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STATE OF THE ORBITAL FLOOR IN A ZYGOMATICO-ORBITAL COMPLEX FRACTURE
Abstract and Figures
Violation of the integrity of the walls of the orbit and displacement of the fragments may lead to functional and aesthetic violations even after repositioning the zygomatic bone. Timely diagnosis of the presence of a fracture of the orbital wall in injuries of the joint zone of the face allows you to choose the right tactics of surgical treatment of patients. The main method for determining the presence of a fracture and the degree of displacement of the fragments of the lower wall of the orbit remains the x-ray method. The use of different types of computer tomography for diagnosis allows to determine reliably the presence of damage to the walls of the orbit.
The aim of the study was to justify the use of CBCT for the diagnosis of fractures of the zygoma-orbital complex and comparative analysis of the spatial position of the lower wall of the orbit in the postoperative period as a criterion of the effectiveness of surgical treatment for fracture of zygoma-orbital complex.
The object of the study were patients (30 patients) with fractures of the orbital complex, who were treated with 11 GKB in Minsk for 2015-2017 years. The study of these medical records and the results of pre- and postoperative x-ray examination.
The study revealed that the CBCT method can be used to assess the state of the lower wall of the orbit in injuries of the orbital complex. The use of CBCT for this purpose makes it possible to qualitatively assess the state of the fragments of the lower reticulum of the orbit and characterize the results of the operative treatment of fractures of the zygoma-orbital complex.
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The aim of this study was to determine the predictors of post-traumatic enophthalmos (PE) in relation to the internal orbital changes following pure orbital blowout fractures. The design was a 10-year retrospective cross-sectional study analysing 629 medical records and computed tomography (CT) data of patients with orbital fractures from January 2008 to January 2017. Demographic, etiology, co-morbidity and clinical characteristics were obtained from the medical records. Assessment of the PE, fracture site and size, intraorbital structures and muscle change were performed using the Digital Imaging and Communications in Medicine (DICOM) viewer software, OsiriX v5.8.2. Of the 629 patients with orbital fractures, 87 were pure orbital blowout fractures. Demographic pattern showed that males outnumbered females in the series, with male: female ratio of 5.7:1. The mean age was 37.2 ± 14.7 and the main etiology was motor vehicle accident. Orbital floor fracture was the most common fracture location (67.8%). The involvement of the posterior ledge and inferior orbital fissure showed statistical significant difference with PE (Fisher’s exact test, p = 0.03). Binary logistic regression showed that after controlling for age, patients with fracture size of more than 150 mm² had three times the odds of sustaining a PE, (adjusted odds ratio (AOR) = 3.01 (95% CI 1.17–7.92).
Fracture size larger than 150 mm² was a radiological predictor of PE. Additional research investigating further on the role of concurrent fracture of the posterior ledge and inferior orbital fissure is advocated.
Introduction:
Treatment decisions for fractures of the orbital floor are based on clinical appearance, ophthalmological examination, and computed tomography (CT) scans. In extensive fractures, decisions are easily made between conservative and surgical treatment. However, objective parameters are rare in inconclusive cases.
Materials and methods:
Our retrospective study included 106 patients with unilateral isolated orbital floor fractures. Correlations between preoperative ophthalmological examinations and specific CT parameters were performed.
Results:
The defect size of the fracture appeared to be significantly associated with the presence of diplopia. CT-morphological parameters and preoperative ophthalmological results showed statistical significance for diplopia and incarceration of inferior rectus muscle (IRM), diplopia and displacement of IRM, decreased mobility and incarceration of IRM, and decreased mobility and displacement of IRM.
Discussion:
Our clinical assessment scheme for CT scans of orbital floor fractures is aimed at facilitating treatment decision making using four CT-based variables. As critical size defects of the orbital floor of ≥2 cm2 are likely to cause clinically significant posterior displacement of the globe, resulting in enophthalmos, the proposed parameters offer a readily accessible and easy to evaluate scheme that helps to identify patients in need of surgical intervention.
Accurate reduction is the key to successful treatment of bone fractures. Complicated zygomaticomaxillary complex fracture, known as one of the most challenging facial bone fractures, is often hard to achieve an accurate reduction, thus leading to facial deformity. In this study, twenty patients with unilateral complicated zygomaticomaxillary complex fractures were included and randomly divided into experimental and control groups, which is with and without the aid of surgical navigation, respectively. The pre- and postoperative imaging data were collected and then analysed using Geomagic Studio 11 software and Brainlab iPlan CMF 3.0. A more precise reduction was showed in the experimental group according to the measurement results of both software programmes than in the control group. In conclusion, surgical navigation showed great value in performing accurate reductions of complicated zygomaticomaxillary complex fractures and restoring facial contour.
Obtaining postoperative images of maxillofacial fractures does not affect the clinical management of asymptomatic patients; however, few studies have evaluated the role of postoperative imaging in the context of orbital floor fractures. In this study, we evaluate current practice techniques and the role of postoperative imaging in the management of orbital floor fractures in isolation and with concomitant facial fractures. Retrospective review of patients who underwent open reduction and internal fixation of orbital floor fractures between 2005 and 2015 at a single medical institution. Operative and perioperative records were reviewed to characterize postoperative imaging as routine or as indicated by concerning clinical symptoms, and to correlate clinical outcomes to postoperative imaging patterns across all identified orbital floor fractures. A total of 139 patients underwent open reduction and internal fixation of orbital floor fractures. Of these, 75 (54%) had zygomaticomaxillary (ZMC) involvement. The remaining 64 (46%) were isolated orbital floor fractures. Overall, 54 (39%) patients underwent postoperative imaging. Of these, 38 (70%) had postoperative imaging in the absence of concerning clinical symptoms. There was no observed difference in complication rates in those who underwent postoperative imaging, and those who did not. Patients with orbital + ZMC fractures underwent a significantly higher number of postoperative imaging studies (p < 0.001); however, there was no observed difference in complications between isolated orbital and orbital + ZMC fractures. Routine postoperative imaging is not warranted in the absence of persistent clinical symptoms following open reduction and internal fixation of orbital floor fractures.
Zygomatic fractures are among the most common fractures to the facial skeleton. However, because no standard and reliable method of evaluation is available to assess postoperative patients, we often rely on photographs and subjective assessments. A portable mirror stand device (MiRS), which is a new method for the standardization of photography, was developed in our institution. Used with image analysis software, this device provides a new method for evaluating outcomes after the open reduction and internal fixation of zygomatic fractures. The portable mirror stand device was set up in our outpatient clinic at the Cleft Craniofacial Center at Cipto Mangunkusumo Hospital. Photographs of 11 postoperative patients were taken using the device, and they were analyzed both manually and using image analysis software (ImageJ 1.46) for symmetry. The two methods were then compared to assess the correlation and agreement of the results. The measurements taken using the manual method and the software-assisted method did not differ significantly, which indicated the good agreement between the two methods. The results of the symmetry achieved atour center were similar to other centers in the Asian region (ΔZy = 3.4±1.5 mm, ΔBc = 2.6±1.6 mm, ΔCh = 2.3±2.4 mm) compared with (ΔZy = 3.2±1.7 mm, ΔBc = 2.6±1.6 mm, ΔCh = 2.3±2.5 mm). The treatment of zygomatic fracture a tour center achieved good results. The portable mirror stand device assisted the image analysis software (ImageJ 1.46), which could be beneficial in assessing symmetry in postoperative zygomatic fracture patients.
Background and purpose:
Extensive orbital floor and medial wall fractures compared with isolated orbital wall fractures are more likely to require surgical correction because of a higher possibility of complications like diplopia, enophthalmos, or numbness. The unique and complex contours of the orbital anatomy limit the intraoperative view of the intraorbital anatomy, and complex orbital fractures involving the buttress of the transition zone area all make orbital reconstruction surgery more challenging. The aim of this study was to describe our experience with surgical approaches using navigation- and endoscope-assisted guidance for extensive orbital floor and medial wall fracture reconstruction.
Patients and methods:
A retrospective study was conducted on consecutive 17 patients from 2015 to 2017 presenting with unilateral extensive orbital floor and medial wall fractures at the Chang Gung Memorial Hospital, Linkou Branch. The fractures were treated surgically with a preformed mesh plate and layered Medpor (Porex Surgical Inc, Atlanta, Ga) through navigation and endoscopy. The preoperative and postoperative functional and aesthetic outcomes were described.
Results:
All extensive orbital floor and medial wall fractures were successfully reconstructed. Of the 17 patients, 11 experienced diplopia preoperatively, and for 2 of the 11 patients, diplopia improved immediately after surgery. In the remaining 9 patients, diplopia still persisted after surgery; however, diplopia recovered after an average of 3.44 months (range, 1-9 months). Average enophthalmos among the 10 patients, evaluated by postoperative follow-up computed tomography scan, improved from 2.99 to 0.68 mm. There were no major complications during follow-up, and all patients were satisfied with their final appearance and function.
Conclusions:
On the basis of the results, our surgical approach using preformed titanium mesh plates and Medpor under the assistance of navigation and endoscopy can be a safe, accurate, and effective method for the management of extensive orbital floor and medial wall fractures and clearly optimizes functional and aesthetic outcomes.
Purpose:
Planes of reference for orbital fractures (PROF) was developed to standardize measurements made on orbital computed tomography scans. This study describes the use of PROF in determining the location along the orbital floor where the posterior ledge (PL) most commonly occurs. The transverse inclination and anterior-posterior inclination of the orbital floor will also be measured.
Methods:
This study evaluates 104 patients with unilateral orbital fracture. Fifty-two patients had intact infra-orbital margin (IM) and 52 had fractured IM. Facial computed tomography scans were analyzed using Osirix Lite Digital Imaging and Communications in Medicine Viewer version 7.0.1 (Geneva, Switzerland). All skull positions were standardized by orientation according to Frankfurt and mid-sagittal planes. Measurements of distance of PL from IM were determined in the sagittal view. Measurements of the inclination of the orbital floor in the transverse and anterior-posterior sections were done on the coronal and sagittal views respectively.
Results:
For patients with intact and fractured IM, the mean distances of PL from IM were 22.1 mm (95% CI: 21.2-23.0) and 21.1 mm (95% CI: 20.2-21.9) respectively. Mean transverse inclination was 19.4° (95% CI: 18.3-20.5). Mean anterior-posterior inclination was 15.5° (95% CI: 14.5-16.5).
Conclusion:
Planes of reference for orbital fractures is a simple and effective method to acquire standardized measurements of the orbital cavity on computed tomography scans. Understanding the commonest location of PL and the orientation of the orbital floor in 3-dimensional space allows surgeons to perform dissection with greater precision.
Purpose:
In evaluating patients sustaining bilateral isolated internal orbital fractures, the authors have observed both similar fracture locations and also similar expansion of orbital volumes. In this study, we aim to investigate if there is a propensity for the 2 orbits to fracture in symmetrically similar patterns when sustaining similar trauma.
Methods:
A retrospective chart review was performed studying all cases at our institution of bilateral isolated internal orbital fractures involving the medial wall and/or the floor at the time of presentation. The similarity of the bilateral fracture locations was evaluated using the Fisher's exact test. The bilateral expanded orbital volumes were analyzed using the Wilcoxon signed-rank test to assess for orbital volume similarity.
Results:
Twenty-four patients with bilateral internal orbital fractures were analyzed for fracture location similarity. Seventeen patients (70.8%) had 100% concordance in the orbital subregion fractured, and the association between the right and the left orbital fracture subregion locations was statistically significant (P < 0.0001). Fifteen patients were analyzed for orbital volume similarity. The average orbital cavity volume was 31.2 ± 3.8 cm on the right and 32.0 ± 3.7 cm on the left. There was a statistically significant difference between right and left orbital cavity volumes (P = 0.0026).
Conclusions:
The data from this study suggest that an individual who suffers isolated bilateral internal orbital fractures has a statistically significant similarity in the location of their orbital fractures. However, there does not appear to be statistically significant similarity in the expansion of the orbital volumes in these patients.
Objective:
At present, the effect of the visual electrophysiology and vision field examination in patients with orbital blowout fracture is rarely studied. So, the authors investigate the value of visual electrophysiology and vision field examination in the diagnosis of ocular contusion.
Methods:
The position and range of fracture of 81 patients were determined by computed tomography (CT) scanning. Visual evoked potential (VEP), electroretinogram (ERG), and mfERG were vision field examination detected in 81 patients and the results were compared with those of contralateral healthy eyes. In addition, visual electrophysiology and vision field examination in diagnosis of eye contusion was analyzed and the correlation of the VEP, ERG, mfERG injury duration, and visual acuity was further analyzed.
Results:
The visual acuity of orbital fractures was significantly decreased compared with that in the uninjured eyes (t = 2.181, P = 0.032). Compared injured eyes and normal eyes in 54 patients, b wave of Max-ERG and Cone-ERG implied value extension (t = -2.426, P = 0.025; t = -2.942, P = 0.014), P-VEP P100 Peak duration and amplitude significantly extended (t = 3.162, P = 0.007; t = 9.314, P = 0.000), and F-VEP P1 amplitude decreased significantly (t = 3.362, P = 0.004). mfERG showed that the injured eye central reaction was significantly decreased (t = 8.727, P = 0.000). There was a significant correlation between P-VEP P100 amplitude and visual acuity (r = 0.067, P = 0.000). But there was no significant correlation between the P100 peak value, amplitude of P-VEP, mfERG central reaction, and injured days, respectively. There was significant difference between 2 groups with average visual acuity and mean defect value (t = 3.253, 3.461, P = 0.006, 0.003). There was statistical means the difference in P-VEP abnormal group, visual field abnormal group, and combined detection abnormal groups, the abnormal rate increased significantly (χ = 3.931, P < 0.01).
Conclusion:
Orbital floor fracture can lead to optic nerve damage and also may be associated with decreased macular function. The combination analysis of visual electrophysiology and vision field examination is beneficial to early diagnosis of ocular trauma and can improve the positive rate in clinic practice.
The treatment has been improved on the accurate reduction of blow-out fracture for many decades. But still, it has been limited to reduce completely when surgeons are approaching by conventional technique. The authors analyzed the postoperative results using computed tomography (CT) scans after conventional open reduction of isolated medial wall fracture. Thirty-seven patients with isolated medial wall fracture were reviewed. All patients underwent preoperative, immediate, and postoperative CT scans. Two surgeons have performed the surgery by conventional open reduction with transcaruncular approach and absorbable mesh insertion. The authors evaluated changing orbital volume and distance, comparing the immediate and 6 months postoperative outcomes with preoperative outcome. The differences between immediate postoperative and 6 months postoperatively data were statistically evaluated. The authors used the distant value to minimize bias of CT view selection. Significant differences from the 2 kinds of data were observed (P < 0.05 for volume, P < 0.01 for distance, Paired t test). Bone remodeling process after conventional open reduction of orbital wall has not been fully understood. Most popular technique is conventional open reduction and mesh insertion but it is not easy for surgeons to reduce fractured bones completely. The authors analyzed the bone remodeling after incomplete reduction. These results suggest that the decreased measurements might be caused from the scar contracture with fibrosis. This research is very limited to explain the change while bone remodeling is progressed. Further research should be continued to discover the understanding of the process.