Abstract
In the 1980s, computed tomography was introduced as an imaging modality for diagnosing orbital fractures. Since then, new light has been shed on the field of orbital fracture management. Currently, most surgeons are likely to repair orbital fractures based on clinical findings and particularly on data obtained from computed tomography scans. However, an important but unresolved issue is the fracture size, which dictates the extent and type of reconstruction. In other fields of trauma surgery, an increasing body of evidence is stressing the importance of complexity-based treatment models. The aim of this study was to systematically review all articles on orbital reconstruction, with a focus on the indication for surgery and the defect size and location, in order to identify the reconstruction methods that show the best results for the different types of orbital fractures.
Introduction
Orbital defects are one of the most commonly encountered facial fractures because of the exposed position and thin bony walls of the midface area. Orbital fractures may occur alone or in combination with other midfacial fractures, including zygomatic complex fractures, Le Fort II and III fractures, naso-orbito-ethmoidal fractures, and frontal bone/orbital roof fractures. The classic blowout fractures are believed to result from buckling of the orbital rim and retropulsion of the orbital content. Approximately half of all orbital fractures consist of isolated wall fractures, which primarily comprise orbital floor defects and medial wall fractures.
The management of orbital fracture treatment remains controversial, and a particular subject of debate is the indication for surgery. Most surgeons are apt to repair orbital fractures based on clinical findings and particularly on data obtained from computed tomography (CT) scans, and the key question is, what fracture size needs reconstruction? In the early 1970s, Putterman et al. advocated guidelines with a conservative approach. In particular, the primary recommendation was to wait watchfully and follow the course of the patient’s recovery to detect the possible development of post-traumatic diplopia, enophthalmos, and hypoglobus. Later insights led to well-defined indications for immediate surgery ( Table 1 ).
| Immediate | Early | Observation | |
|---|---|---|---|
| Time frame | Within 24 h | 1–14 days | >14 days |
| Indications | • Diplopia with CT evidence of an entrapped muscle or peri-orbital tissue associated with a non-resolving oculocardiac reflex: bradycardia, heart block, nausea, vomiting, or syncope • ‘White-eyed blowout fracture’, young patient (<18 years), history of peri-ocular trauma, little ecchymosis or oedema (white eye), marked extraocular motility vertical restriction, and CT examination revealing an orbital floor fracture with entrapped muscle or peri-muscular soft tissue • Early enophthalmos/hypoglobus causing facial asymmetry |
• Symptomatic diplopia with positive forced duction, evidence of an entrapped muscle or peri-muscular soft tissue on CT examination, and minimal clinical improvement over time • Large floor fracture causing latent enophthalmos • Significant hypo-ophthalmos • Progressive infraorbital hypaesthesia |
• Minimal diplopia (not in primary or downgaze), good ocular motility, and no significant enophthalmos or hypo-ophthalmos |
Strong indications for immediate repair include (1) diplopia with radiological evidence of compressed orbital tissue resulting in early ischemic necrosis and oculocardiac reflex, (2) life-threatening white-eyed blowouts or trapdoor fractures in children with eye motility disturbances, and (3) radiological evidence of orbital tissue compression accompanied by oculocardiac reflex, early enophthalmos, or hypoglobus producing facial asymmetry that affects function and cosmesis. In addition, to prevent the fibrosis of injured orbital tissue, early repair within 2 weeks has been proposed for some indications, such as clinically unimproved diplopia with radiological evidence of orbital tissue compression. Further, several studies have shown that early reconstruction of large orbital defects is essential for good functional results. The most difficult management decisions occur with regard to patients with smaller orbital defects. For example, patients with orbital fractures who have good ocular motility and only slight displacement of the orbital content are often treated expectantly. Estimating the benefit of surgery in these cases is challenging, since the behaviour of the soft tissues over time is unpredictable. Thus, the indication for surgical intervention in these types of cases remains controversial.
The clinical outcomes of treatment for the different types of orbital fracture are difficult to compare. The decision to choose a certain implant material must be based on the size and location of the defect and the remaining structural support in combination with clinical symptomatology. In the case of linear fractures with small defects and entrapment of the orbital content, the placement of a membrane may be suitable, whereas in larger defects affecting one wall or multiple walls, a stronger, supportive material may be necessary.
Jaquiéry et al. proposed a simplified two-dimensional model to describe these fractures semi-quantitatively in a trefoil-shaped diagram of the internal orbit. Five categories of the extent of the fracture were defined; fractures with a higher classification were associated with a lower accuracy of reconstruction due to repositioning of the globe ( Fig. 1 ). In our experience, the current process of surgical decision-making is rarely influenced by this classification.
The aim of this study was to systematically review all prospective and retrospective clinical trials on orbital reconstruction. Particular focus was placed on the indication for surgery in relation to defect size and location, in order to identify the reconstruction methods that show the best results for the different types of orbital fracture.
Methods
A systematic literature search in PubMed (updated until 4 October 2013; all indexed years) was performed using multiple search terms, combining the subjects ‘orbital fracture’, ‘reconstruction material’, ‘volume’, and ‘classification’. The search excluded case series with 10 or fewer subjects. The language was restricted to English and German. All human clinical studies (prospective and retrospective) on various surgical reconstruction methods used for orbital fracture treatments met our entry criteria. Preclinical animal and cadaveric studies, as well as clinical studies comparing different incisions or approaches rather than reconstruction methods, were excluded. Fig. 2 shows a flow diagram of the inclusion process. Two authors (SS and LD) appraised the relevance of the articles based on the abstracts (in a primary review process, according to the PRISMA criteria (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) ). In a secondary review, full articles were retrieved, and relevant articles were included. Disagreement was resolved through discussion with a third person (PG).
The PubMed search terms were as follows: (((((“Orbital Fractures”[Mesh])) OR (orbital fracture*[tiab] OR orbit fracture*[tiab] OR orbital trauma*[tiab] OR orbit trauma*[tiab] OR orbital injur*[tiab] OR orbit injur*[tiab] OR orbital wall fracture*[tiab] OR orbital wall injur*[tiab] OR orbital wall trauma*[tiab] OR orbital floor fracture*[tiab] OR orbital floor injur*[tiab] OR orbital floor trauma*[tiab] OR blow-out fracture*[tiab] OR blowout fracture*[tiab] OR supraorbital fracture*[tiab] OR trapdoor fracture*[tiab] OR malar fracture*[tiab] OR tripod fracture*[tiab] OR orbitozygomatic fracture*[tiab] OR orbito-zygomatic fracture*[tiab] OR zygomatico-orbital fracture*[tiab] OR zygomaticoorbital fracture*[tiab] OR tripartite fracture*[tiab] OR (le fort[tiab] AND fracture*[tiab]) OR (lefort[tiab] AND fracture*[tiab])))) AND ((“Prostheses and Implants”[Mesh] OR prosthes*[tiab] OR implant*[tiab]) OR (“Internal Fixators”[Mesh] OR internal fixat*[tiab] OR plate*[tiab] OR reconstruct*[tiab] OR membrane*[tiab] OR sheet*[tiab] OR mesh*[tiab]) OR (“Bone Transplantation”[Mesh] OR bone transplant*[tiab] OR bone graft*[tiab] OR “Cartilage”[Mesh] OR cartilage[tiab] OR “Fascia Lata”[Mesh] OR fascia lata*[tiab] OR “Periosteum”[Mesh] OR periosteum*[tiab] OR “Dura Mater”[Mesh] OR dura[tiab] OR “Gelatin”[Mesh] OR gelatin[tiab] OR “Sclera”[Mesh] OR sclera*[tiab]) OR (“Biocompatible Materials”[Mesh] OR biomaterial*[tiab] OR bioceramic*[tiab] OR animal derived[tiab]) OR (“Durapatite”[Mesh] OR durapatite[tiab] OR hydroxyapatite[tiab] OR hydroxylapatite[tiab] OR bioactive glass[tiab] OR “Titanium”[Mesh] OR titanium[tiab] OR “Cobalt”[Mesh] OR cobalt[tiab] OR “Silicones”[Mesh] OR silicone*[tiab]) OR (“Polymers”[Mesh] OR polymer[tiab] OR polymers[tiab] OR polymeric[tiab] OR polyethylene*[tiab] OR nylon*[tiab] OR teflon[tiab] OR “poly(lactic acid)”[Supplementary Concept] OR “poly(lactic acid)”[tiab] OR polylactic acid[tiab] OR poly- d,l -lactic acid[tiab] OR poly- l -lactic acid[tiab] OR “poly(lactic- co -hydroxymethyl glycolic acid)”[Supplementary Concept] OR PLA/PGA[tiab] OR polydioxanone*[tiab] OR polyglactin 910[tiab]) OR (“Alloys”[Mesh] OR alloy*[tiab]))) NOT case reports[pt].
Methods
A systematic literature search in PubMed (updated until 4 October 2013; all indexed years) was performed using multiple search terms, combining the subjects ‘orbital fracture’, ‘reconstruction material’, ‘volume’, and ‘classification’. The search excluded case series with 10 or fewer subjects. The language was restricted to English and German. All human clinical studies (prospective and retrospective) on various surgical reconstruction methods used for orbital fracture treatments met our entry criteria. Preclinical animal and cadaveric studies, as well as clinical studies comparing different incisions or approaches rather than reconstruction methods, were excluded. Fig. 2 shows a flow diagram of the inclusion process. Two authors (SS and LD) appraised the relevance of the articles based on the abstracts (in a primary review process, according to the PRISMA criteria (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) ). In a secondary review, full articles were retrieved, and relevant articles were included. Disagreement was resolved through discussion with a third person (PG).
The PubMed search terms were as follows: (((((“Orbital Fractures”[Mesh])) OR (orbital fracture*[tiab] OR orbit fracture*[tiab] OR orbital trauma*[tiab] OR orbit trauma*[tiab] OR orbital injur*[tiab] OR orbit injur*[tiab] OR orbital wall fracture*[tiab] OR orbital wall injur*[tiab] OR orbital wall trauma*[tiab] OR orbital floor fracture*[tiab] OR orbital floor injur*[tiab] OR orbital floor trauma*[tiab] OR blow-out fracture*[tiab] OR blowout fracture*[tiab] OR supraorbital fracture*[tiab] OR trapdoor fracture*[tiab] OR malar fracture*[tiab] OR tripod fracture*[tiab] OR orbitozygomatic fracture*[tiab] OR orbito-zygomatic fracture*[tiab] OR zygomatico-orbital fracture*[tiab] OR zygomaticoorbital fracture*[tiab] OR tripartite fracture*[tiab] OR (le fort[tiab] AND fracture*[tiab]) OR (lefort[tiab] AND fracture*[tiab])))) AND ((“Prostheses and Implants”[Mesh] OR prosthes*[tiab] OR implant*[tiab]) OR (“Internal Fixators”[Mesh] OR internal fixat*[tiab] OR plate*[tiab] OR reconstruct*[tiab] OR membrane*[tiab] OR sheet*[tiab] OR mesh*[tiab]) OR (“Bone Transplantation”[Mesh] OR bone transplant*[tiab] OR bone graft*[tiab] OR “Cartilage”[Mesh] OR cartilage[tiab] OR “Fascia Lata”[Mesh] OR fascia lata*[tiab] OR “Periosteum”[Mesh] OR periosteum*[tiab] OR “Dura Mater”[Mesh] OR dura[tiab] OR “Gelatin”[Mesh] OR gelatin[tiab] OR “Sclera”[Mesh] OR sclera*[tiab]) OR (“Biocompatible Materials”[Mesh] OR biomaterial*[tiab] OR bioceramic*[tiab] OR animal derived[tiab]) OR (“Durapatite”[Mesh] OR durapatite[tiab] OR hydroxyapatite[tiab] OR hydroxylapatite[tiab] OR bioactive glass[tiab] OR “Titanium”[Mesh] OR titanium[tiab] OR “Cobalt”[Mesh] OR cobalt[tiab] OR “Silicones”[Mesh] OR silicone*[tiab]) OR (“Polymers”[Mesh] OR polymer[tiab] OR polymers[tiab] OR polymeric[tiab] OR polyethylene*[tiab] OR nylon*[tiab] OR teflon[tiab] OR “poly(lactic acid)”[Supplementary Concept] OR “poly(lactic acid)”[tiab] OR polylactic acid[tiab] OR poly- d,l -lactic acid[tiab] OR poly- l -lactic acid[tiab] OR “poly(lactic- co -hydroxymethyl glycolic acid)”[Supplementary Concept] OR PLA/PGA[tiab] OR polydioxanone*[tiab] OR polyglactin 910[tiab]) OR (“Alloys”[Mesh] OR alloy*[tiab]))) NOT case reports[pt].
Results
From the systematic search, a total of 231 studies including 15,032 patients with orbital injuries were identified ( Tables 2 and 3 ).
| Fracture type | Reconstruction materials | Number of studies a | Number of patients |
|---|---|---|---|
| Orbital floor/pure blowout | Resorbable alloplastic | ||
| Porous polyethylene | 12 | 824 | |
| PGA 910/PDA mesh | 2 | 41 | |
| Ethisorb Dura | 1 | 44 | |
| PDA plate/foil | 2 | 26 | |
| Resorbable PDS sheet | 4 | 429 | |
| PGA membrane | 2 | 24 | |
| PLA membrane | 2 | 79 | |
| PMMA | 2 | N/A | |
| Fibrin glue and scaffold | 1 | 10 | |
| Collagen membrane | 1 | 23 | |
| Autograft | |||
| Temporalis fascia | 1 | 32 | |
| Lyoph. tensor fascia lata | 1 | 12 | |
| Lyoph. dura mater | 4 | 185 | |
| Maxillary bone | 4 | 150 | |
| Mandibular cortex | 4 | 124 | |
| Iliac cancellous bone | 2 | 106 | |
| Calvarial bone | 4 | 102 | |
| Antral bone | 1 | 11 | |
| Autogenous cartilage | 7 | 91 | |
| Heterologous bone | 1 | 20 | |
| Bovine processed bone | 1 | N/A | |
| Non-resorbable alloplastic material | |||
| Titanium mesh | 5 | 214 | |
| Kirschner wire fixation | 2 | 56 | |
| Bioactive glass plates | 3 | 85 | |
| Hydroxylapatite | 2 | 103 | |
| Silicone implants | 11 | 590 | |
| Implants and balloon | 5 | 426 | |
| Stent | 1 | N/A | |
| PTFE sheets | 4 | 440 | |
| Not specified/various | 23 | 2546 | |
| Orbital floor and medial wall | Porous polyethylene | 1 | 39 |
| Titanium mesh | 3 | 68 | |
| Bone graft | 1 | 41 | |
| Mandibular cortex | 1 | 46 | |
| CAD/CAM anatomical plates | 1 | 15 | |
| Nylon foil ‘wraparound’ | 1 | 98 | |
| Not specified/various | 4 | 176 | |
| Medial wall | Porous polyethylene | 3 | 185 |
| Hydroxylapatite | 1 | 48 | |
| Customized titanium mesh | 1 | 22 | |
| PGA 910/PDA mesh | 1 | 31 | |
| Not specified/various | 4 | 97 | |
| Lateral wall | Bone graft | 1 | 85 |
| Orbital roof | PGA 910/PDA mesh | 1 | 85 |
| Not specified/various | 4 | 251 | |
| ‘Large’, ‘extensive’, ‘complex’ or comminuted orbital fractures | Porous polyethylene | 3 | 198 |
| CAD/CAM titanium sheets | 2 | 29 | |
| Titanium and LactoSorb | 1 | 20 | |
| Titanium implants | 2 | 65 | |
| PLA/PGA plates and screws | 1 | 11 | |
| Bone grafts | 1 | 49 | |
| Not specified/various | 2 | 89 | |
| Zygomatico-orbital fractures | Porous polyethylene | 2 | 27 |
| Autogenous conchal cartilage | 1 | 52 | |
| Maxillary wall graft | 1 | 7 | |
| Hydroxylapatite | 1 | 5 | |
| Titanium mesh | 2 | 93 | |
| Plates and screws | 3 | 112 | |
| Not specified/various | 7 | 625 | |
| Heterogeneous/mixed | Macropore | 1 | 106 |
| Titanium implant | 5 | 284 | |
| CAD/CAM titanium sheets | 1 | 1411 | |
| Resorbable sheets | 12 | 176 | |
| Vitallium mesh | 1 | 46 | |
| Autogenous graft | 8 | 274 | |
| Biodegradable plates and screws | 1 | 295 | |
| Bioactive glass plates | 2 | 71 | |
| Polyethylene + hydroxyapatite | 2 | 450 | |
| X-ray film implant | 1 | 56 | |
| Not specified/various | 16 | 2019 | |
| Total | 217 | 14,650 | |
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