Orbital wall restoration with primary bone fragments in complex orbital fractures

박종현,Dong Hee Kang,Hong Bae Jeon,Hyonsurk Kim 대한두개안면성형외과학회 2023 Archives of Craniofacial Surgery Vol.24 No.2

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.

Reconstruction of Medial Orbital Wall Fractures without Subperiosteal Dissection: The “Push-Out” Technique

김용하,이진호,박영수,김성은,정규진,이준호,김태곤 대한성형외과학회 2017 Archives of Plastic Surgery Vol.44 No.6

Background Various surgical methods for repairing medial orbital wall fractures have been introduced. The conventional technique requires total separation of the displaced orbital bones from the orbital soft tissues. However, subperiosteal dissection around the fracture can cause additional damage. The aim of the present study is to introduce a method of reconstructing medial orbital wall fractures without subperiosteal dissection named the “push-out” technique. Methods Six patients with post-traumatic enophthalmos resulting from an old medial orbital wall fracture and 10 patients with an acute medial orbital wall fracture were included. All were treated with the push-out technique. Postoperative computed tomography (CT) was performed to assess the correct positioning of the implants. The Hertel scale and a comparison between preoperative and postoperative orbital volume were used to assess the surgical results. Results Restoration of the normal orbital cavity shape was confirmed by examining the postoperative CT scans. In the old fracture group, the median orbital volume of the fractured side was 29.22 cm3 preoperatively, and significantly improved postoperatively to a value of 25.13 cm3. In the acute fracture group, the median orbital volume of the fractured side was 28.73 cm3 preoperatively, and significantly improved postoperatively to a value of 24.90 cm3. Differences on the Hertel scale also improved, from 2.13 mm preoperatively to 0.25 mm postoperatively in the old fracture group and from 1.67 mm preoperatively to 0.33 mm postoperatively in the acute fracture group. Conclusions The push-out technique can be considered a good alternative choice for old medial orbital wall fractures with posttraumatic enophthalmos, acute medial orbital wall fractures including large fractured bone segments, and single-hinged greenstick fractures.

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

Jung, Joo Sung,Kang, Dong Hee,Lim, Nam Kyu,Kim, Hyonsurk Korean Cleft Palate-Craniofacial Association 2020 Archives of Craniofacial Surgery Vol.21 No.3

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.

Reconstruction of Medial Orbital Wall Fractures without Subperiosteal Dissection: The "Push-Out" Technique

Kim, Yong-Ha,Lee, Jin Ho,Park, Youngsoo,Kim, Sung-Eun,Chung, Kyu-Jin,Lee, Jun-Ho,Kim, Tae Gon Korean Society of Plastic and Reconstructive Surge 2017 Archives of Plastic Surgery Vol.44 No.6

Background Various surgical methods for repairing medial orbital wall fractures have been introduced. The conventional technique requires total separation of the displaced orbital bones from the orbital soft tissues. However, subperiosteal dissection around the fracture can cause additional damage. The aim of the present study is to introduce a method of reconstructing medial orbital wall fractures without subperiosteal dissection named the "push-out" technique. Methods Six patients with post-traumatic enophthalmos resulting from an old medial orbital wall fracture and 10 patients with an acute medial orbital wall fracture were included. All were treated with the push-out technique. Postoperative computed tomography (CT) was performed to assess the correct positioning of the implants. The Hertel scale and a comparison between preoperative and postoperative orbital volume were used to assess the surgical results. Results Restoration of the normal orbital cavity shape was confirmed by examining the postoperative CT scans. In the old fracture group, the median orbital volume of the fractured side was $29.22cm^3$ preoperatively, and significantly improved postoperatively to a value of $25.13cm^3$. In the acute fracture group, the median orbital volume of the fractured side was $28.73cm^3$ preoperatively, and significantly improved postoperatively to a value of $24.90cm^3$. Differences on the Hertel scale also improved, from 2.13 mm preoperatively to 0.25 mm postoperatively in the old fracture group and from 1.67 mm preoperatively to 0.33 mm postoperatively in the acute fracture group. Conclusions The push-out technique can be considered a good alternative choice for old medial orbital wall fractures with posttraumatic enophthalmos, acute medial orbital wall fractures including large fractured bone segments, and single-hinged greenstick fractures.

Sensory change and recovery of infraorbital area after zygomaticomaxillary and orbital floor fractures

Sang Woo Han,Jeong Ho Kim,Sug Won Kim,Sung Hwa Kim,Dae Ryong Kang,Jiye Kim 대한두개안면성형외과학회 2022 Archives of Craniofacial Surgery Vol.23 No.6

Background: To compare the sensory change and recovery of infraorbital area associated with zygomaticomaxillary and orbital floor fractures and their recoveries and investigate the factors that affect them. Methods: We retrospectively reviewed 652 patients diagnosed with zygomaticomaxillary (n= 430) or orbital floor (n= 222) fractures in a single center between January 2016 and January 2021. Patient data, including age, sex, medical history, injury mechanism, Knight and North classification (in zygomaticomaxillary fracture cases), injury indication for surgery (in orbital floor cases), combined injury, sensory change, and recovery period, were reviewed. The chi-square test was used for statistical analysis. Results: Orbital floor fractures occurred more frequently in younger patients than zygomaticomaxillary fractures (p< 0.001). High-energy injuries were more likely to be associated with zygomaticomaxillary fractures (p< 0.001), whereas low-energy injuries were more likely to be associated with orbital floor fractures (p< 0.001). The sensory changes associated with orbital floor and zygomaticomaxillary fractures were not significantly different (p= 0.773). Sensory recovery was more rapid and better after orbital floor than after zygomaticomaxillary fractures; however, the difference was not significantly different. Additionally, the low-energy group showed a higher incidence of sensory changes than the high-energy group, but the difference was not statistically significant (p= 0.512). Permanent sensory changes were more frequent in the high-energy group, the difference was statistically significant (p= 0.043). Conclusion: The study found no significant difference in the incidence of sensory changes associated with orbital floor and zygomaticomaxillary fractures. In case of orbital floor fractures and high-energy injuries, the risk of permanent sensory impairment should be considered.

안와 내벽 골절의 임상 양상

윤세동,오천환 대한이비인후과학회 1998 대한이비인후과학회지 두경부외과학 Vol.41 No.7

안와골절 환자의 수술시행 여부에 영향을 주는 인자에 대한 고찰

신선우,조익준,송형곤,김병권 대한응급의학회 2007 大韓應急醫學會誌 Vol.18 No.4

Purpose: This study was performed to evaluate factors affecting the decision to operate in orbital fracture patients. Methods: This study included 396 orbital fracture patients who visited an urban tertiary teaching hospital emergency room from January 1, 2002 to December 31, 2005. We reviewed medical records of the patients. Data collected included a patient’s sex, age, mechanism of trauma, wall fractures, associated other facial bone fracture, visual disturbance and ocular motility disturbance. The Chi-square test, t-test were applied in order to evaluate the factors associated with the decision to operate in orbital fracture cases. Multinomial logistic regression was applied to those factors which achieved significance in Chi-square test. Results: As seen in other studies, orbital fractures were frequent in young males ages 10 through 40. The most common cause of orbital fractures was violence (41.0%). In the Chi-square test, medial, lateral and inferior wall fractures; skull vault fracture; nasal septum fracture; diplopia; ocular motor dysfunction; and fractures involving more than two walls were found to be statistically significant in the decision to operate compared to other factors. Diplopia, lateral wall fracture, ocular motor dysfunction, skull vault fracture, and inferior wall fracture were confirmed by multinominal logistic regression analysis as positive predictors of a decision to operate in orbital fracture. Conclusion: Orbital wall fracture patient with diplopia, lateral or inferior wall fracture, ocular motor dysfunction, and skull vault fracture are likely to result in surgical intervention.

안와파열골절의 비강내 내시경적 접근을 통한 교정에서 수술 전후 안와 용적 변화

이재우,남수봉,최수종,배용찬,강철욱 대한성형외과학회 2009 Archives of Plastic Surgery Vol.36 No.5

Purpose: Endoscopic transnasal correction of the blowout fractures has many advantages over other techniques. But after removal of packing material, there were some patients with recurrence of preoperative symptoms. Authors tried to make a quantitative anterograde analysis of orbital volume change over whole perioperative period which might be related with recurrence of preoperative symptoms. Methods: 10 patients with pure medial wall fracture(Group I) and 10 patients with medial wall fracture combined with fracture of orbital floor(Group II) were selected to evaluate the final orbital volume change, who took 3 CT scans, pre-, postoperative and 4 months after packing removal. By multiplying cross - section area of orbit in coronal view with section thickness, orbital volume were calculated. Then, mean orbital volume increment after trauma, mean orbital volume decrement after endoscopic correction and volume increment after packing removal were found out. And we tried to find correlations between type of fracture, initial correction rate and final correction rate. Results: The mean orbital volume increment of the fractured orbits were 7.23% in group I and 13.69% in group II. After endoscopic surgery, mean orbital volume decrement were 11.0% in group I and 12.46% in group II. Mean volume increment after packing removal showed 3.10% in group I and 6.50% in group II. The initial correction rate(%) showed linear correlation with final correction rate(%) after packing removal. And there were negative linear correlation between increment percentage of orbital volume by fracture and final correction rate(%). Conclusion: Orbital volume was proved to be increasing after removal of packing or foley catheter and it was dependent upon type of fracture. Overcorrection should be done to improve the final result of orbital blowout fracture especially when there are severe fracture is present.

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

Kim, Seung Hyun,Choi, Jun Ho,Hwang, Jae Ha,Kim, Kwang Seog,Lee, Sam Yong Korean Cleft Palate-Craniofacial Association 2020 Archives of Craniofacial Surgery Vol.21 No.5

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 ㎠ 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 ㎠ may be considered as extensive fractures that can result in enophthalmos and consequent cosmetic problems.

안와내벽골절의 진단과 수술에 대한 고찰

오석준,정철훈,이종욱,정찬민 大韓成形外科學會 1994 Archives of Plastic Surgery Vol.21 No.6

Medial orbital wall fracture may easily be overlooked because they give clinical symptoms in only a few instances and are located in an area difficult to visualize radiologically. Thus the chance to diagnose this type of fracture depends solely on the thoroughness of the clinical examinations, the skill and persistence to find a medial orbital wall fracture and the type of radiograph taken. We experienced 21 patients with medial orbital wall fractures from 1989 to 1993. The isolated medial orbital wall fractures were 7 cases and combined medial orbital wall fractures were 14 cases and the most common combined fracture was the nasal bone fracture(9 cases). The most common cause of fracture was the traffic accident. The medial orbital wall fracture was confirmed by facial CT scan. In conclusion, the authors state that 1) A medial orbital wall fracture is frequently seen in conjunction with similar type of blow-out fracture of the orbital floor and nasal bone fracture, so careful examination for signs of the medial orbital wall fracture in addition to orbital floor and nasal bone fracture should be carried out. 2) Facial CT scan is superior to conventional radiography in diagnosis of medial orbital wall fractures. 3) In early cases, we used bone graft to correct the medial orbital wall defect, but resorption of the grafted bone was occurred, so recent cases, the alloplastic implants(silastic sheet, titanium mesh) were used.