Orbital Volume Augmentation in Enophthalmos

PURPOSE

To investigate the clinical and histologic response of Novabone-C/M as an osteoproductive alloplastic implant for volume augmentation in the orbit in the treatment of enophthalmos and to compare its outcome alone versus its use in combination with autogenous bone or Medpor granules.

METHODS

Novabone-C/M, a bioactive silicone glass material, was implanted in the subperiosteal space of the left orbit of 12 New Zealand White rabbits. The animals were divided into 3 groups, each with 4 animals, based on the material implanted in the orbit: group 1, Novabone alone; group 2, Novabone plus Medpor granules; and group 3, Novabone plus autogenous bone fragments. All rabbits were studied clinically, radiographically, and histologically at 1-, 3-, and 6-month intervals. Animals underwent preoperative and postoperative computed tomography (CT) with 3-dimensional reconstruction, proptosis measurements, and volumetric analysis. Orbit specimens were studied histologically with mineralized bone stain (MIBS) to look for bone formation, reactivity, infection, implant resorption, and migration.

RESULTS

There were no signs of significant inflammation or infection. Subcutaneous migration of the implant was seen radiographically but not clinically in groups 1 and 3. Induced proptosis averaged 2.5 mm (at 1 month) and showed regression in all groups over a 6-month period but was not statistically significant. Implant volume was markedly reduced in all groups, averaging 69% in group 1, 37% in group 2, and 59% in group 3 at 6 months. New bone formation and bone remodeling was present in all 3 groups at 3 months and only in group 2 at 6 months. The rate and amount of implant remodeling and bone formation was greatest in the Novabone/Medpor group (group 2).

CONCLUSIONS

Bioglass particulate is biocompatible, easy to use in the orbit, and stimulates bone growth. Bioglass is associated with volume loss and migration over 6 months and may not provide adequate volume augmentation in the orbit when used alone for the treatment of enophthalmos. The duration and amount of bone formation may be enhanced when Novabone is used in conjunction with Medpor.

Effectiveness of operative treatment of internal orbital wall fracture with polydioxanone implant

Many implants, some made from teflon or silicone, have been used for internal orbital wall reconstruction. Late complications relating to use of such implants have been reported. In this prospective study a polydioxanone (PDS) implant absorbable in vivo was used for internal orbital wall reconstruction. Follow-up involved clinical examination, magnetic resonance imaging (MRI) and computerized tomography (CT). Clinical examinations were undertaken before operation and up to 36 weeks postoperatively. Sixteen consecutive patients (10 pure blow-out fractures, six with associated zygomatic fracture) took part in the study. Prevalences of diplopia, proptosis and enophthalmus were recorded during each follow-up examination. This study revealed no muscle entrapment within the fracture line. Although CT results confirmed bone growth in the internal orbital wall, shape was unsatisfactory, and orbital volume was not reduced. MRI revealed thick scar formations in six cases (37.5%), fibrotic sinuses filled with air or gas in three cases (19%) and a fibrotic sinus with fluid around the PDS in one case (6%). Our results suggest that use of PDS in reconstructing the internal orbital wall is inadvisable.

Reconstruction of orbital floor with polydioxanone plate

The use of a polydioxanone (PDS) plate for orbital reconstruction was evaluated in 20 patients with various traumatic defects of the orbital floor. The follow-up time was 9 to 45 months (mean 20.4 months). A CT scan was obtained in 13 patients. Radiographic analysis showed that in 12 of the 13 patients there was new bone in the orbital floor. Clinically, most patients had transitory postoperative diplopia (lasting for a mean of 29 days) because of overcorrection. Only 2 patients, however, suffered from persistent diplopia. In one patient, abducens nerve paresis was the cause. It is concluded that PDS is suitable for orbital floor reconstruction, at least in cases in which defects do not exceed 1-2 cm in diameter. Overcorrection seems necessary. The material is well tolerated, is totally absorbed and appears to be replaced by bone in nearly all cases.

Poly(L-lactide) implants in repair of defects of the orbital floor: an animal study

Because of the life-long presence of alloplastic, nonresorbable orbital floor implants and the complications of their use mentioned in literature, the use of a resorbable material appears to be preferable in the repair of orbital floor defects. A high-molecular-weight, as-polymerized poly(L-lactide) (PLLA) was used for repair of orbital floor defects of the blowout type in goats. An artificial defect was created in the bony floor of both orbits. Reconstruction of the orbital floor was then carried out using a concave PLLA implant of 0.4-mm thickness. At 3, 6, 12, 19, 26, 52, and 78 weeks postoperatively, one goat was killed. Microscopic examination showed full encapsulation of the implant by connective tissue after 3 weeks. After 6 weeks, resorption and remodeling of the bone at the points of support of the implant could be detected. A differentiation between the sinus and orbital sides of the connective tissue capsule was observed. The orbital side showed a significantly more dense capsule than the antral side, which had a loose appearance. At 19 weeks, a bony plate was progressively being formed, and at 78 weeks, new bone had fully covered the plate on the antral and orbital side. No inflammation or rejection of the PLLA implant was seen.

The alterations in sensitivity of the infraorbital nerve following fractures of the zygomaticomaxillary complex

52 patients with fractures of the zygomaticomaxillary complex associated with hypoaesthesia of the infraorbital nerve were evaluated as to the degree of residual impairment in sensitivity. Those with minor displacements or no displacements at all showed complete recovery. Early treatment was associated with better results, while no correlation was found between the degree of anatomical reduction and the improvement in nerve sensitivity. The results appeared to be better when the lateral orbital approach was part of the treatment.

Use of blocks of hydroxylapatite for secondary reconstruction of the orbital floor

Malposition of the globe and failure to fuse images may be the result of orbital trauma. Five patients are reviewed in whom secondary correction of enophthalmos, sunken globe and diplopia was performed by implantation of blocks of dense hydroxylapatite.

The influence of the mode of treatment of zygomatic bone fractures on the healing process of the infraorbital nerve

Several authors have described the influence of the method of treatment of a fracture of the zygomatic complex on the recovery of the infraorbital nerve. In this study, the results of treatment of 106 patients with an isolated, non-comminuted, unstable fracture of the zygomatic bone are presented. Thirty-eight patients underwent fixation with interosseous wiring and 68 patients were treated with a miniplate osteosynthesis across the frontozygomatic suture. In the group with wire fixation, 50% suffered persistent reduced sensitivity in the infraorbital region at follow-up examination, whereas in the group with a miniplate osteosynthesis only 22.1% had persistent neurological sequelae. On the basis of these findings we recommend a miniplate osteosynthesis in all unstable zygomatic bone fractures with displacement.

Orbital floor repair with lyophilized porcine dermis

Various implants have been used to repair defects in orbital walls. Few are fully biocompatible. The indications for repair of a defect of the orbital floor are reviewed, and the suitability in selected cases of placement of lyophilized porcine dermis (xenograft) is discussed.

Medial orbital wall fracture with enophthalmos

An isolated blow-out fracture of the medial orbital wall is uncommon, whereas the incidence in conjunction with an orbital floor fracture is high. The most striking features of an isolated medial wall fracture are diplopia on medial and lateral gaze and/or enophthalmos. The cases of two patients with a fracture of the medial orbital wall with enophthalmos are presented. One patient had an isolated medial wall fracture, whereas the other had a combined medial and inferior orbital wall fracture. Treatment of the enophthalmos consisted of exposure of the medial wall fracture site using a bicoronal flap, freeing of the herniated soft tissues and reconstruction of the defect with an autogenous medial iliac bone graft. The incidence, aetiology, pathogenesis, signs and symptoms and surgical treatment of the isolated orbital medial blow-out fracture are discussed.

Reconstruction of orbital defects with autogenous bone from mandibular symphysis

Autotransplant bone is superior to other bone, cartilage, or alloplastic materials for the reconstruction of orbital floor defects. The bone used for filling orbital floor defects is taken from the symphysis of the lower jaw. The piece of bone, up to 3.5 X 1.5 cm in diameter is strong enough to support the orbital contents, while at the same time it is easily modelled and positioned. This method is indicated for reconstruction of the orbital floor, with or without rim defects. Taking of the transplant, while retaining the lower margin of the mandibular symphysis, preserves the contour of the chin.

Orbital floor fractures: early repair and results

In the 5-year period 1978-1982, 34 patients with facial fractures underwent repair of the orbital floor. Reconstruction of the orbital floor by means of an implant was used in 28 of 34 patients (82%). Nineteen patients (56%) had a balloon inflated in the maxillary sinus to stabilize the orbital floor. Radiographic contrast solution was used in the balloon to facilitate the postoperative radiographic control of the balloon and the orbital floor. It was possible to make a follow-up study of 30 of the 34 patients. Nine of the patients had persisting reduced sensitivity in the infraorbital nerve region and 7 patients had slight enophthalmos. Out of the 30 patients, only 2 patients had persisting diplopia of a slight to moderate degree and none found it disturbing enough to need further surgery. This series shows that good results can be expected after early surgery and active management with open reposition, reconstruction and placing of an intral balloon are recommended.

Periorbital soft tissue retractor

A retractor which is useful for soft tissue manipulations in and around the orbit is described.