Update on orbital reconstruction

Discovery of CTSK+ Periosteal Stem Cells Mediating Bone Repair in Orbital Reconstruction

Purpose

The purpose of this study was to explore the role of cathepsin K positive (CTSK+) periosteal stem cells (PSCs) in orbital bone repair and to clarify the source of endogenous stem cells for orbital bone self-repair.

Methods

Periosteum samples obtained by clinical orbital bone repair surgery were analyzed, after which immunofluorescence and immunohistochemical staining were used to detect the content of bone marrow-derived cells and CTSK+ PSCs in periosteum as well as the mobilization of PSCs. CTSK+ PSCs were characterized by flow cytometry. Transcriptome sequencing was used to compare the transcriptomic characteristics of CTSK+ PSCs and bone marrow mesenchymal stem cells (BMSCs).

Results

The orbital periosteum contained CTSK+CD200+ cell lineage, including CD200+CD105- PSCs and CD200+CD105+ progenitor cells. CTSK and osteocalcin (OCN) colocalized in the inner layer of the orbital periosteum, suggesting the osteogenic differentiation potential of CTSK+ PSCs. CTSK expression was much higher in periosteum after mobilization. Immunofluorescence showed low amounts of scattered CD31+ and CD45+ cells in the orbital periosteum. The stem cell characteristics of CTSK+ PSCs were verified by multidirectional differentiation. Flow cytometry found CD200+CD105- CTSK+ PSCs and CD200variantCD105+ progenitor cells. Transcriptome sequencing of CTSK+ PSCs and BMSCs found 3613 differential genes with significant differences. Gene Ontology (GO) analysis showed the differences between the two types of stem cells, revealing that PSCs were more suitable for intramembranous osteogenesis.

Conclusions

CTSK+ PSCs may be endogenous stem cells for orbital bone repair. They are mobilized after orbital fracture and have unique features suitable for intramembranous osteogenesis, completely different from BMSCs.

Orbital floor fractures-a comparison between CT images and findings at surgery

PURPOSE

The present study aims to investigate how well CT images correlate to surgical findings in orbital floor fractures and to the presence of diplopia.

METHODS

In this cross-sectional study, 27 consecutive patients already selected for surgery due to an orbital floor fracture underwent a routine CT scan (axial, coronal, sagittal). An ophthalmologist established any presence of diplopia. Extent of fracture/injury seen on CT was compared to that discovered during surgery.

RESULTS

In the surgeons´ opinions CT-images were in concordance with surgical findings in 71% of the cases. Agreement for pure blow out fractures was high (92%). Tetrapod fractures as a cause of an orbital floor fracture was only identified as such by surgeons in three of 11 cases, all subjected to orbital exploration, not only a closed reduction. Diplopia showed a significant correlation to rounding of the inferior rectus muscle at coronal CT. "Rounding" significantly correlated with the presence of a floor defect, to herniation of soft tissues and to the volume of displaced tissue.

CONCLUSIONS

The results imply that the joint professional interaction between neuroradiology and surgery is important and would benefit from the use of an easy and well-defined classification system of orbital floor fractures. In Sweden a national record to collect data on all zygomaticomaxillary complex fractures assessed is to be started aiming at making general statements possible by time.

Patient-specific Implants for Orbital Fractures: A Systematic Review

PURPOSE

Orbital fractures are common facial fractures that can be challenging to repair and require careful attention to avoid unacceptable ophthalmic complications. Customized implants that are unique to an individual patient, or patient-specific implants (PSIs), have been increasingly used to repair orbital wall fractures. This systematic review summarizes the current evidence regarding custom-made orbital wall implants.

METHODS

A keyword search of published literature from January 2010 to September 2021 was performed using Ovid MEDLINE, PubMed, and the Cochrane Library databases. Original articles that included more than 3 human subjects with an orbital fracture repaired with a PSI were included. The search results were reviewed, duplicates were removed and relevant articles were included for analysis.

RESULTS

Fifteen articles meeting the inclusion criteria. The articles were categorized into 3 separate groups based on the method of PSI fabrication: manual molding of a PSI on a 3D-printed orbital model (53%), directly from a 3D printer (27%), or via a template fabricated from a 3D printer (20%). Three primary postoperative outcomes were assessed: rates of diplopia, enophthalmos, and orbital volume. Postoperative rates of diplopia and enophthalmos improved regardless of the PSI technique, and postoperative orbital volumes were reduced compared with their preoperative state. When PSIs were compared to conventional implants, patient outcomes were comparable.

CONCLUSIONS

This review of existing PSI orbital implant literature highlights that while PSI can accurately and safely repair orbital fractures, patient outcomes are largely comparable to orbital fractures repaired by conventional methods, and PSI do not offer a definitive benefit over conventional implants.

Combined Subciliary/Transantral Approach for Reconstruction of Orbital Floor Fracture

Orbital floor fracture, especially with constriction of orbital soft tissue, should be reconstructed surgically. Although various approaches to treat the orbital floor have been reported, procedures have not been unified among hospitals or surgeons. Since 2009, we have adopted a procedure combining a transorbital approach via subciliary incision with a transantral approach through upper gingival incision. The combined approach compensates for the shortcomings of each approach, leading to successful reconstruction. It is applicable safely for trapdoor fracture of the orbital floor in children, which more frequently constricts orbital soft tissue and which leaves permanent diplopia. This report retrospectively assessed clinical preoperative findings and postoperative outcomes of patients who received reconstruction of orbital floor fracture with the combined approach in our department from August 2009 through March 2021. Data of 21 patients with orbital floor fracture were analyzed, only one (4.8%) of whom had postoperative diplopia. Specifically, we describe children with trapdoor fracture treated with the combined approach, resulting in complete recovery. The combined approach stands as an excellent procedure for reconstruction of orbital floor fracture in adults and even in children.

Transoral Endoscopic Plating for Orbital Blowout Fractures

ABSTRACT

Orbital fractures account for up to 40% of craniofacial injuries. In this article, the authors present the transoral endoscopy-assisted plating technique for treating orbital blowout fractures (OBF). A retrospective analysis of 56 cases treated with transoral endoscopy-assisted approach was performed. Immediate versus delayed surgery decision-making was performed by using our 2-week algorithm. The surgical technique included only transoral incisions, forced duction and "pulse" tests, osteotomy, endoscopic inspections, the reduction with a curved elevator and an indwelling balloon, the retrieval of prolapsed fatty tissue back into the orbit, removal of sharp bony fragments, adaptation of the titanium mesh to the orbital floor and its fixation with screws to stable bony structures, reattachment of the osteotomized lateral wall, and postoperative computed tomography (CT) scan with 3D CT reconstruction. The overall success rate of surgeries was 96%. The resolution of comorbidities resulted in a normal globe position, normal eye movement, and the resolution of diplopia. Postoperative complications were insignificant with one case of surgical edema and one case of infection and sequestration that appeared six months after surgery. These results remained unchanged after 20 to 24 months of follow-up. The suggested minimally invasive transoral technique can be effectively implemented in cases of OBF as well as in cases when the medial wall of the orbit is involved. Our results presented a high success rate with minimal rate of complications, thus our technique is a safe way with minimal morbidity for treating OBF.

Repair of unilateral combined orbital floor and medial wall fracture using two titanium mesh plates: a modified technique

Background

Compared to isolated orbital wall fracture, combined orbital floor and medial wall fractures are more likely to be required surgical correction due to a higher possibility of complications. However, it remains a challenge to repair concomitant orbital fracture using a one-piece implant due to the complex anatomic structures of the orbit. Aiming to reduce surgical difficulties and enhance therapeutic effects, we repaired unilateral combined orbital floor and medial wall fractures using two separated modified titanium mesh plates in this study.

Methods

A retrospective study was conducted on 21 consecutive patients who presented with unilateral combined orbital floor and medial wall fractures in Tianjin Medical University General Hospital between November 2010 and January 2016. The orbital fractures were repaired with two separated titanium mesh plates. The corner at the transition zone area between the orbital floor and the medial wall was reconstructed simultaneously through a combined transcaruncular and inferior subciliary approach with lateral canthotomy. The pre- and post-operative functions and aesthetic results were evaluated.

Results

Preoperatively, all patients presented with 3.5-6.5 mm enophthalmos, five patients presented with diplopia with ocular motility limitation in injured eyes, and six patients presented with hypoglobus ranging from 1.5 to 3.5 mm. Orbital floor and medial wall fractures of all patients were successfully repaired with two separated titanium mesh plates. Postoperatively, enophthalmos was improved in all patients, which was less than 2 mm on the last follow-up day. Hypoglobus was disappeared in all six patients postoperatively. Diplopia was resolved in five patients within 3 months post operation, and was reduced in one patient.

Conclusions

In cases of unilateral concomitant orbital floor and medial wall fractures, two titanium mesh plates implantation is a safe and effective procedure. It is worthwhile to take the technique into account when the key points to consider when applying this method include reconstruction of the special orbital shape and the complete return reposition of prolapsed intraorbital soft tissues were intended.

Oculocardiac reflex in an adult with a trapdoor orbital floor fracture: case report, literature review, and differential diagnosis

Orbital floor blowout fractures can result in a variety of signs and symptoms depending on the severity of the bone defect. Large defects often result in enophthalmos and restriction of ocular movement; yet the timing of surgery can be delayed up to two weeks with good functional outcomes. In contrast, an orbital trapdoor defect with entrapment of the inferior rectus muscle usually elicits pain with marked restriction of the upward gaze and activation of the oculocardiac reflex without significant dystopia or enophthalmos. When autonomic cardiac derangement is diagnosed along with an orbital floor fracture, it has been suggested that the fracture should be treated immediately. Otherwise, it will result in continued hemodynamic instability and muscular injury and may require a second surgery. This article reports the management of an unusual presentation of a trapdoor blowout orbital floor fracture surgery with oculocardiac response in an adult, with emphasis on its pathophysiology, management, and differential diagnosis.

Barotraumatic Blow-out Fracture of the Medial Orbital Wall by Nose Blowing

Blow-out fracture is one of the most common facial bone fractures and mainly caused by blunt trauma, whereas barotraumatic causes are relatively rare. In this report, we present the case of a patient with an orbital medial wall blow out fracture caused by nose blowing. This case is unique in that the barotraumatic blow out fracture occurred in a patient without previous known risk factors, except that she had previously been operated on for orbital floor blow-out fracture. It is possible that barotraumatic orbital medial wall fracture occurred due to postoperative changes in the aerodynamics or shock-absorbing capacity of the paranasal sinuses. To prevent barotraumatic trauma in the orbital wall, patients undergoing surgery for orbital fractures should consider avoiding excessive nose blowing not only in the weeks after surgery, but for a sufficient period of time.

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.

Theoretical model of pediatric orbital trapdoor fractures and provisional personalized 3D printing-assisted surgical solution

Pediatric orbital trapdoor fractures are common in children and adolescents and usually require emergency surgical intervention. Herein, a personalized 3D printing-assisted approach to surgical treatment is proposed, serving to accurately and effectively repair pediatric orbital trapdoor fractures. We first investigated stress distribution in external force-induced orbital blowout fractures via numerical simulation, determining that maximum stresses on inferior and medial walls exceed those on superior and lateral walls and thus confer higher probability of fracture. We also examined 36 pediatric patients treated for orbital trapdoor fractures between 2014 and 2019 to verify our theoretical construct. Using 3D printing technique, we then created orbital models based on computed tomography (CT) studies of these patients. Absorbable implants were tailor-made, replicating those of 3D-printed models during surgical repairs of fractured orbital bones. As follow-up, we compared CT images and clinical parameters (extraocular movements, diplopia, enophthalmos) before and 12 months after operative procedures. There were only two patients with diplopia and six with enophthalmos >2 mm at 12 months, attesting to the efficacy of our novel 3D printing-assisted strategy.

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Numerical simulation is used to theoretically investigate the mechanism of external force-induced orbital blowout fractures.

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3D printing--assisted surgical treatment is proposed to effectively repair pediatric orbital trapdoor fractures.

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Clinical studies are performed by repairing fractured orbital bones via 3D printed customized absorbable implants.

Application of Three-Dimensional Printing Technology in the Orbital Blowout Fracture Reconstruction

The aim of this study was to investigate the clinical outcomes of orbital blowout fracture repair by using the three-dimensional (3D) printing-assisted fabrication of individual titanium mesh. Clinical and radiologic data were analyzed for 12 patients with orbital floor and/or medial wall fractures. Lower eyelid incision was used to expose the fractures. Preoperative computed tomographic data were input into an imaging software to rebuild a 3D orbit and mirror the unaffected side into the affected side to replace the demolished orbit. A resin model of the reshaped orbit was generated and used to develop an individual titanium mesh for repairing the fractured orbital. The surgical results were assessed by value of enophthalmos and a comparison of preoperative and postoperative orbital volume difference. All patients had a successful treatment outcome without any complications. Clinical significant enophthalmos were not observed after treatment, and diplopia were solved within 2 weeks postoperative. No extraocular muscle limitation was observed. Postoperative computed tomography scans demonstrated appropriate positioning of titanium mesh and there was no implant displacement. The postoperative orbital volume and enophthalmos difference between the 2 eyes decreased significantly than preoperative (P < 0.001). Three-dimensional printing-assisted fabrication of individual titanium mesh is appropriate for use in orbital blowout fracture.

Fronto-naso-orbital Reconstructions

BACKGROUND

Significant defects at the fronto-naso-orbital area always present with severe facial disfigurement for the afflicted individuals. It may occur after tumor ablations, compound comminuted fractures, or craniofacial surgeries at this area.

PATIENTS AND METHODS

Reconstructions of 11 patients with this problem had been performed by the authors, with follow-up for 3 to 25 years. The modes of reconstruction involved carved cartilage block with fascia grafts in 3 patients, split calvarial bone grafting covered with fascia grafts in 2 patients, drilled bone chips harvested from outer table of calvarial bone encased with fascia for smaller defects in 2 patients, 3-dimensional computed tomographic reconstruction and reformation of replica to replace the destroyed framework in 4 patients.

RESULTS

Patients in this series all achieved good results, with symmetric face, acceptable facial contour, and being willing to attend social activities with deliberate evaluation and planning, selection of proper method, with proficient skills in reconstruction. One patient who received cartilage block grafting came back for refining facial contour 18 years later.

CONCLUSIONS

Midline fronto-naso-orbital defects could be reconstructed with carved cartilage graft or bone graft, overlaid with fascia graft, intricate asymmetric defects can be reconstructed with the aid of 3-dimensional computed tomographic image reconstruction and reformation of the defect replica to achieve symmetric esthetic result with individualized approaches.

Gun-related eye injuries: A primer

Gun-related eye injuries are relatively common in the context of gunshot wounds to the head and neck. Many of the fundamental principles of gunshot wound management apply to the care of these patients, but the complex anatomy and functional relationships of the periocular region do pose special challenges. We provide a focused primer for physicians seeking a more in-depth understanding of gun-related eye injuries and present 3 representative cases outlining the spectrum of pathology, provide a focused review of the relevant ballistics concepts, and discuss the management of injuries to the periocular soft tissues, orbital structures, and globe. We found that good cosmetic and functional results can often be achieved with appropriate early intervention, but visual prognosis may remain guarded despite optimal treatment.

Three-dimensional orbital wall modeling using paranasal sinus segmentation

PURPOSE

Three-dimensional orbital wall modeling is a time-consuming process because of the presence of pseudoforamina. We developed an automated three-dimensional modeling software to characterize the orbital wall, and evaluated it using data from fracture patients.

METHODS

We first characterized the air and face regions using multiphase segmentation; the sinuses were segmented by applying morphological operations to air regions. Pseudoforamina of the orbital wall were offset with the segmented sinuses. Finally, the three-dimensional facial bone model, with orbital wall, was reconstructed from the segmented images.

RESULTS

Ten computed tomography data sets were used to evaluate the proposed method. Results were compared with those obtained using the active contour model and manual segmentation. The process took 31.7 ± 8.0 s, which was 30-60 times faster than other methods. The average distances between surfaces obtained with the proposed method and those obtained with manual segmentation (normal side: 0.20 ± 0.06 mm; fractured side: 0.28 ± 0.10 mm) were approximately half those obtained using the active contour model.

CONCLUSIONS

Three-dimensional orbital wall models, which were very similar to the manually segmented models, were archived within 1 min using the developed software, regardless of fracture presence. The proposed method might improve the safety and accuracy of surgical procedures.

Enhanced radiographic visualization of resorbable foils for orbital floor reconstruction: A proof of principle

PURPOSE

Despite the advantages and broad applications of alloplastic resorbable implants, postoperative radiological control is challenging due to its radiolucency. The aim of the present study was to evaluate the radiographic visibility of newly developed materials for orbital floor reconstruction.

MATERIALS AND METHODS

The radiographic visibility of four different material combinations consisting of poly-(L-lactic acid)/poly-glycolic acid (PLLA/PGA) or poly(D,L-lactic acid) (PDLLA) enriched with magnesium (Mg), hydroxyapatite (HA) or β-tricalcium phosphate (β-TCP) with various layers of thicknesses (0.3, 0.6, and 1 mm), surgically placed above the orbital floor of a human head specimen, was evaluated using computed tomography (CT) and cone beam computed tomography (CBCT). The visibility was rated on a scale of 0-10 in CT/CBCT and by Hounsfield Units in CT for each subject.

RESULTS

All of the materials were clearly detectable in CT scans. Visibility was significantly higher (p < 0.001) in the standard soft tissue window (mean score: 7.3, ranging from 2 to 10) in comparison to the standard bone window (mean score: 5.2, ranging from 1 to 10). In CBCT (mean score: 3.3, ranging from 0 to 7), there was significantly lower but still sufficient visibility of the materials compared to the CT soft tissue window (p < 0.001) and CT bone window (p < 0.001). Comparing the different materials' visibility among the group of same layer thicknesses with each other, in the majority of cases, PDLLA enriched with β-TCP appeared to be most visible in both CT and CBCT.

CONCLUSION

The incorporation of radiopaque elements to PLLA/PGA and PDLLA polymers is a promising strategy to improve their visibility in CT and CBCT. Our data suggest that the reconstruction of the orbital floor with these new materials could provide an advantageous postoperative radiographic control.

Management of old naso-orbital fractures with ocular involvement and associated complications caused by facial trauma

A 14-years-old boy came with chief complaint of epiphora and history of globe rupture repair surgery due to facial trauma one year ago. Patient got complications from the trauma, including nasolacrimal duct obstruction, phthisis bulbi, enophthalmos, facial deformities, and ptosis. Multidisciplinary approach was performed simultaneously in one session surgery which included oral mucosal graft for non-irritative phthisis bulbi, silicone block implant for blowout fracture, external dacrycystorhinostomy for obstructed nasolacrimal duct, fascia lata brow suspension/frontalis sling for ptosis, and septorhinoplasty for nasal augmentation. After the surgery, symptoms of epiphora had resolved and aesthetical improvement of facial deformities was also prominent. Management of old orbital fracture poses additional challenges due to the complications that have occurred over time. Loss of functionality may seem impractical to manage because no function can be pertained. Nevertheless, it is important to still perform surgical repair for aesthetic purposes due to the psychological effect on their daily lives.

Clinical outcomes for minimally invasive primary and secondary orbital reconstruction using an advanced synergistic combination of navigation and endoscopy

BACKGROUND

Sequelae of inadequate orbital reconstruction include enophthalmos, hypoglobus, and diplopia. Accuracy of orbital reconstruction is largely subjective and especially difficult to achieve because of anatomic distortion in secondary or late reconstruction and in extensive injury. We combined computer navigation and endoscopy to perform accurate, aesthetic, and safe minimal-access primary and secondary orbital reconstruction.

METHODS

From 2013 to 2014, 24 patients underwent unilateral primary and secondary or late minimally invasive orbital reconstruction with mainly Medpor and/or titanium mesh by navigation and endoscopic assistance through transantral, transconjunctival, or upper blepharoplasty approaches. Mean follow-up was 13.8 months (range, 6.2 months to 2.8 years).

RESULTS

All orbital fractures were successfully reduced. Average enophthalmos among patients who underwent early reconstruction, late reconstruction, and multiorbital wall repair improved (p < .001) to 0.2 mm from 1.6, 2.6, and 2.6 mm, respectively. Hypoglobus and diplopia resolved in all. In early reconstruction patients, mean interorbital volume difference improved from 1.72 ± 0.87 to 0.53 ± 0.83 ml (P = .03). For late reconstruction patients, this difference improved from 3.41 ± 1.23 to 0.56 ± 0.96 ml (p < .001). There were no major complications during follow-up, and all were satisfied with their final appearance and function.

CONCLUSION

Navigation sharpens reconstructive accuracy and avoids injury to vital structures. Combined with endoscopic assistance for minimal-access reconstruction of wide-ranging orbital defects from primary to secondary or late cases and to extensive multiwall fractures, navigation facilitates minimal cosmetic incision and synergistic endoscope use and clearly optimizes aesthetic and functional outcomes, all with enhanced safety and unparalleled intraoperative visualization.

Rapid prototyping modelling in oral and maxillofacial surgery: A two year retrospective study

Background

The use of rapid prototyping (RP) models in medicine to construct bony models is increasing.

Material and Methods

The aim of the study was to evaluate retrospectively the indication for the use of RP models in oral and maxillofacial surgery at Helsinki University Central Hospital during 2009-2010. Also, the used computed tomography (CT) examination – multislice CT (MSCT) or cone beam CT (CBCT) - method was evaluated.

Results

In total 114 RP models were fabricated for 102 patients. The mean age of the patients at the time of the production of the model was 50.4 years. The indications for the modelling included malignant lesions (29%), secondary reconstruction (25%), prosthodontic treatment (22%), orthognathic surgery or asymmetry (13%), benign lesions (8%), and TMJ disorders (4%). MSCT examination was used in 92 and CBCT examination in 22 cases. Most of the models (75%) were conventional hard tissue models. Models with colored tumour or other structure(s) of interest were ordered in 24%. Two out of the 114 models were soft tissue models.

Conclusions

The main benefit of the models was in treatment planning and in connection with the production of pre-bent plates or custom made implants. The RP models both facilitate and improve treatment planning and intraoperative efficiency.

Key words:Rapid prototyping, radiology, computed tomography, cone beam computed tomography.

A Case of Aggravated Medial Orbital Wall Fracture After Reduction of Orbital Floor Fracture

Concomitant fractures of the inferior and medial orbital wall can cause more severe orbital symptoms and lead to incomplete reduction postoperatively. This report presents the case of a 17-year-old boy, presenting with persistent diplopia and enophthalmos after floor reduction for concomitant fractures. At the time of the fracture, surgery was performed for only the orbital floor by a plastic surgeon, because the medial wall fracture was minimal. However, he presented with persistent orbital symptoms after surgery. An aggravated medial wall fracture was discovered via computed tomography (CT) examination. It was treated with a minimal-invasive method using an endoscopic approach.

Correction of orbital wall fracture close to the optic canal using computer-assisted navigation surgery

BACKGROUND

Repairing orbital wall fractures can result in serious complications, including enophthalmos, diplopia, or even blindness. Especially, surgeons worry about damaging the optic nerve while dissecting the optic canal area. We avoid these complications by using a navigation system that was adapted to stereotactic concept based on three-dimensional imaging of the patient's anatomy. Here, we report 5 cases of orbital wall fracture that were repaired using a navigation system.

METHODS

The Navigation System II (Stryker, Freiburg, Germany) and the iNtellect Cranial Navigation (version 1.1) platform were used for each operation. A computer-assisted navigation surgery was performed according to the following procedures: (1) image set, (2) planning, (3) apparatus setup, (4) registration, and (5) intraoperative navigation. Operations were performed under general anesthesia. Dissection was performed up to the periosteum immediately anterior to the optic canal, near the fracture. Vulnerable surrounding structures were identified with the intraoperative pointer. After navigation, we inserted an implant into the defect, successfully, avoiding damage to the optic canal and optic nerve.

RESULTS

None of the patients had any surgical complications. Postoperative computed tomography scans demonstrated that the fractures were corrected, and continuity was maintained without displacement. The three-dimensional image allowed us to easily visualize intraoperative anatomical structure, allowing us to avoid unnecessary procedures and to correct the orbital wall. The mean volume of fractured orbital cavity was 29.2 cm(3) (range, 28.3-30.4 cm(3)) preoperatively and 27.0 cm(3) (range, 25.9-28.5 cm(3)) postoperatively; thus, the defects were corrected by 2.2 cm(3) (range, 1.3-2.8 cm(3)) on average.

CONCLUSIONS

We used a navigation system to perform accurate and safe surgery in patients with extensive orbital wall fracture, including around the optic canal. By using the functions to visualize the locations indicated by the pointer, we were able to perform successful dissections and implantations in areas adjacent to the optic canal. The good outcomes obtained here provide evidence that surgical correction of the orbital wall using a navigation system is useful in cases of deep, extensive orbital wall fracture.

Three-dimensional pre-bent titanium implant for concomitant orbital floor and medial wall fractures in an East asian population

Background

The objective of this article is to evaluate clinical outcomes of combined orbital floor and medial wall fracture repair using a three-dimensional pre-bent titanium implant in an East Asian population.

Methods

Clinical and radiologic data were analyzed for 11 patients with concomitant orbital floor and medial wall fractures. A combined transcaruncular and inferior fornix approach with lateral canthotomy was used for the exposure of fractures. An appropriate three-dimensional preformed titanium implant was selected and inserted according to the characteristics of a given defect.

Results

Follow-up time ranged from 2 to 6 months (median, 4.07 months). All patients had a successful treatment outcome without any complications. Clinically significant enophthalmos was not observed after treatment.

Conclusions

Three-dimensional pre-bent titanium implants are appropriate for use in the East Asian population, with a high success rate of anatomic restoration of the orbital volume and prevention of enophthalmos in combined orbital floor and medial wall fracture cases.

The temporoparietal adipofascial flap for the correction of recurrent idiopathic enophthalmos

Enophthalmos, the posterior displacement of a normal-size ocular globe relative to the orbital cavity, is usually repaired using autogenous grafts or alloplastic materials. We present the case of a 40-year-old man with bilateral idiopathic enophthalmos whose symptoms recurred 8 years after initial successful surgical repair. We describe the successful and safe use of a bilateral temporoparietal adipofascial flap in the treatment of recurrent idiopathic enophthalmos.

Use of x-ray film implant for the repair of orbital fractures

PURPOSE

To evaluate the experience with sterilized x-ray film in the repair of orbital blow-out fractures (BOFs).

METHODS

A retrospective review of case notes from 56 patients with orbital BOF repaired using sterilized x-ray film onlay implants at 2 institutions between November 2004 and December 2010. Patient demographics, timing of surgery, surgical approach, postoperative complications, and length of follow up were recorded.

RESULTS

Fifty-six patients (44 men, 12 women) received sterilized x-ray film implants during the 6-year study period. Mean age at the time of repair was 29 years (range 4-85 years). For 68% of patients, surgical repair was performed within 2 weeks of injury. Average length of postoperative follow up was 5.5 months (range 1-36 months), 48% had follow up >3 months. Following surgical repair, diplopia in primary or down gaze reduced from 98% to 4% and enophthalmos ≥2 mm reduced from 21% to 5% cases. One patient required a second operation for repositioning of an incompletely reduced fracture. A second patient presented 9 months postoperatively with recurrent episodes of proptosis, and the implant and its surrounding pseudocapsule were subsequently removed. There were no cases of visual loss, implant infection, or migration.

CONCLUSIONS

This series has demonstrated that in selected orbital fractures sterilized x-ray film can provide a safe, effective, and low-cost onlay implant.