The aim of this study was to compare the postoperative results of open reduction versus endoscopically controlled reconstructions of orbital floor fractures. The medical records of 83 patients, treated between January 2000 and December 2008, were reviewed for enophthalmos, diplopia and complications. Fifty-eight patients were operated on using open reduction and in 25 patients the open reduction was endoscopically controlled. A significantly better outcome, regarding enophthalmos and diplopia improvement, was found in the endoscopically controlled group. Endoscopically controlled reconstruction of orbital floor fractures seems to be a more accurate and successful treatment.
Orbital wall fractures are relatively common facial injuries. They occur as pure or complicated blow-out fractures. Facial fractures vary in type, severity, and cause depending on the population studied. These differences may be the result of risk factors and cultural differences. The aetiology of orbital trauma is mainly traffic accidents, sports accidents, falling, work related accidents and violence.
The criteria for surgical repair of an orbital floor fracture are based on well-accepted findings, such as persistent diplopia, enophthalmos, presence of a large defect, pain with extraocular motility, and presence of the oculocardiac reflex associated with an orbital fracture. The indication for repair of orbital wall fractures is based on the clinical symptoms, exophthalmometry and computed tomography (CT). The timing of treatment, surgical technique and type of reconstruction material used is debated. Some advocate following the post trauma course for the development of diplopia or enophthalmos before starting treatment. Although a variety of approaches to orbital floor fractures have been proposed, satisfactory postoperative results have not been obtained in all cases.
The key to successful surgical repair of these injuries is adequate exposure, visualization of the posterior bone shelf, and anatomical reconstruction of the entire defect. The traditional approach exposes the orbital floor, but it is difficult to see the posterior edge of the fracture and the condition of the herniated tissue before and after reduction of the orbital contents. Posterior dissection is the most difficult manoeuvre and is a common reason for failure of orbital floor repair. Transmaxillary endoscopic visualization of the orbital floor offers an excellent view of the entire defect and the surgical reconstruction.
Materials and methods
Between January 2000 and December 2008, 171 patients underwent surgical reconstruction of orbital fractures (pure and complicated blow outs). The indications for surgical treatment were incomplete resolution of diplopia 2 weeks after injury, enophthalmos of more than 2 mm (Hertel measurement) and/or motility disturbance within the first 6 weeks following injury.
From 2000 to 2005 only open reduction reconstruction was used to treat all orbital floor fractures. Starting in 2005, in order to improve the results, endoscopically controlled reconstruction replaced open reduction repair in most cases. Overall, an open reduction reconstruction was used in 139 patients and an endoscopically controlled reconstruction in 32 patients. Of the 171 patients, 83 (58 open reconstruction and 25 endoscopic controlled) were included in a retrospective study analysing the outcome of orbital floor fractures. The selection criteria are given in Table 1 . The 83 patients were divided into two groups. Group I consisted of 58 patients treated with open reduction repair of the orbital floor fracture. Group 2 consisted of 25 patients treated with open reduction and endoscopically controlled repair. All 83 patients had preoperative and postoperative ophthalmological examinations at the 1, 2, 6 and 12 months follow-up assessments. The medical records were reviewed. A difference of more than 2 mm between the eyes is considered aesthetically disturbing. Enophthalmos was determined by a Hertel exophthalmometer. Diplopia was defined as double vision in the primary position and within 30° of gaze that interferes with the patient’s daily activities subjectively. In groups 1 and 2 the orbital floor defect was reconstructed with autogenous iliac crest bone.
|Inclusion criteria||Exclusion criteria|
|Orbital floor fracture||Bilateral orbital floor fractures|
|Primary reconstruction||Incomplete medical documentation|
|Reconstruction with autogenous iliac crest|
|Preoperative and postoperative CT scans (axial and coronal sections)|
|Pre-and postoperative ophthalmological examination (enophthalmos, diplopia)|
|Follow-up 1 year|
During surgery all patients were placed, under general anaesthesia in the supine position with the head slightly elevated. The access to the orbital floor, in both groups, was made using an infra-orbital incision. In group 2, 2% lidocaine was injected locally in the vestibule at the mucogingival junction. Using a gingivobuccal incision and a small round bony window was made in the anterior wall of the maxillary sinus. Through this bony window a 2.7 rigid 30° or 0° endoscope was brought into the maxillary sinus ( Fig. 1 ). A 4 mm diameter endoscope (Karl Storz GmBH&Co, Germany) was used. This provided complete visualization of the orbital floor, the lateral wall and the sinus ostium. When the side of the fracture was situated more medially there was a better view from the 30° scope.
To verify the fracture site and size, light pressure is placed on the globe, and the transmitted pulsation is observed on the floor. This manoeuvre was termed the ‘pulse test’ by Strong ( Fig. 2 ). When necessary, the maxillary mucosa is stripped circumferentially around the fracture site. With the fracture area delineated, all small bony fragments are removed and a stable shelf is defined medially, laterally, and posteriorly.
The endoscope was used to control the reduction of the floor fracture and the prolapsed orbital tissue into the orbital cavity. In both groups, autogenous bone was used to reconstruct the floor. The autogenous bone was taken from the inner table of the iliac crest to reconstruct the orbital floor. The cortical bone is shaped to the right size and adapted to the orbital floor without fixation, depending on stability. For instability of the cortical bone plate a suture is used for fixation. The suture is fixed to the cortical bone plate and the infra orbital rim.
In group 2, endoscopic control of correct implant placement and complete reduction of herniated or prolapsed orbital soft tissues was performed ( Fig. 3 ).
All orbital floor defects were measured preoperatively on CT scans (Sidexis software, supplied by Sirona).
Statistical analysis was performed using SPSS for Windows XP (version 15.0, SPSS Inc., Chicago, USA). Mean values are given with standard deviations (SD). For comparison of continuous variables in paired samples, the Wilcoxon test was used. Two-sided P -values equal to, or smaller than, 0.05 were considered significant.
Eighty-three patients (groups 1 and 2) were included in this retrospective study. There were 35 males and 23 females in group 1 and 14 males and 11 females in group 2. Average age at time of orbital trauma in group 1 was 38.68 years (range 17–77 years) and in group 2 36.14 years (range 11–68 years) ( Table 2 ).
|Group 1||Group 2|
|Average age (years)||38.68||36.14|
|Enophthalmos over 2 mm before surgery ( n = patients)||37 (70%)||17 (68%)|
|Enophthalmos over 2 mm after surgery ( n = patients)||15 (30%)||3 (12%)|
|Diplopia before surgery ( n = patients)||35 (66%)||15 (60%)|
|Diplopia after surgery ( n = patients)||18 (34%)||4 (16%)|
|Reduction of enophthalmos of more than 2 mm ( n = patients)||22 (42%)||14 (56%)|
|Reduction of diplopia ( n = patients)||16 (31%)||11 (44%)|