Utilization of panoramic radiographs to evaluate short-term complications of mandibular fracture repair

Revision Surgery With Refixation After Mandibular Fractures

Study Design

Retrospective, descriptive observational study.

Objective

The need for revision surgery after mandibular fractures is an indicator for severe postoperative complications. This study aimed to characterise this patient cohort, describe solutions to deal with complications and evaluate treatment quality as a risk variable for complications.

Methods

Patients with revision surgery with refixation after open reduction and internal fixation (ORIF) of a mandible fracture were included. Patient- and therapy-specific information were assessed together with postoperative complications. The quality of fixation was evaluated individually by 6 specialists. Interobserver agreement was analysed using Fleiss' kappa.

Results

Out of 630 patients, inclusion criteria were met by 17 patients (14 male, 3 female) with an average age of 43.3 (±15.5) years. Complications at the mandible body/angle/symphysis led to refixation in all cases. Main indications for refixation were osteomyelitis (52.9%) or pseudarthrosis (41.2%). Risk factors were drug-related immune suppression, local infection or substance abuse (nicotine, alcohol or drugs). Six patients did not present any of these predictors. Of these, treatment of 4 patients was rated as not in accordance to the AO principles. The interrater reliability of treatment quality assessments was .239.

Conclusions

Patients with risk factors need to be carefully observed perioperatively after ORIF of mandibular fractures and treatments need to be adapted to these patients. Discrepancies of treatments to common guidelines may also be an independent predictor for treatment failure in patients without risk factors. Current treatment guidelines should be re-evaluated concerning additional treatment strategies for patients with specific risk factors.

Development of a financially viable model for the management of mandibular fractures as day cases in a level 1 major trauma centre

There is a subgroup of patients with mandibular fractures who could safely and effectively be managed in an outpatient day-care unit. Suitability depends on medical, social, and operative factors, and identification of the correct criteria will govern management after that in the emergency department. Reduced use of beds would lead to less money being spent on emergency treatment, and increased capacity for elective surgery. The aims of this study were to identify a group of patients with mandibular fractures whose duration of operation and period of recovery would be suitable for treatment in the day-care unit, and to evaluate the potential financial benefits. Inpatients were assessed for day surgery using medical, social, and surgical criteria. Each patient's suitability for discharge was assessed two, three, and five hours postoperatively. A financial feasibility study was made retrospectively on a larger sample of patients with mandibular fractures. The discharge criteria from the day-care unit were fully met by 26/40 patients at five hours postoperatively, mean (range) duration of operation was 145 (40-285) minutes, and mean (SD) Mandibular Injury Severity Score was 13 (3), range 7-20. When all the criteria were combined (n=100), 12 of the patients were suitable for day care. With 24 bed-day savings/100 patients, potential earnings would increase to around £80 000/year at this hospital. In conclusion, we have identified a group of patients who were suitable for management of mandibular fractures in the day-care unit. Considerable cost savings are anticipated.

Routine Postoperative Imaging Is Not Indicated in the Management of Mandibular Fractures

PURPOSE

Prior literature has shown that routine postoperative computed tomography (CT) scans for mandibular fractures have no effect on outcomes and complications; however, past surveys have reported that most clinicians continue to order routine scans. We aimed to determine the current use of routine postoperative CT scans, evaluate what factors contribute to this practice, and identify differences in outcomes and complications among patients with either routine, indicated, or no postoperative CT scans.

PATIENTS AND METHODS

We conducted a retrospective review of consecutive patients treated for a mandibular fracture at Vancouver General Hospital from January 1, 2007, to March 1, 2012.

RESULTS

We included 167 patients in the study for analysis. No significant differences in outcomes or complications were found between patients who had an indicated postoperative CT scan (27%) and patients with no scans (64%). Only the treating surgeon had a statistically significant effect on whether a patient received a postoperative CT scan (P < .001), and those patients who had an indicated postoperative CT scan (9%) were more likely to have a decreased level of temporomandibular joint function (P = .002) and increased incidence of complications and secondary operations (P < .001 and P < .001, respectively).

CONCLUSIONS

Routine postoperative CT scans were found to have no significant effect on outcomes and complications, and a clinician's individual practice was the most significant factor for whether a patient received a routine postoperative CT scan. Future work should aim at providing well-defined indications for postoperative imaging.

Routine Screening Radiography for Retained Wire Following Arch Bar Removal Is Not Indicated

PURPOSE

To estimate the screening test value of routine radiography after arch bar wire removal by assessing the incidence of retained wires and the importance of their sequelae.

MATERIALS AND METHODS

This was a retrospective medical record review. Records of arch bar removal procedures were examined and divided into those screened with radiography after removal (screen group) and those that were not screened (comparison group). The incidence of retained wire was calculated for each group. Study variables included wire-related radiographic or clinical findings.

RESULTS

Records of 546 mandible fractures were reviewed; 95 met the study criteria. Most exclusions were due to lack of arch bars, missing postoperative radiographs, or insufficient postoperative documentation. Of the 55 records in the screen group, 1 wire was detected (2%); of the 40 records in the comparison group, 1 wire was detected (3%). The total incidence of retained wire findings was not statistically different between the 2 groups and there were no adverse wire-related sequelae reported by any of the 95 patients.

CONCLUSION

Because of the low incidence of retained wires and wire-related sequelae, routine imaging after wire removal is probably not an effective screening test for retained wire and should be limited to situations in which there is clinical suspicion of retained wire.

Postoperative radiographs after maxillofacial trauma: Sense or nonsense?

The purpose of the present study was to investigate the necessity of routine postoperative radiographic analysis in patients with maxillofacial trauma. Between January 2000 and January 2010, 579 patients were treated surgically for 646 maxillofacial fractures including complex maxillofacial trauma. The incidence of surgical retreatments based on postoperative radiographs after maxillofacial trauma were investigated. 16 patients needed surgical retreatment. The decision to revise was based on postoperative imaging alone in one patient (0.2%). The available data in the literature concerning postoperative radiography in maxillofacial trauma was reviewed. Six useful studies concerning postoperative radiography in maxillofacial trauma were available for review. When combining these studies a total of 1377 patients underwent surgery for correction of a maxillofacial fracture. Nine patients returned to the operating theatre for correction of the initial procedure after trauma (0.7%). The present results are in line with the available literature. Routine postoperative radiography is not necessary after surgical treatment of maxillofacial trauma. Avoiding routine postoperative radiography will lead to a reduction in exposure of patients to ionizing radiation, a reduction of costs and probably a more efficient discharge.

The value of postoperative radiographs in the management of zygomatic fractures: Prospective study

It is customary in maxillofacial surgical practice for all patients who have undergone open reduction and or fixation of a fracture of the zygomatic complex to have postoperative radiographs taken before they are discharged. These radiographs are often not reviewed before the patient's departure and in many cases have no bearing on the patient's management. We prospectively reviewed over a 3-month period all patients who were treated for fractures of the zygomatic complex and had no postoperative radiographs. None of these patients had to return to the operating theatre for a further operation, which emphasises the lack of clinical evidence to support routine postoperative radiography in the management of fractures of the zygomatic complex.

Postoperative radiographs after open reduction and internal fixation of the mandible: Are they useful?

Mandibular fractures are common in oral and maxillofacial departments in the UK. The aim of this study was to find out the national practice in preoperative and postoperative radiographic investigations for fractured mandibles and to audit their diagnostic capacity, including specificity and sensitivity to short-term complications. The audit took place over a 4-month period and involved 100 patients across the Northern region. Ninety percent of patients were reviewed up to discharge and five of these patients developed a short-term postoperative complication. The postoperative radiograph was diagnostic in only one of the five cases. Overall, postoperative radiographs had a sensitivity of 20% and a specificity of 5% in their ability to predict short-term postoperative complications.