Orbital wall restoring surgery with primary orbital wall fragments in blowout fracture

Orbital wall restoration with primary bone fragments in complex orbital fractures

BACKGROUND

Complex orbital fractures are impure orbital fractures because they involve the orbital walls and mid-facial bones. The author reported an orbital wall restoration technique in which the primary orbital wall fragments were restored to their prior position in complex orbital fractures in 2020. As a follow-up to a previous preliminary study, this study retrospectively reviewed the surgical results of complex orbital wall fractures over a 4-year period and compared the surgical outcomes by dividing them into groups with and without balloon restoration.

METHODS

Data of 939 patients with facial bone fractures between August 2018 and August 2022 were reviewed. Of these, 154 had complex orbital fractures. Among them, 44 and 110 underwent reduction with and without the balloon technique respectively. Pre- and postoperative Naugle exophthalmometer (Good-Lite Co.) scales were evaluated. The orbital volume and orbital volume ratio were calculated from preoperative and 6 months postoperative computed tomography images.

RESULTS

Among 154 patients with complex orbital fractures, 44 patients underwent restoration with the balloon technique, and 110 patients underwent restoration without it. The Naugle scale did not differ significantly between the two groups, but the orbital volume ratio significantly decreased by 3.32% and 2.39% in groups with and without the balloon technique and the difference in OVR was significantly greater in patients in the balloon restoration group compared with the control group. Postoperative balloon rupture occurred in six out of 44 cases (13.64%). None of the six patients with balloon rupture showed significant enophthalmos at 6 months of follow-up.

CONCLUSION

The balloon rupture rate was 13.64% (6/44 cases) with marginal screw fixation, blunt screws, and extra protection with a resorbable foam dressing. Furthermore, we restored the orbital wall with primary orbital fragments using balloon support in complex orbital wall fractures.

Delayed-type retrobulbar hematoma caused by low temperature after reconstruction of inferior blow-out fracture

Retrobulbar hemorrhage is a disastrous condition that can lead to permanent blindness. As such, rapid diagnosis and treatment are critical. Here, we report a patient who presented with retrobulbar hemorrhage following an orbital floor fracture. Restoration of inferior orbital wall with porous polyethylene implant was underwent. Four days after the orbital floor reconstruction, the patient smoked a cigarette outdoors in –3˚C weather. Cold temperature and smoking caused an increase in his systemic blood pressure. The elevated blood pressure increased intraorbital pressure to the extent of causing central retinal artery occlusion and exacerbated oozing. During exploratory surgery, 3 mL of hematoma and diffuse oozing without arterial bleeding were observed. Prompt diagnosis and treatment prevented vision impairment. Few studies have reported on the risk factors for retrobulbar hemorrhage. This case showed that daily activities, such as exposure to cold weather or tobacco smoking, could be risk factors for retrobulbar hemorrhage.

Surgical indication analysis according to bony defect size in pediatric orbital wall fractures

Background

Orbital fractures are the most common pediatric facial fractures. Treatment is conservative due to the anatomical differences that make children more resilient to severe displacement or orbital volume change than adults. Although rarely, extensive fractures may result in enophthalmos, causing cosmetic problems. We aimed to establish criteria for extensive fractures that may result in enophthalmos.

Methods

We retrospectively reviewed the charts of patients aged 0–15 years diagnosed with orbital fractures in our hospital from January 2010 to February 2019. Computed tomography images were used to classify the fractures into linear, trapdoor, and open-door types, and to estimate the defect size. Data on enophthalmos severity (Hertel exophthalmometry results) and fracture pattern and size at the time of injury were obtained from patients who did not undergo surgery during the follow-up and were used to identify the surgical indications for pediatric orbital fractures.

Results

A total of 305 pediatric patients with pure orbital fractures were included–257 males (84.3%), 48 females (15.7%); mean age, 12.01± 2.99 years. The defect size (p= 0.002) and fracture type (p= 0.017) were identified as the variables affecting the enophthalmometric difference between the eyes of non-operated patients. In the linear regression analysis, the variable affecting the fracture size was open-door type fracture (p< 0.001). Pearson’s correlation analysis demonstrated a positive correlation between the enophthalmometric difference and the bony defect size (p= 0.003). Using receiver operating characteristic curve analysis, a cutoff value of 1.81 cm² was obtained (sensitivity, 0.543; specificity, 0.724; p= 0.002).

Conclusion

The incidence of enophthalmos in pediatric pure orbital fractures was found to increase with fracture size, with an even higher incidence when open-door type fracture was a cofactor. In clinical settings, pediatric orbital fractures larger than 1.81 cm² may be considered as extensive fractures that can result in enophthalmos and consequent cosmetic problems.

Orbital wall restoration with primary bone fragments in complex orbital fractures: A preliminary study

BACKGROUND

We have reported orbital wall restoration surgery with primary orbital wall fragment in pure blowout fractures using a combination of transorbital and transnasal approach in pure blow out fractures. However, this method was thought to be difficult to use for complex orbital wall fractures, since the sharp screw tip that fixate the maxillary wall increases the risk of balloon ruptures. In this study, we reviewed 23 cases of complex orbital fractures that underwent orbital wall restoration surgery with primary orbital wall fragment and evaluated the result.

METHODS

A retrospective review was conducted of 23 patients with complex orbital fracture who underwent orbital restoration surgery with primary orbital wall fragments between 2012 and 2019. The patients underwent orbital wall restoration surgery with primary orbital wall fragment with temporary balloon support. The surgical results were evaluated by the Naugle scale and a comparison of preoperative and postoperative orbital volume ratio. Complex fracture type, type of screw used for fixation and complications such as balloon rupture were also investigated.

RESULTS

There were 23 patients with complex orbital fracture that used transnasal balloon technique for restoration. 17 cases had a successful outcome with no complications, three patients had postoperative balloon rupture, two patients had soft-tissue infection, and one patient had balloon malposition.

CONCLUSION

The orbital wall restoration technique with temporary balloon support can produce favorable results when done correctly even in complex orbital wall fracture. Seventeen cases had favorable results, six cases had postoperative complications thus additional procedure seems necessary to complement this method.