Intraoperative Computed Tomography Scan for Orbital Fracture Reconstruction (original) (raw)
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Turkish journal of trauma & emergency surgery, 2011
İzole orbita taban kırıklarının cerrahi endikasyonu, zamanlaması, kullanılacak rekonstrüksiyon materyali hakkında halen görüş birliği yoktur. GEREÇ VE YÖNTEM 2002-2010 yılları arasında izole orbita taban kırığı tanısı alarak ameliyat edilen hastalar (41 erkek, 13 kadın) geriye dönük olarak değerlendirildi. BULGULAR İzole orbita taban kırığı tanısı alan 54 hastadan, ameliyat edilen 49 hastanın cerrahi endikasyonuna bakıldığında, %20,4'ünde göz hareketlerinde kısıtlılık ve belirgin enoftalmi, %79,6'sında koronal planda çekilen bilgisayarlı tomografi görüntülerinin etkili olduğu görüldü. Hastaların %36,7'si ilk 16 saat içinde %10,2'si en geç 72-96 saat içinde ameliyat edildi. Orbita taban onarımı için ultra ince poröz polyetilen kullanıldı. Bu çalışma nedeniyle kendilerine ulaşılan 12 hastanın enoftalmi-egzoftalmi açısından normal sınırlarda olduğu, hiçbir hastada ektropiyon ya da skleral show bulgusu olmadığı, hastaların skara bağlı herhangi bir şikayetlerinin olmadığı görüldü. SONUÇ Tedavi edilmediğinde enoftalmi ve çift görme ile sonuçlanabilecek olan orbita taban kırığında, iyi prognoz doğru cerrahi endikasyon, erken cerrahi girişim ve uygun materyal ile onarıma bağlı olduğunu düşünmekteyiz. Anahtar Sözcükler: Bilgisayarlı tomografi; orbita kırıkları; orbita implantları; X-ışınları. BACKGROUND A common consent regarding repair indications, timing of repair and choice of reconstruction materials for isolated orbital base fractures does not yet exist. METHODS We retrospectively reviewed our patients (41 male, 13 female) who were operated due to a diagnosis of isolated orbital floor fracture between 2002 and 2010. RESULTS Fifty-four patients diagnosed with isolated orbital base fracture were found; 49 of 54 patients required surgery. The indications for surgery were restricted ocular motility and marked enophthalmos in 20.4% of the patients, whereas in 79.6%, surgical intervention was decided largely based on the coronal computed tomography images. 36.7% of the cases were operated earliest, in the first 16 hours, and 10.2% were operated the latest, in 72-96 hours. Ultra-thin porous polyethylene was used in the orbital base repair. Twelve patients contacted for this study were evaluated. Enophthalmia and exophthalmia were in normal limits in patients, and none of the patients displayed ectropion or scleral show findings or reported any complaints related to scar formation. CONCLUSION When not treated in a timely manner and with appropriate materials, orbital base fractures might result in enophthalmia and diplopia. We believe that a good prognosis of orbital base fractures relies on the right decision for surgical indication, early surgical intervention, and repair with appropriate material.
Journal of Maxillofacial and Oral Surgery, 2020
Purpose Zygomatico-orbital (ZMO) fractures pose considerable difficulty in intraoperative assessment during open reduction and internal fixation (ORIF), and this can be attributed to its three-dimensional complex anatomy and articulations. Recent advancements in the form of intraoperative imaging and navigation have led to an adequate assessment and correct reduction of these fractures minimizing chances of any revision surgery. The purpose of this study was to evaluate the advantage of intraoperative computerized tomography (CT) scan in the management of ZMO/isolated orbital complex fracture and further to develop a protocol for managing such fractures. Methods Twenty-three cases of ZMO/isolated orbital fractures were managed with ORIF, followed by an intraoperative CT scan. The evaluation was focused on the articulations of the zygoma and orbital wall reconstruction. The score of 0 and 1 was given for inadequate and adequate reduction, respectively. Necessary corrections were performed in case of improper reduction followed by a repeat CT scan if required. The reduction score was statistically correlated with number of incisions. Results In 8 (35%) out of 23 patients, clinical judgment was inaccurate when radiologically assessed with an intraoperative CT scan. In 6 out of 8 cases, a repeat CT scan was done after revision of reduction. The reduction score improved with additional incision and revision in the second CT scan. Conclusion Intraoperative CT has an important role in assessing the accuracy of reduction and confirming implant position in ZMO/isolated orbital fractures. This can avoid the need for secondary corrective surgery and postoperative imaging. Intraoperative CT is an important tool to improve surgical outcomes in the management of ZMO orbital fractures. Keywords Zygomatico-orbital complex Á Orbital floor fracture Á Intraoperative imaging Á Open reduction Á Midface fractures Á Computerized tomography scan & Sachin Rai
Computed tomography imaging strategies and perspectives in orbital fractures
Journal of Applied Oral …, 2007
OBJECTIVE: The objective of this study was to demonstrate the sensitivity and specificity of multislice computed tomography (CT) for diagnosis of orbital fractures following different protocols, using an independent workstation. MATERIALS AND METHODS: CT images of 36 patients with maxillofacial fractures (symptomatic to orbit region) who were submitted to multislice CT scanning were analyzed, retrospectively. The images were interpreted based on 5 protocols, using an independent workstation: 1) axial (original images); 2) multiplanar reconstruction (MPR); 3) 3D images; 4) association of axial/MPR/3D images and 5) coronal images. The evaluated anatomical sites were divided according to the orbital walls: lateral (with or without zygomatic frontal process fracture); medial; superior (roof) and inferior (anterior, medial). The collected data were analyzed statistically using a validity test (Youden's J index; p<0.05). The clinical and/or surgical findings (medical records) were considered as the gold standard to corroborate the diagnosis of the anatomical localization of the orbital fracture. RESULTS: 3D-CT scanning presented sensitivity of 78.9%, which was not superior to that of MPR (84.0%), axial/MPR/3D (90.5%) and coronal images (86.1%). On the other hand, the diagnostic value of axial images was considered limited for orbital fractures region, with sensitivity of 44.2%. CONCLUSIONS: Except for the axial images, which presented a low sensitivity, all methods evaluated in this study showed high specificity and sensitivity for the diagnosis of orbital fractures according to the proposed methodology. This protocol can add valuable information to the diagnosis of fractures using the association of axial/MPR/3D with multislice CT.
Journal of Plastic Reconstructive and Aesthetic Surgery, 2021
Background: Secondary post-traumatic orbital reconstructions are challenging. Portable computed tomography (CT) provides the option to acquire real-time, intraoperative images that help to detect the insufficient reconstruction of the orbit immediately. We retrospectively analyzed patients who received intraoperative CT imaging and analyzed the effect of intraoperative CT scans on revision rates and orbital volume changes before, during, and after surgery. Methods: From August 2014 to September 2016, eleven patients received intraoperative cone-beam CT scans to evaluate the results of secondary orbit reconstruction using Medpor + titanium implants. Patient demographics, surgical details, CT scanning protocol, and follow-up results were analyzed. 3D CT volumetry was used to analyze the orbital volume based on OsiriX MD software. Results: Based on intraoperative CT findings, seven cases required intraoperative revision to further augment the orbital cavity or adjust implants. The mean preoperative measured enophthalmos was 3.41 ±1.4 mm (range: 2-6 mm), which decreased to 0.73 ±0.4 mm (range: 0-1 mm) at postop assessment (p < 0.0001). On the fracture side, there was a significant difference between preoperative vs. intraoperative and preoperative vs. postoperative volume measurements (p < 0.01 for both subsets), but no significant difference between intraoperative vs. postoperative measurements.
Intraoperative imaging O-Arm™ in secondary surgical correction of post-traumatic orbital fractures
Oral and Maxillofacial Surgery Cases, 2017
To determine the safety and efficacy of O-Arm™ intraoperative imaging in maxillofacial surgery of post-traumatic orbital fractures. In order to ensure correct placement of titanium plate, immediately after fixing, viewable, in the axial, sagittal and coronal images. Methods: The authors evaluated 5 consecutive adult patients with orbital fractures who required a reoperation involving displacement of titanium mesh between January and December 2015. The displacement or incorrect positioning of titanium mesh was detected at post-operative CT scan or clinical neurological findings. Intraoperative O-Arm™ imaging was used for our patients who underwent secondary maxillofacial orbital fracture surgery due to the failure of first surgical approach. Results: An eyelid incision was performed in order to obtain maximal exposure and minimizing cosmetic defects. Any previous fixation device was skeletonized and removed, any improperly reduced fracture was mobilized, reduced and refixated with 1.5 mm plates, screws and titanium mesh. The intra-operative O-Arm™ imaging technique was used at the end of the procedures. In 4 cases it confirmed the appropriateness of the newly obtained reconstruction, in 1 case a first scan showed a suboptimal result and the devices were correctly repositioned, guided by the O-Arm™ images. Conclusions: Intraoperative O-Arm™ assisted craniofacial reconstruction surgery improves the assessment of neurovascular structure decompression, skeletal fragment identification, fixation procedures and for the correct re-establishment of facial symmetry in orbital floor fractures.
Journal of Oral and Maxillofacial Surgery, 2015
PURPOSE This study evaluated whether intraoperative imaging with computer-assisted virtual reconstruction would be advantageous in reconstructions of orbital floor fractures. The surgeon's intention to revise a reconstructed primary orbital floor fracture by evaluating a postoperative mirrored computed tomographic (CT) scan was analyzed intraoperatively before wound closure, during inpatient hospitalization, and after hospitalization. The inter-rater agreement and the match of intention to revise and actual revision were analyzed. MATERIALS AND METHODS Fifty-one anonymized postoperative CT scans of patients with a unilateral orbital floor fracture were mirrored using software. These computer-assisted virtual reconstructions were consecutively examined by 4 examiners. Seven of these patients underwent a revision. In the first part, the inter-rater agreements for all 3 times were analyzed. In the second part, the examiners' intentions to revise were compared with the actual performed revisions. RESULTS The overall inter-rater agreements were 0.69 for the intraoperative phase, 0.55 for the in-hospital phase, and 0.39 for the post-hospital phase. The intraoperative inter-rater agreement for each examiner was 0.58 to 0.80. The Fleiss value for the in-hospital and post-hospital phases was lower. The comparison of the examiners' intention to revise and the actual revisions showed that 15 to 24 additional would have been revised. In contrast, 6 of 7 actual revisions would have been revised intraoperatively. The missed actual revision was the same case by all 4 examiners. The accordance of intention to revise with the actual revisions decreased during hospitalization and even more after hospitalization. This study showed strong agreement among examiners for revising anatomically incorrectly reduced orbital floor fractures intraoperatively by evaluating postoperative mirrored CT scans. During the in-hospital and post-hospital phases, the restraints against revision seemed to increase, thus leading to poorer interrater agreement. This analysis of postoperative CT scans with computer-assisted virtual reconstructions of the orbit would have led to considerably more revisions intraoperatively, but all actual revisions were detected except for 1 case. This case was the same for all 4 examiners. Operation time would have been prolonged in the additional revised cases, but a better anatomic reconstruction would have been achieved. Furthermore, the intraoperative result of the reconstruction would have been controlled instantly and corrected immediately, if needed. CONCLUSION This study showed that of 6 of 7 actual revisions, implant placement would have been revised intraoperatively by all 4 examiners, if intraoperative imaging with computer-assisted virtual reconstruction of the orbit would have been applied. Therefore, the authors suggest that intraoperative imaging with computer-assisted virtual reconstruction could be advantageous in the prevention of later revisions of orbital floor fractures. In this study, the threshold to revise implant placement intraoperatively seemed to be lower when using intraoperative imaging with virtual reconstructions, because considerably more cases would have been revised intraoperatively by the examiners. In the in-hospital and post-hospital phases, this threshold increased, suggesting the more important role of clinical findings. It is uncertain whether the actual surgeons would have revised the same cases as the examiners if they had used intraoperative imaging with virtual reconstructions for their deliberation. However, the intraoperative inter-rater agreement was good and cost-intensive postoperative revisions might be prevented.
Advances in the Reconstruction of Orbital Fractures
Facial Plastic Surgery Clinics of North America, 2017
Repair of orbital fractures should be carried out to restore premorbid orbital contours with the greatest possible precision. Reconstruction should be performed after resolution of edema from the injury. Exophthalmometry is important in the decision to operate, intraoperative measurements, and postoperative outcome evaluation. Orbital endoscopy improves ability to visualize the entire extent of the fracture with increased illumination and magnification while reducing retraction of orbital contents. Surgical navigation with mirror-image overlay guidance provides a template for reconstruction when normal anatomic landmarks have been damaged and, when used with an endoscopic technique, leads to significant improvement in multiple surgical outcome metrics.
Journal of Craniofacial Surgery, 2019
Objective: To define a reliable and consistent landmark, the superior posterior wall of the maxillary sinus, and to describe how this landmark can be used when repairing orbital floor fractures. Methods: Retrospective chart review. Patients >18 years old diagnosed with unilateral orbital floor and/or zygomaticomaxillary complex fractures. Main outcomes: The distance from the inferior orbital rim to the superior posterior wall of the maxillary sinus (landmark distance), and the distance from the landmark to the entrance of the optic canal were reported. Results: Eighty patients were included in the study. Each had unilateral isolated orbital floor fractures (n ¼ 46) or unilateral zygomaticomaxillary complex fractures with an orbital floor component (n ¼ 34). The contralateral eye in all patients was uninjured, and was used as an internal control. In orbital floor fractures, the mean landmark distance was 38.8 AE 1.4 mm, with a mean distance on the normal side of 38.8 AE 1.6 mm (P ¼ 0.49). Distance to the optic canal on the injured side in isolated orbital floor fracture patients was 9.0 AE 0.8 mm with the same measurement on the normal side being 8.8 AE 0.7 (P ¼ 0.21). In the setting of zygomaticomaxillary complex fracture, the orbital floor length was 38.2 AE 1.3 mm with a mean normal floor length of 37.8 AE 1.1 mm (P ¼ 0.18). The mean distance from the superior posterior wall to optic canal in zygomaticomaxillary complex fractured orbits was 9.2 AE 1.1 mm with a normal side mean length of 9.5 AE 1.0 mm (P ¼ 0.23). No significant difference was found between the measured distances in the fractured orbit and its normal counterpart for both fracture groups. Conclusions and Relevance: The superior posterior wall of the maxillary sinus is a reliable landmark that can be used to assist in placement of an orbital floor reconstructive plate. The landmark is unchanged despite the presence of an orbital floor or zygomaticomaxillary sinus fracture.
Journal of Cranio-maxillofacial Surgery, 2015
The aim of this study is to describe the reduction of medial orbital wall fractures using a combination of two different techniques: the endoscopic reduction and the navigation aided reconstruction. The endoscopic approach avoids an external incision and allows the observation of the fracture site clearly. Navigation-aided reconstruction is essential to achieve precise and predictable results in orbital reconstruction. It consists in an ideal virtual reconstruction of the target area created using a mirroring tool, and superimposing and comparing the unaffected and the affected sides. This technique opens a broad spectrum of possible surgical approaches, especially in situations in which anatomical landmarks for precise positioning of bone fragments, or bone grafts, are missing. This study is the first to combine these two techniques. The study was carried out in seven patients who underwent endoscopic reduction of isolated blowout fractures of the medial orbital wall and navigation-aided reconstruction at the authors' institution. This pilot study clearly shows that a combination of the endoscopic reduction and the navigation-aided reconstruction provides functional results and great advantages in terms of anatomical preservation and postoperative morbidity.