Surgical management of isolated orbital floor and zygomaticomaxillary complex fractures with focus on surgical approaches and complications

Analysis of postoperative complications of orbital fracture

OBJECTIVE

To analyze the types and causes of complications following orbital fracture reconstruction and enhance clinicians' capacity to manage or prevent such complications.

METHODS

We conducted a retrospective case series analysis, retrospectively collecting and analyzing clinical data of patients with orbital fractures who received surgical treatment at the Affiliated Eye Hospital of Nanchang University from May 2012 to May 2022. Descriptive statistics were employed to document common postoperative complications, and we recorded complications persisting after a minimum 6-month follow-up period.

RESULTS

Among the 227 patients who underwent orbital fracture surgery, they were followed up for 6 to 36 months, and complications occurred in 15 cases, resulting in an incidence rate of 6.61%. These complications included implant material infections and rejections (4 cases), persistent diplopia (3 cases), intraorbital hematomas (2 cases), epiphora (2 cases), lower eyelid eversion or retraction (2 cases), and skin scars (2 cases). The primary cause of postoperative infection was chronic inflammation in the paranasal sinuses or closed cavities within the fracture area. Postoperative complications in orbital fractures were associated with various factors, including the timing of surgery, surgical approach, repair materials, surgical skills, and auxiliary techniques.

CONCLUSION

Standardizing surgical techniques and implementing precise auxiliary technologies may reduce the incidence of complications and enhance the operation's success rate.

Polyfracture and Cranial Injuries Drive the Cost and Inpatient Burden of Zygoma Fractures

IMPORTANCE

Facial trauma makes up a significant number of emergency room visits, with morbidity costs in excess of 1 billion dollars each year. Few studies have evaluated the economic outcomes of management and inpatient burden of facial trauma, most focusing solely on the mandible and isolated midface fractures.

OBJECTIVE

The authors aim to evaluate characteristics associated with increased cost and length of hospitalization of zygoma fracture management.

DESIGN

Cross-sectional study.

SETTING

Level 1-trauma academic medical center.

PARTICIPANTS

Patients with zygoma fractures who presented to our institution from 2008 to 2021.

MAIN OUTCOMES AND MEASURES

Demographics, injury mechanisms, associated injuries, treatment information, and associated costs were collected. Univariate and multivariate analyses were performed to identify the patient and fracture characteristics associated with increased cost and length of hospitalization.

RESULTS

Our 14-year experience identified 689 patients with zygoma fractures who presented from 2008 to 2021. Seventy percent were male, and 40% occurred in Caucasian patients. The mean cost, adjusted for inflation, was $21,799.34, and the mean length of hospitalization was 5.5 days. Four or more fractures, associated cranial or intracranial injuries, and length of stay were associated with significantly higher cost, and 4 or more fractures, associated cranial or intracranial injuries, and female gender were associated with significantly longer length of hospitalization.

CONCLUSIONS AND RELEVANCE

This study represents one of the largest comprehensive databases of zygoma fractures and one of the first to provide a descriptive cost and inpatient burden analysis. To improve outcomes and reduce hospital cost and inpatient burden, protocols should be implemented to address the factors that the authors identified as contributing to increased cost and length of hospitalization.

Orbital floor fracture (blow out) and its repercussions on eye movement: a systematic review

The aim of this systematic review was to investigate the relationship between fractures of the floor of the orbit (blow outs) and their repercussions on eye movement, based on the available scientific literature. In order to obtain more reliable results, we opted for a methodology that could answer the guiding question of this research. To this end, a systematic review of the literature was carried out, using a rigorous methodological approach. The risk of bias was assessed using version 2 of the Cochrane tool for the risk of bias in randomized trials (RoB 2). This systematic review was carried out according to a systematic review protocol previously registered on the PROSPERO platform. The searches were carried out in the PubMed (National Library of Medicine), Scopus, ScienceDirect, SciELO, Web of Science, Cochrane Library and Embase databases, initially resulting in 553 studies. After removing duplicates, 515 articles remained, 7 were considered eligible, of which 3 were selected for detailed analysis. However, the results of the included studies did not provide conclusive evidence of a direct relationship between orbital floor fractures and eye movement.

Patterns of ZMC and Le Fort Fractures under the Impact of the COVID-19 Pandemic-"A Changing Face?"

Background: The aim of this study was to analyze the impact of the COVID-19 pandemic on midfacial fracture patterns/distributions and circumstances in a German craniomaxillofacial trauma center. Methods: This retrospective study compared the midface fracture patterns (excluding nasal fractures) of patients in the pre-COVID (PC) era (February 2019-January 2020) with patients in the intra-COVID (IC) era (February 2020-January 2021). In addition to baseline characteristics, the type of midface fractures, the circumstances leading to midface fractures, and hospital admissions/treatments were analyzed. Results: During the COVID-19 pandemic, a reduction in the total number of midface fractures was observed (PC = 88 vs. IC = 57). No significant differences were found regarding the midfacial fracture localization between both periods. During the pandemic, there was a significant increase in falls, accidents at home, and virus/flu-associated syncopes. At the same time, a significant decrease in sports accidents, interpersonal violence, and alcohol-related accidents leading to midface fractures was recorded. Furthermore, there was a significant increase in accidents during the morning time with a simultaneous reduction in accidents during the nighttime. In addition to that, a significant delay in days from trauma leading to midface fracture until hospital admission and surgical treatment (ORIF) was revealed. Conclusions: Despite the limitations of a monocentric retrospective study, the current findings lead to the conclusion that the COVID-19 pandemic had a significant impact on the patterns and circumstances leading to midface fractures. Analyzing the specific characteristics of patients suffering from midfacial fractures under the influence of the COVID-19 period can represent added value in order to treat facial fractures in future pandemics.

A deep learning-based automatic segmentation of zygomatic bones from cone-beam computed tomography images: A proof of concept

OBJECTIVES

To investigate the efficiency and accuracy of a deep learning-based automatic segmentation method for zygomatic bones from cone-beam computed tomography (CBCT) images.

METHODS

One hundred thirty CBCT scans were included and randomly divided into three subsets (training, validation, and test) in a 6:2:2 ratio. A deep learning-based model was developed, and it included a classification network and a segmentation network, where an edge supervision module was added to increase the attention of the edges of zygomatic bones. Attention maps were generated by the Grad-CAM and Guided Grad-CAM algorithms to improve the interpretability of the model. The performance of the model was then compared with that of four dentists on 10 CBCT scans from the test dataset. A p value <.05 was considered statistically significant.

RESULTS

The accuracy of the classification network was 99.64%. The Dice coefficient (Dice) of the deep learning-based model for the test dataset was 92.34 ± 2.04%, the average surface distance (ASD) was 0.1 ± 0.15 mm, and the 95% Hausdorff distance (HD) was 0.98 ± 0.42 mm. The model required 17.03 seconds on average to segment zygomatic bones, whereas this task took 49.3 minutes for dentists to complete. The Dice score of the model for the 10 CBCT scans was 93.2 ± 1.3%, while that of the dentists was 90.37 ± 3.32%.

CONCLUSIONS

The proposed deep learning-based model could segment zygomatic bones with high accuracy and efficiency compared with those of dentists.

CLINICAL SIGNIFICANCE

The proposed automatic segmentation model for zygomatic bone could generate an accurate 3D model for the preoperative digital planning of zygoma reconstruction, orbital surgery, zygomatic implant surgery, and orthodontics.

Comparison of Transconjunctival versus Subtarsal Approach in Orbital Reconstruction with Respect to Post-Operative Complications and Aesthetic Outcome - A Systematic Review

Background

Limited evidence exists regarding the optimal surgical approach for orbital floor reconstruction, resulting in uncertainty regarding the choice of approach with the best aesthetic outcomes and lowest post-operative complications.

Objectives

This systematic review aimed to compare the transconjunctival and subtarsal approaches (STA) in orbital reconstruction in terms of post-operative complications and aesthetic outcomes.

Data Sources

The systematic review was conducted following PRISMA guidelines. PubMed, Google Scholar and Cochrane databases were searched from January 1, 2000 and December 31, 2021.

Study Eligibility Criteria

Eligible studies included clinical studies comparing the transconjunctival and STA approaches in orbital reconstruction. The outcome variables assessed were aesthetic scar, hyperaesthesia, entropion, ectropion, enophthalmos, epiphora and other complications. A total of 346 articles were initially identified, and after evaluation using Mendeley software, 292 articles were reviewed. Finally, five articles that met the inclusion criteria were included in this systematic review.

Study Appraisal and Results

The transconjunctival approach demonstrated superior aesthetic outcomes compared to the STA approach. However, the STA approach had a lower incidence of post-operative complications, including hyperaesthesia, entropion, ectropion, enophthalmos and epiphora.

Limitations

The main limitation of this systematic review is the limited availability of literature directly comparing these two approaches, which precluded the inclusion of randomised controlled trials. Furthermore, the search strategy was restricted to specific databases, namely PubMed/Medline, Google Scholar and the Cochrane Collaboration Library.

Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction

Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction, to identify predictive factors for LEM, and to assess the effect of the eyelid complication on patients' daily lives. The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction, were analysed. The overall occurrence of LEM was 8%, with ectropion in 6% and entropion in 2% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wounds, and implant material were associated with the development of LEM. Of all patients, 3% needed surgical correction of LEM. Six of the 13 patients (46%) who developed LEM required surgical correction. The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and those with more complex fractures. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic.

Primary reconstruction of combined orbital and zygomatic complex fractures with patient-specific milled titanium implants - A retrospective study

The aim of this retrospective study was to compare mid-facial symmetry and clinical outcomes between patients treated with patient-specific and standard implants in primary fracture reconstructions of combined orbital and zygomaticomaxillary complex fractures. Patients who underwent primary reconstruction of orbital and zygomaticomaxillary complex fractures during the study period were identified and background and clinical variables and computed tomography images were collected from patient records. Zygomaticomaxillary complex dislocation and orbital volume were measured from pre- and postoperative images and compared between groups. Out of 165 primary orbital reconstructions, eight patients treated with patient-specific and 12 patients treated with standard implants were identified with mean follow-up time of was 110 days and 121 days, respectively. Postoperative orbital volume difference was similar between groups (0.2 ml for patient-specific vs 0.3 ml for standard implants, p = 0.942) despite larger preoperative difference in patient-specific implant group (2.1 ml vs 1,5 ml, p = 0.428), although no statistical differences were obtained in symmetricity or accuracy between the reconstruction groups. Within the limitations of the study it seems that patient-specific implants are a viable option for primary reconstructions of combined zygomaticomaxillary complex and orbital fractures, because with patient-specific implants at least as symmetrical results as with standard implants can be obtained in a single surgery.

Application of optimized three-dimensional digital surgical guide plates for complex midfacial fractures

INTRODUCTION

The treatment of midfacial fractures is always difficult. The purpose of this study was to verify whether optimized three-dimensional (3D) digital surgical guide plates combined with preformed titanium plates improved the treatment effect in complex midfacial fractures.

PATIENTS AND METHODS

Twenty-six patients with complex midfacial fractures were recruited and randomized into three groups: ten for Group A, eight for Group B, and eight for Group C. Group A was treated with a combination of preformed titanium plates and optimized 3D digital surgical guide plates. Group B was treated with preformed titanium plates only. Group C was treated conventionally. Clinical effects, patient-reported outcome measures (PROMs), midfacial contour, facial symmetry, surgical accuracy, △orbital volume (the absolute value of the bilateral orbital volume difference), and maximum deviation were evaluated in each of the three groups.

RESULTS

Group A had the best postoperative clinical effects and patient-reported outcomes. Significant improvements in midfacial contour (L1[0.72±0.29 mm, P = 0.001], L2[1.04±0.46 mm, P < 0.001]), facial symmetry (S1[0.71±0.30 mm, P < 0.001], S2[0.96±0.58 mm, P < 0.001], S3[0.86±0.40 mm, P < 0.001], S5[0.81±0.16 mm, P = 0.003], S8[0.95±0.30 mm, P < 0.001], S9[1.03±0.38 mm, P < 0.001], S11[0.64±0.46 mm, P < 0.001]) and surgical accuracy (M1[R, 0.82±0.31 mm, P < 0.001], M2[R, 0.87±0.44 mm, P < 0.001], M3[L, 0.88±0.22 mm, P = 0.004], M3[R, 1.06±0.31 mm, P = 0.003], M4[L, 0.96±0.45 mm, P = 0.008], M4[R, 1.11±0.57 mm, P = 0.003], M5[R, 0.76±0.26 mm, P < 0.001], M6[L, 1.00±0.46 mm, P = 0.003], M6[R, 1.00±0.58 mm, P = 0.001], M7[0.87±0.53 mm, P = 0.001], M8[R, 0.91±0.53 mm, P < 0.001], M9[R, 0.81±0.32 mm, P = 0.010], M10[R, 1.19±0.42 mm, P = 0.009], M11[L, 0.85±0.51 mm, P = 0.021], M11[R, 0.96±0.49 mm, P = 0.003]) were found in Group A compared with the other two groups. The results of △orbital volume and maximum deviation analysis showed an ideal surgical treatment effect in Group A.

CONCLUSION

Optimized 3D digital guide plates can accurately locate preformed titanium plates and effectively improve the treatment effect in complex midfacial fractures.

The application of augmented reality in craniofacial bone fracture reduction: study protocol for a randomized controlled trial

Background

Augmented reality (AR) is a new technology that increases users’ perception of the real world. The purpose of this study is to evaluate the efficacy and safety of augmented reality navigation system in treatment with craniofacial fracture reduction.

Methods

This will be a single-center prospective randomized controlled trial. Twenty-two patients will be assigned to two groups of 11, and those with zygomaticomaxillary complex fractures will undergo preoperative three-dimensional CT modeling and have operational plans designed. The control team will use traditional optical navigation to perform the surgery, and the experimental team will use an AR navigation system. The primary outcome measures will be the accuracy of the key points of surgical area between the preoperational surgical plan and post-operation. The secondary outcome measures will be the blood loss, operation time, bone reduction time, hospital time, and complication rate. The findings obtained through this study are expected to evaluate efficacy and safety of the augmented reality navigation system in the treatment of zygomaticomaxillary complex fractures.

Discussion

This controlled trial of augmented reality navigation system in treatment with zygomaticomaxillary complex fracture reduction will clarify the efficacy and safety of this technology by measuring the accuracy of the key points of surgical area and blood loss, operation and bone reduction times, hospital stay duration, and complication rates. This is a single-center study, and the results are expected to promote the application of augmented reality in craniofacial fracture reduction to improve surgery accuracy and efficacy.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900022626. Registered on April 19, 2019.