·Clinical
Research·
Analysis
of the effect of repair materials for orbital blowout fracture on complications
Qi-Hua Xu1, Jin-Hai Yu2, Yao-Hua
Wang1, An-An Wang1, Hong-Fei Liao1
1Department of Ocular Trauma, Orbital
Disease, Affiliated Eye Hospital of Nanchang University, Nanchang 330006,
Jiangxi Province, China
2Jiangxi Research Institute of
Ophthalmology & Visual Sciences, Nanchang 330006, Jiangxi Province, China
Correspondence to: Hong-Fei Liao. Department of Ocular
Trauma, Orbital Disease, Affiliated Eye Hospital of Nanchang University,
Nanchang 330006, Jiangxi Province, China. lhfzf@126.com
Received:
Abstract
AIM: To investigate the effect of repair materials for orbital blowout
fractures on the occurrence of postoperative complications.
METHODS: The clinical data and follow-up data of 54 subjects
with orbital blowout fractures were retrospectively analyzed. The study was
divided into three groups according to the used repair materials: titanium mesh
(16 cases), Medpor (12 cases), and Medpor titanium mesh (26 cases). All test
data were analyzed using the SPSS version 23.0 statistical software. The mean
age and duration of disease between the groups were compared through one-way
analysis of variance. The Chi-square (χ2) test was used to compare the
number of males and females, different fracture types, and different surgical
approaches among groups. The χ2 test was used to compare the
frequencies for complications in each group.
RESULTS: The baseline characteristics of age and gender in
each group were matched (F=1.763, P=0.172; χ2=0.026, P=0.987). In
addition, there was no difference in the type of fracture and surgical approach
(χ2=0.460, P=0.977; χ2=0.691, P=0.952), or the
incidence of complications (χ2=0.081, P=0.960) between the three groups.
CONCLUSION: Although there is no difference in effect of
various repair materials on the incidence of complications, the effect of repair materials on
postoperative complications of orbital blowout fractures should not be ignored.
KEYWORDS: orbital blowout fracture; repair
materials; postoperative complications
DOI:10.18240/ijo.2019.11.13
Citation: Xu
QH, Yu JH, Wang YH, Wang AA, Liao HF. Analysis of the effect of repair
materials for orbital blowout fracture on complications. hthalmol
2019;12(11):1746-1750
INTRODUCTION
With the rapid development of social
and economic undertakings, an increasing number of cases of orbital fractures
are caused by industrial production and traffic accidents[1].
Orbital blowout fracture refers to the application of an external force on the
orbit, causing the pressure to suddenly increase or the external force to pass
along the orbital margin to the orbital wall. Consequently, the thinner orbital
bone wall bursts under the action of the force[2].
Orbital blowout fractures may result in enophthalmos, diplopia, eye movement
disorders, decreased vision, and infraorbital nerve sensory disorders. Surgical
treatment is required when orbital soft tissue is incarcerated by fracture
slices, and associated clinical symptoms appear. The main treatment method for
recovery or improvement of clinical symptoms involves surgical removal of bone
fragments, release of incarcerated or herniated orbital soft tissues into the
paranasal sinus, and use of repair materials to cover the bone wall of the
defect. Depending on the surgical timing and approach, repair materials, and
the experience of the surgeon, residual elevation or depression limitation,
diplopia, and eye movement disorder may remain following surgery. Moreover,
incision scarring, infraorbital nerve sensory disorder, lower eyelid
retraction, implant infection, and other complications may occur[3-5]. Among them, the effect of repair
materials on long-term postoperative efficacy is particularly prominent. The
aim of this study was to investigate the effect of orbital fracture repair
materials (i.e., titanium mesh, Medpor, and Medpor titanium mesh) on the
occurrence of postoperative complications.
SUBJECTS AND METHODS
Ethical Approval The retrospective study was approved
by the Ethics Committee of the Affiliated Eye Hospital of Nanchang University.
All subjects provided written informed consent prior to surgery.
Subjects This was a retrospective analysis of
the clinical data of subjects with orbital fractures admitted to the Affiliated
Eye Hospital of Nanchang University (Nanchang, China) between July 2012 and
July 2017. Inclusion criteria were as follows: all subjects who were
operated by a single surgeon, and those with complete clinical data and a
follow-up period ≥6mo. Exclusion criteria are as follows: subjects with orbital
margin fracture and eyeball rupture, and those aged <18y. A total of 54 eyes
(21 right eyes and 33 left eyes) of 54 subjects (41 males and 13 females) were
included in the study. The subjects were aged 18-61y (average age:
37.67±12.69y). In terms of the cause of injury, 25, 12, 10, and 9 cases were
attributed to car accidents, falls, boxing smashing, and other accidents. The
interval from injury to surgery ranged from 5 to 307d (average: 28.48±46.03d);
the follow-up period after surgery ranged from 6 to 28mo. The selected cases
were divided into three groups according to repair materials: titanium mesh
(Synthes GmbH, Switzerland), Medpor (Porex Surgical Inc., USA), and Medpor
titanium mesh (Stryker Leibinger GmbH & Co. KG, Germany). The baseline
characteristics of the population, fracture status, and surgical approach were
matched for the three groups of subjects (Table 1).
Table 1 Comparison of the baseline
characteristics of the population, fracture status, and surgical approach in
the three groups
|
Groups |
No. of cases |
Age (y,
mean±SD) |
Gender (male/female) |
Duration of illness (d, mean±SD) |
Fracture condition (lower wall/inner wall/inner and
lower wall combined) |
Surgical approach (skin/conjunctival/skin combined
conjunctiva) |
|
Medpor |
12 |
36.58±14.20 |
8/4 |
22.50±31.70 |
|
|
|
Titanium mesh |
16 |
37.06±12.78 |
11/5 |
25.38±34.05 |
|
|
|
Medpor titanium mesh |
26 |
38.54±12.36 |
18/8 |
33.15±57.52 |
|
|
|
F/χ2 |
- |
1.763 |
0.026 |
65.366 |
0.460 |
0.691 |
|
P |
- |
0.172 |
0.987 |
0.000 |
0.977 |
0.952 |
Surgical Methods All subjects underwent general
anesthesia. Following routine skin disinfection, the appropriate surgical
approach was selected according to the condition of the fracture (i.e., conjunctival
approach for small fractures and skin approach for larger fractures). Lower
eyelid lashes approach may be used for fracture of the inferior wall with
larger area. The skin was incised
Indicators of Clinical Detection and
Evaluation of The Effect The duration of illness indicated
the time from the injury to the start of surgery. Preoperative observation was
performed, and data for the eyelids, vision, enophthalmos, diplopia, eye
movement disorders, and subgingival nerve sensory disorders were recorded. The
eyelids and the anterior segment of the eye were observed through a slit lamp.
The Hertel exophthalmometer was used to detect differences in eyeballs on the
affected side of the subject. A difference >
Statistical Analysis All test data were analyzed using
the SPSS version 23.0 statistical software. The age and duration of disease in
each group were expressed as mean±SD, and the mean of such data between groups
was compared through one-way analysis of variance. The Chi-square test was used
to compare the number of males and females, different fracture types, and
different surgical approaches among groups. The Chi-square test was used to
compare the frequencies (i.e., complications) in each group. A P<0.05
denoted statistical significance.
RESULTS
In the titanium mesh group, there
were 16 cases. At 1mo following surgery, two subjects continued to have
diplopia (both improved: level 3 to 2), which were caused by paralytic
strabismus, two subjects had eye movement disorder with elevation limitation
(both improved: level 3 to 2), one subject had obvious residual skin scarring,
and one subject had infraorbital nerve sensory disorder. At 3mo following
surgery, enophthalmos, diplopia (improved: level 2 to 1), and eye movement
disorder (one improved: level 2 to 1) were present in three subjects (one per
condition).
In the Medpor group, there were 12
cases. One month following surgery, three subjects continued to have diplopia,
which were caused by paralytic strabismus too; the conditions of two subjects
improved compared with the preoperative condition, while that of one subject
remained unchanged. Of the three subjects, one had residual eye movement
disorder with external turn limitation (though improved: level 2 to 1), while
another subject had lower eyelid retraction. At 3mo after surgery, there were
two subjects with diplopia (one improved: level 2 to 1, one unchanged);
symptoms disappeared in subject with eye movement disorder.
In the Medpor titanium mesh group,
there were 26 cases. At 1mo following surgery, four subjects had residual
diplopia (all improved: level 3 to 2), which also were caused by paralytic
strabismus, two subjects had eye movement disorder with elevation limitation
(both improved: level 3 to 2), one subject had skin scarring, and one subject
had infraorbital nerve sensory disorder. At 3mo after surgery, two subjects had
diplopia (both improved: level 2 to 1), one subject had eye movement disorder
(one improved: level 2 to 1), and one subject had implant displacement. We
performed HE pathological staining on the surrounding tissues of the implant
and found that there were neutrophils and multinucleated giant cells
infiltrating in the tissues.
At 6mo after surgery, some
complications had resolved, whereas others persisted. Table 2 shows the
incidence of complications at the 6-month follow-up (χ2=0.081,
P=0.960).
Table 2 Complications at 6mo after
surgery in the three repair material groups
|
Groups |
No. of cases |
Enophthalmos |
Diplopia |
Eye movement disorder |
Skin scarring |
Nerve sensory disorder |
Lower eyelid retraction |
Implant infection |
Total complications |
|
Medpor group |
12 |
0 |
1 |
0 |
0 |
0 |
1 |
0 |
2 |
|
Titanium mesh group |
16 |
1 |
0 |
0 |
1 |
1 |
0 |
0 |
3 |
|
Medpor titanium mesh group |
26 |
0 |
0 |
1 |
1 |
1 |
0 |
1 |
4 |
DISCUSSION
Common complications after surgery
for the repair of orbital blowout fractures include the following: diplopia,
enophthalmos, eye movement disorders, infraorbital nerve sensory disorders,
skin scarring, lower eyelid retraction, scleral exposure, conjunctival
granuloma, and implant infection. The main factors affecting the occurrence of
complications are the timing of surgery, surgical techniques, surgical
approach, and repair materials[8]. Regarding the
timing of the operation, in the first week of the orbital fracture, the soft
tissue in the orbit is in the stage of inflammatory edema. During this period,
the soft tissue in the incarceration may be aggravated by edema and extraocular
muscle damage. If surgery is performed 4wk after fracture, the incarcerated or
scooped soft tissue may undergo ischemic necrosis or fibrosis, which is not
conducive to intraoperative and postoperative recovery. Therefore, surgery
should be performed within 2-3wk after the fracture. Owing to subjects’
personal reasons, there were cases in the three groups with disease duration
>3mo. This may increase the incidence of complications, such as
postoperative diplopia and eye movement disorder. The difference in duration of
illness in the three groups of this study was statistically significant (F=65.366,
P=0.000), which would affect the accuracy of the final conclusion. The
proficiency and experience of the surgeon in relation to the surgical
techniques were also evident in the effects of surgical outcomes and
postoperative complications[9]. During the
operation, injury to important nerve vessels, incomplete release of
incarcerated soft tissue, or negligence in the pruning, placement, and fixation
of the repair materials may to lead to a series of postoperative complications.
All operations in this study were performed by a single surgeon to avoid
interference with the results of the different surgical techniques between
groups.
The surgical approach for orbital
fractures mainly includes the following: the lower eyelid skin approach,
inferior conjunctival approach, and lacrimal caruncle conjunctival approach[10]. For fractures involving the lateral or supraorbital
wall, it is necessary to combine the external skin with the skin under the
eyebrow approach. The skin approach may fully expose the surgical field of
view; however, it is prone to skin scarring and affects appearance. The
conjunctival approach is less invasive and thus, less prone to scarring.
However, the limited exposure of the surgical field affects the operation[11]. For the inferior and medial walls of the fracture,
the lower conjunctival approach or the lacrimal caruncle conjunctival approach
may be used. In the case of a combination of internal and inferior wall
fractures, the lower conjunctiva combined with the lacrimal internal
conjunctival approach or the lower eyelid skin combined with the lacrimal
internal conjunctival approach should be selected. In short, it is necessary to
select the appropriate surgical approach based on the specific conditions of
the fracture, aiming for the best possible cosmetic outcome. In this study, an
analysis using the Chi-squared test was performed on the different surgical
approaches used between groups. There was no statistically significant
difference observed in the choice of surgical approach between the groups (χ2=0.691,
P=0.952).
Orbital fracture repair materials
include autologous bone, allogeneic bone[12], and
heterogeneous materials. Autologous bone exhibits good tissue compatibility;
however, it has the disadvantage of limited source and the risk of damaging the
anatomical function of the donor site[13].
Allogeneic bone is of sufficient origin, but is associated with a risk of immune
rejection and disease transmission. Heterogeneous materials mainly include
absorbable polymer compounds, high-density porous polyethylene (Medpor),
titanium mesh, and Medpor titanium mesh. Absorbable materials are mainly used
for the repair of orbital fractures in children. Medpor is capable of good
biocompatibility and rapid vascularization of human tissue after implantation
with a multi-aperture structure[14]. However, it
is difficult to evaluate the accuracy of the implantation site because this
material is not radiopaque[15]. Medpor is
typically selected for the repair of smaller fractures of the medial and
inferior walls of the orbital bone. In this study, one case of lower eyelid
retraction occurred in the Medpor group. This may be attributed to the pulling
effect of the repair material wrapped by the surrounding tissue on the lower
eyelid tissue. Titanium mesh can be radiopaque, it is easily shapeable, and
exhibits high mechanical strength. For the repair of large-area wall defects,
we usually select preformed titanium mesh. This material can better restore the
anatomy of the defective area of the orbital wall. However, the titanium mesh
is thin and cannot complement the traumatic atrophy of the orbital tissue. On
the other hand, its mesh is large, and the soft tissue in the orbit can
partially leak out of the mesh, which further increases the loss of tissue in
the orbit. This may explain the development of enophthalmos in one subject in
the titanium mesh group 3mo after surgery. Medpor Titan is a titanium mesh
embedded in Medpor that combines the advantages of both materials. it is
radiopaque. Moreover, It can fill the orbital volume, which can avoid the
occurrence of postoperative enophthalmos[16]. In
cases with a small defective area, we select the Medpor titanium mesh for the
repair of the bone defect. However, in this study, one subject in the Medpor
Titanium mesh group developed clinical manifestations of implant displacement
and infection 3mo after surgery. This is consistent with previous reports in
the literature[17-18]. We
performed pathological examination and bacterial culture on the surrounding
tissues of the implants. The results showed that neutrophils and multinucleated
giant cells had infiltrated the tissues, and revealed the presence of Staphylococcus
epidermidis infection (a low-toxicity bacterium) in the focal area. Studies
had suggested that in addition to these inflammatory cells, the presence of
fibrous vascular tissue around the implant helps to reduce implant displacement[19]. Bacterial culture results showed: Staphylococcus
epidermidis infection. This is a common organism of conjunctival flora[20]. There are numerous reasons for the displacement and
infection of the implant (e.g., presence of bacteria during the
operation, or immune rejection induced through stimulation of the tissue by the
foreign body)[21]. In addition, the ability of
different repair materials to resist microbial colonization is also a factor
affecting the occurrence of postoperative infection. For example, recent
studies have found that Silicone orbital implants can resist microbial
colonization better than porous polyethylene implants[20].
Collectively, the results of the
present study showed that different repair materials for orbital blowout
fractures exert similar effects on the long-term occurrence of postoperative
complications. However, this study is a retrospective study with a small sample
size, and these factors have an impact on the credibility of the research
conclusions. Improvements in the surgical techniques, timing of surgery, and
selection of the most appropriate surgical approach are essential to reduce the
incidence of complications. The development of new repair materials with good
biocompatibility, high mechanical strength, and plasticity is warranted to
improve the repair of orbital wall fractures.
ACKNOWLEDGEMENTS
Foundations: Supported by Jiangxi Provincial
Science and Technology Department Key Research and Development Program Fund
(No.20171BBG70096, No.20181BBG70007).
Conflicts of Interest: Xu QH, None; Yu JH,
None; Wang YH, None; Wang AA, None; Liao HF, None.
REFERENCES