Management of Orbital Fractures Using Intraoperative Navigational Surgery. A Prospective Case Series

Management of Orbital Fractures using Intraoperative Navigational Surgery. A prospective case series.

 

Ketan Patel DDS, PhD., Scott Claiborne DDS, MD. And Deepak Kademani, DMD, MD, FACS

North Memorial Medical Center, 3366 Oakdale Ave N, Suite#200, Robbinsdale, MN 55422

Objectives:  Reconstruction of orbital trauma is one of the most challenging areas of facial trauma surgery. To ensure optimal results with limited morbidity it is essential that orbital surgery be performed with the highest level of accuracy to ensure optimal functional and aesthetic outcomes. Computer navigation systems for reconstruction of the facial skeleton has received increased attention in recent years.  This study describes repair of complex orbital fractures using a treatment protocol of computer planning with preoperative scanning, intraoperative navigation and intraoperative CT scanning to ensure optimal placement of orbital implants.  Our hypothesis was that this technique improves outcomes in complex orbital fractures with decreased requirements for revisional surgery.

Methods:   Over an 18-month period a review of 48 consecutive orbital trauma cases were completed in a prospective manner using our protocol. An IRB approval was obtained from the review committee for the study at North Memorial Medical center which is a Level I trauma Center.  Data were collected on patient characteristics; fracture severity, diplopia and globe position, complications, and need for revision surgery and most importantly repositioning of the implant after placement.

Results:  Our results showed that the average age of all the patients was at 39.75 years (Range 12-88 yrs.). Male to female ratio was noted to be 3:1.  The majority of fractures were related to assault (37.5%), followed by motor vehicle collisions (29.12%), and then followed by falls (11%) with gunshot wounds at  6.25%.  The average time to get a patient from the time of injury to the operating room was 8 days to allow for a reduction of swelling.  Single orbital injuries were noted in about 37.5% of cases, while the commonest injury associated with an orbital fracture was a ZMC fracture (60%). The orbital floor was involved almost 91% of the times, with the medial wall also being involved in 50% of cases.  Lateral wall involvement and medial wall involvement were fairly similar at 16.67% and 14.58% respectively.  Single wall defects were noted in about 49.7% of cases, two-walled defects noted in 37.5% of cases, three-walled defects noted in 10.4% of cases and all four-wall involvement was noted in approximately 4% of cases.  The median number of walls fractured in any case was 1.7. Intraoperatively, the implant was repositioned in 6.25% of the patients. Major complication rates were at 14.6% however none of the patients required any repositioning of the implant.  The complications included a pseudoaneurysm of the ophthalmic artery due to a gunshot injury that was coiled, nasolacrimal duct injury, entropion and enopthalamos due to fat atrophy in four cases. No patients required repositioning of the orbital implant postoperatively.

Conclusions:  Intraoperative navigational surgery can improve the quality and outcomes of orbital reconstruction.  This study is the first to qualitatively assess orbital surgery outcomes using intraoperative navigation at a single institution in a prospective manner. Based on significant improved outcomes in postoperative diplopia and orbital volume, as well as the decreased need for revision surgery, we demonstrate improved outcomes in complex orbital reconstruction and recommend its use for complex orbital fracture repair.

Reference:

1)     Shin HS et al. Real Time Navigation-Assisted Orbital Wall Reconstruction in Blowout Fractures. J Craniofac Surg. 2016 Mar;27(2):370-3.

2)     Baumann A, Sinko K, Dorner G.  Late Reconstruction of the Orbit With Patient-Specific Implants Using Computer-Aided Planning and Navigation. J Oral Maxillofac Surg. 2015 Dec;73(12 Suppl):S101-6