The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Diplopia and Orbital Wall Fractures Paolo Boffano, MD,* Fabio Roccia, MD,* Cesare Gallesio, MD, DDS,* K. Hakki Karagozoglu, MD, DDS,Þ Tymour Forouzanfar, MD, DDSÞ Abstract: Diplopia is a symptom that is frequently associated with orbital wall fractures. The aim of this article was to present the incidence and patterns of diplopia after orbital wall blow-out fractures in 2 European centers, Turin and Amsterdam, and to identify any correlation between this symptom and such fractures. This study is based on 2 databases that have continuously recorded data of patients hospitalized with maxillofacial fractures between 2001 and 2010. On the whole, 447 patients (334 males, 113 females) with pure blow-out orbital wall fractures were included. The most frequently involved orbital site was the floor (359 fractures), followed by medial wall (41 fractures) and lateral wall (5 fractures). At presentation, 227 patients (50.7%) had evidence of diplopia. In particular, in most patients, a diplopia in all directions was referred (78 patients). Statistically significant associations were found between diplopia on eye elevation and orbital floor fractures (P G 0.05) and between horizontal diplopia and medial wall fractures (P G 0.000005). In patients under evaluation for orbital trauma, the observation of diplopia on eye elevation and horizontal diplopia at presentation could be useful clinical indicators orbital floor and medial wall fractures, respectively. Key Words: Diplopia, orbital fracture, symptoms, diagnosis, orbital floor
D
iplopia is a symptom that is frequently associated with orbital wall fractures.1Y10 Posttraumatic diplopia may be commonly determined by extrusion of the extraocular muscles or orbital soft tissues, injury of the extraocular muscles, edema of the intraorbital fat tissue, or vertical deviation of the eyeball.2 Pure blow-out orbital wall fractures are determined by a direct blunt trauma that leads to a fracture of part of the orbital wall without any involvement of the orbital rim (although fractures of the orbital rim may often be combined with fractures of the internal orbital walls).3,4 When orbital trauma is suspected, an immediate and appropriate diagnosis is crucial to allow an early treatment because several symptoms, such as diplopia and enophthalmos, can persist even after surgical treatment, especially if diagnosis is delayed.6 Computed tomography is the most common method used for the imaging diagnosis in orbital traumatology. However, correct di-
From the *Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Turin, Italy; and †Department of Oral and Maxillofacial Surgery/Oral Pathology, Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands. Received July 3, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Paolo Boffano, MD, Corso Dogliotti 14, 10126, Torino, Italy. E-mail: [email protected] No funding was received for this study. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000437
Brief Clinical Studies
agnosis and indications for open surgery can be obtained, thanks to a combination of both clinical investigation and imaging.4 In particular, during the physical examination of patients referred for orbital trauma, the finding of diplopia should make surgeons suspect the presence of an orbital fracture and alert the radiologist of the possibility of a peculiar orbital injury. However, different kinds of diplopia (horizontal, vertical, all directions) are usually referred by patients with various type of orbital wall fractures. Therefore, the aim of this article was to present the incidence and patterns of diplopia after orbital wall blow-out fractures in a double center population and to identify any correlation between this symptom and such fractures.
MATERIALS AND METHODS This study is based on 2 systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures and surgically treated in the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin, Italy, and in the Department of Oral and Maxillofacial Surgery, Vrije Universiteit University Medical Center (VUMC), Amsterdam, the Netherlands, between January 1, 2001, and January 1, 2010. Only patients who were admitted and surgically treated for pure blow-out orbital wall (medial wall, floor, lateral wall, or a combination of these) fractures were considered for this study. Patients affected by fractures involving the orbital rim and incomplete patient charts were excluded from this study. The following data for the injured patients were considered: sex, age, site and severity (Facial Injury Severity Scale) of facial fractures,1 etiology, characteristics of diplopia, and infraorbital nerve injury. The characteristics of diplopia were determined by the admitting maxillofacial surgeon who had performed a rapid ophthalmological assessment.7 Infraorbital nerve sensory disturbances were defined when a loss or abnormal sensation over the second branch of the trigeminal nerve distribution could be found by 2-point discrimination test. The nonaffected site served as an internal control in 2-point discrimination.8 Statistical analysis was used to search for associations among multiple variables. Statistical significance was determined using the W2 or Fisher exact test, if the sample sizes were too small.
RESULTS During the considered time frame, 1818 patients with maxillofacial fractures were admitted and surgically treated at the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin (UNITO), Italy, whereas 523 patients were admitted and surgically treated at the Department of Oral and Maxillofacial Surgery, VUMC. On the whole, 447 patients (334 males, 113 females; male-tofemale ratio, 2.95:1) with pure blow-out orbital wall fractures were included. In both centers, male patients were more numerous than females (Fig. 1).
FIGURE 1. Percentages of sex distribution in VUMC and UNITO centers.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 2. Decades of ages of patients from VUMC and UNITO hospitals.
& Volume 25, Number 2, March 2014
FIGURE 3. Etiological factors in the 2 study populations.
The mean age of the patients was 40 (SD, 18.6)years (range, 7Y97 years; median, 36 years). In both VUMC and UNITO series, most frequently involved patients were between 20 and 49 years of age, thus confirming the higher involvement of second, third, and fourth decades (Fig. 2). The most common causes of orbital wall fractures were assaults (37.1%), followed by falls (21.5%), sport accidents (14.3%), and motor-vehicle accidents (13.9%) (Table 1). The higher frequency of assaults as etiological factor has been encountered in both VUMC and UNITO study populations (Fig. 3). The most frequently involved orbital site was the floor (359 fractures), followed by medial wall (41 fractures) and lateral wall (5 fractures), whereas a combination of floor and lateral wall and floor and medial wall was encountered in 1 and 41 patients, respectively (Table 2). The mean Facial Injury Severity Scale score in the study population was 1.3 (SD, 0.69) (range, 1Y7; median, 1). On the whole, 227 patients (50.7%) had evidence of diplopia at presentation. In particular, in most patients, a diplopia in all directions was referred (78 patients) (Table 3). Instead, 131 patients demonstrated infraorbital nerve sensory disturbances. As for etiology, no statistically significant associations were observed between etiological categories and the presence of diplopia, whereas a statistically significant association was found between work accidents and the absence of diplopia (P G 0.05) (Table 1). Moreover, no statistically significant associations were also observed between the presence of diplopia and orbital fracture site (Table 2). Instead, statistically significant associations were found between diplopia on eye elevation and orbital floor fractures (P G 0.05) and between horizontal diplopia and medial wall fractures (P G 0.000005) (Table 3). Finally, no further statistically significant associations were observed between diplopia and age, sex, or infraorbital nerve deficit.
DISCUSSION Immediate diagnosis and treatment of orbital wall fractures are fundamental, as these fractures may lead to acute or chronic complications, such as diplopia, limitation of extraocular movement,
retrobulbar hematoma, ectropion, and enophthalmos.6 Therefore, careful history, physical examination, and computed tomography scans are essential for an appropriate assessment and management of patients with orbital wall fractures. Thorough ocular examination is crucial; in particular, special attention should be paid to evaluate extraocular motility and diplopia.5 The eyes normally move parallel to each other, aligned to the visual axis. If not, diplopia occurs unless there is a congenital or other early or chronic, compensated, or masked defect in eye motility. The inferior rectus muscle is the most frequently involved muscle in blow fractures, whereas the function of the superior rectus muscle can be considered normal in these injuries.3 However, disturbances in ocular motility may be determined by intraorbital tissue edema; entrapment of the extraocular muscles, tissues, orbital fat, or all, within the fractured bone; or direct damage to the extraocular muscles.4 Fractures of the orbital walls may be determined by increased orbital pressure because of hydraulic forces (hydraulic theory) or by buckling of the floor because of a direct trauma to the inferior orbital rim (buckling theory).5 In our study population, we found that most blow-out orbital fractures had been caused by assaults (37.1%), followed by falls (21.5%) and sports accidents (14.3%). However, no statistically significant associations were observed between etiological categories and the presence of diplopia, whereas a statistically significant association was curiously found between work accidents and the absence of diplopia, with no apparent explanation. As expected, orbital floor was the most common site of fracture, whereas relatively few patients presented medial wall or lateral wall fractures. Furthermore, following our statistical analysis, it was not possible to predict on the basis of the presence of diplopia per se what orbital wall had been fractured (Table 2). We observed that most patients with blow-out fractures had evidence of diplopia in all directions (78 patients), whereas complete vertical diplopia (on both eye elevation and depression) and diplopia on eye elevation were encountered in 65 and 57 patients, respectively. Our findings do not concur with previous studies where limited elevation was found to be the most common presentation.4 However, we found statistically significant associations between diplopia on eye elevation and orbital floor fractures (P G 0.05) and
TABLE 1. Etiology of Trauma in the Study Population Patients, n Cause Assault Fall Sport Motor-vehicle accident Work Bicycle Other Total
With Diplopia
Without Diplopia
Total
%
P
81 55 35 31 10 7 8 227
85 41 29 31 23 6 5 220
166 96 64 62 33 13 13 447
37.1 21.5 14.3 13.9 7.4 2.9 2.9 100
90.05 90.05 90.05 90.05 0.02* 90.05 90.05
*The category ‘‘work’’ resulted to be associated with the absence of diplopia.
e184
TABLE 2. Diplopia and Orbital Wall Fracture Location in the Study Population Patients, n
Floor Medial wall Lateral wall Floor + medial wall Floor + lateral wall Total
With Diplopia
Without Diplopia
Total
%
P
188 21 1 17 0 227
171 20 4 24 1 220
359 41 5 41 1 447
80.3 9.2 1.1 9.2 0.2 100
90.05 90.05 90.05 90.05 90.05
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
TABLE 3. Types of Diplopia According to Symptomatic Orbital Wall Fractures in the Study Population All Directions Floor 62 (79.2%) Medial wall 9 (11.7%) Lateral wall 1 (1.3%) Floor + 6 (7.8%) medial wall Floor + 0 lateral wall Total 78
Elevation and Depression 56 (86.1%) 2 (3.1%) 0 7 (10.8%)
Elevation
Depression Horizontal
53* (93%) 14 (87.6%) 4 (36.4%) 1 (1.7%) 1 (6.2%) 7† (63.6%) 0 0 0 3 (5.3%) 1 (6.2%) 0
0
0
0
0
65
57
16
11
*P G 0.05. †P G 0.000005.
Brief Clinical Studies
Computer-Designed Polyetheretherketone Implants Versus Titanium Mesh (TAcrylic Cement) in Alloplastic Cranioplasty: A Retrospective Single-Surgeon, Single-Center Study Zhi Yang Ng, MBChB,* Wei Jie Jensen Ang, BMedSci(Hons),Þ Irfan Nawaz, MBBS, FRCSþ
between horizontal diplopia and medial wall fractures (P G 0.000005) (Table 3).
CONCLUSIONS Our findings suggest that, in patients under evaluation for orbital trauma, the observation of diplopia on eye elevation and horizontal diplopia at presentation could be useful clinical indicators orbital floor and medial wall fractures, respectively. As the clinical investigation still remains an important indicator for open surgery, together with the radiologic investigation, posttraumatic orbital clinical signs should be precisely assessed to help in the diagnosis and surgical planning.
REFERENCES 1. Bagheri SC, Dierks EJ, Kademani D, et al. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64:408Y414 2. Folkestad L, Lindgren G, Moller C, et al. Diplopia in orbital fractures: a simple method to evaluate eye motility. Acta Otolaryngol 2007;127:156Y166 3. Gosse EM, Ferguson AW, Lymburn EG, et al. Blow-out fractures: patterns of ocular motility and effect of surgical repair. Br J Oral Maxillofac Surg 2010;48:40Y43 4. Jank S, Schuchter B, Emshoff R, et al. Clinical signs of orbital wall fractures as a function of anatomic location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:149Y153 5. Lee SH, Lew H, Yun YS. Ocular motility disturbances in orbital wall fracture patients. Yonsei Med J 2005;46:359Y367 6. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204Y208 7. Roccia F, Boffano P, Guglielmi V, et al. Role of the maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fractures. J Emerg Trauma Shock 2011;4:188Y193 8. Vriens JP, Moos KF. Morbidity of the infraorbital nerve following orbitozygomatic complex fractures. J Craniomaxillofac Surg 1995;23:363Y368 9. Boffano P, Roccia F, Gallesio C, et al. Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:275Y280 10. Roccia F, Boffano P, Bianchi FA, et al. Maxillofacial injuries due to work-related accidents in the North West of Italy. Oral Maxillofac Surg 2013;17:181Y186
Background: Polyetheretherketone (PEEK) has emerged as one of the most promising alloplastic materials for calvarial reconstruction because of a number of desirable qualities including resistance to heat and ionizing radiation, biocompatibility, biomechanically similar to native bone, and being nonferromagnetic for postoperative monitoring. We aimed to evaluate and compare the outcomes of alloplastic cranioplasty performed with PEEK, titanium mesh only (Ti-only), and titanium mesh with acrylic cement (Ti-AC); titanium mesh has previously recorded many successes with low complication rates. Methods: A retrospective, single-surgeon, single-center study for alloplastic cranioplasties was performed between January 2008 and December 2012. Titanium meshes were fashioned intraoperatively, whereas PEEK implants were prefabricated from high-resolution computed tomography scans. Patients were routinely followed up in outpatient settings. Results: Twenty-four patients (75% male) underwent delayed cranioplasty following initial craniectomy. Four Ti-only and 3 Ti-AC patients had postoperative complications including wound breakdown and implant exposure. These assumed a bimodal distribution with time postoperatively and culminated in implant removal in 6 patients, of which 4 required further plastic flap coverage. Subgroup analysis showed no significant differences in predictive factors apart from cranioplasty material with means as follows: age = 42 years, interval to surgery = 10 months, defect size = 12 9 cm, operation duration = 181 minutes, hospital stay = 13 days, follow-up = 11 months. Conclusions: Early results suggest that PEEK may be superior to Ti-only or Ti-AC as an alloplastic cranioplasty choice. Further research should include randomized trials between computer-aided,
From the *Department of Plastic Reconstructive and Aesthetic Surgery, KK Women’s and Children’s Hospital, Singapore; †College of Medicine and Veterinary Medicine, University of Edinburgh, Scotland, United Kingdom; and ‡Division of Neurosurgery, Changi General Hospital, Singapore. Received September 23, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Zhi Yang Ng, MBChB, Department of Plastic Reconstructive and Aesthetic Surgery, KK Women’s and Children’s Hospital, 100 Bukit Timah Rd, Singapore 229899; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000623
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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& Volume 25, Number 2, March 2014
Diplopia and Orbital Wall Fractures Paolo Boffano, MD,* Fabio Roccia, MD,* Cesare Gallesio, MD, DDS,* K. Hakki Karagozoglu, MD, DDS,Þ Tymour Forouzanfar, MD, DDSÞ Abstract: Diplopia is a symptom that is frequently associated with orbital wall fractures. The aim of this article was to present the incidence and patterns of diplopia after orbital wall blow-out fractures in 2 European centers, Turin and Amsterdam, and to identify any correlation between this symptom and such fractures. This study is based on 2 databases that have continuously recorded data of patients hospitalized with maxillofacial fractures between 2001 and 2010. On the whole, 447 patients (334 males, 113 females) with pure blow-out orbital wall fractures were included. The most frequently involved orbital site was the floor (359 fractures), followed by medial wall (41 fractures) and lateral wall (5 fractures). At presentation, 227 patients (50.7%) had evidence of diplopia. In particular, in most patients, a diplopia in all directions was referred (78 patients). Statistically significant associations were found between diplopia on eye elevation and orbital floor fractures (P G 0.05) and between horizontal diplopia and medial wall fractures (P G 0.000005). In patients under evaluation for orbital trauma, the observation of diplopia on eye elevation and horizontal diplopia at presentation could be useful clinical indicators orbital floor and medial wall fractures, respectively. Key Words: Diplopia, orbital fracture, symptoms, diagnosis, orbital floor
D
iplopia is a symptom that is frequently associated with orbital wall fractures.1Y10 Posttraumatic diplopia may be commonly determined by extrusion of the extraocular muscles or orbital soft tissues, injury of the extraocular muscles, edema of the intraorbital fat tissue, or vertical deviation of the eyeball.2 Pure blow-out orbital wall fractures are determined by a direct blunt trauma that leads to a fracture of part of the orbital wall without any involvement of the orbital rim (although fractures of the orbital rim may often be combined with fractures of the internal orbital walls).3,4 When orbital trauma is suspected, an immediate and appropriate diagnosis is crucial to allow an early treatment because several symptoms, such as diplopia and enophthalmos, can persist even after surgical treatment, especially if diagnosis is delayed.6 Computed tomography is the most common method used for the imaging diagnosis in orbital traumatology. However, correct di-
From the *Division of Maxillofacial Surgery, Head and Neck Department, San Giovanni Battista Hospital, University of Turin, Turin, Italy; and †Department of Oral and Maxillofacial Surgery/Oral Pathology, Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, the Netherlands. Received July 3, 2013. Accepted for publication August 27, 2013. Address correspondence and reprint requests to Paolo Boffano, MD, Corso Dogliotti 14, 10126, Torino, Italy. E-mail: [email protected] No funding was received for this study. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000437
Brief Clinical Studies
agnosis and indications for open surgery can be obtained, thanks to a combination of both clinical investigation and imaging.4 In particular, during the physical examination of patients referred for orbital trauma, the finding of diplopia should make surgeons suspect the presence of an orbital fracture and alert the radiologist of the possibility of a peculiar orbital injury. However, different kinds of diplopia (horizontal, vertical, all directions) are usually referred by patients with various type of orbital wall fractures. Therefore, the aim of this article was to present the incidence and patterns of diplopia after orbital wall blow-out fractures in a double center population and to identify any correlation between this symptom and such fractures.
MATERIALS AND METHODS This study is based on 2 systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures and surgically treated in the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin, Italy, and in the Department of Oral and Maxillofacial Surgery, Vrije Universiteit University Medical Center (VUMC), Amsterdam, the Netherlands, between January 1, 2001, and January 1, 2010. Only patients who were admitted and surgically treated for pure blow-out orbital wall (medial wall, floor, lateral wall, or a combination of these) fractures were considered for this study. Patients affected by fractures involving the orbital rim and incomplete patient charts were excluded from this study. The following data for the injured patients were considered: sex, age, site and severity (Facial Injury Severity Scale) of facial fractures,1 etiology, characteristics of diplopia, and infraorbital nerve injury. The characteristics of diplopia were determined by the admitting maxillofacial surgeon who had performed a rapid ophthalmological assessment.7 Infraorbital nerve sensory disturbances were defined when a loss or abnormal sensation over the second branch of the trigeminal nerve distribution could be found by 2-point discrimination test. The nonaffected site served as an internal control in 2-point discrimination.8 Statistical analysis was used to search for associations among multiple variables. Statistical significance was determined using the W2 or Fisher exact test, if the sample sizes were too small.
RESULTS During the considered time frame, 1818 patients with maxillofacial fractures were admitted and surgically treated at the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin (UNITO), Italy, whereas 523 patients were admitted and surgically treated at the Department of Oral and Maxillofacial Surgery, VUMC. On the whole, 447 patients (334 males, 113 females; male-tofemale ratio, 2.95:1) with pure blow-out orbital wall fractures were included. In both centers, male patients were more numerous than females (Fig. 1).
FIGURE 1. Percentages of sex distribution in VUMC and UNITO centers.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e183
The Journal of Craniofacial Surgery
Brief Clinical Studies
FIGURE 2. Decades of ages of patients from VUMC and UNITO hospitals.
& Volume 25, Number 2, March 2014
FIGURE 3. Etiological factors in the 2 study populations.
The mean age of the patients was 40 (SD, 18.6)years (range, 7Y97 years; median, 36 years). In both VUMC and UNITO series, most frequently involved patients were between 20 and 49 years of age, thus confirming the higher involvement of second, third, and fourth decades (Fig. 2). The most common causes of orbital wall fractures were assaults (37.1%), followed by falls (21.5%), sport accidents (14.3%), and motor-vehicle accidents (13.9%) (Table 1). The higher frequency of assaults as etiological factor has been encountered in both VUMC and UNITO study populations (Fig. 3). The most frequently involved orbital site was the floor (359 fractures), followed by medial wall (41 fractures) and lateral wall (5 fractures), whereas a combination of floor and lateral wall and floor and medial wall was encountered in 1 and 41 patients, respectively (Table 2). The mean Facial Injury Severity Scale score in the study population was 1.3 (SD, 0.69) (range, 1Y7; median, 1). On the whole, 227 patients (50.7%) had evidence of diplopia at presentation. In particular, in most patients, a diplopia in all directions was referred (78 patients) (Table 3). Instead, 131 patients demonstrated infraorbital nerve sensory disturbances. As for etiology, no statistically significant associations were observed between etiological categories and the presence of diplopia, whereas a statistically significant association was found between work accidents and the absence of diplopia (P G 0.05) (Table 1). Moreover, no statistically significant associations were also observed between the presence of diplopia and orbital fracture site (Table 2). Instead, statistically significant associations were found between diplopia on eye elevation and orbital floor fractures (P G 0.05) and between horizontal diplopia and medial wall fractures (P G 0.000005) (Table 3). Finally, no further statistically significant associations were observed between diplopia and age, sex, or infraorbital nerve deficit.
DISCUSSION Immediate diagnosis and treatment of orbital wall fractures are fundamental, as these fractures may lead to acute or chronic complications, such as diplopia, limitation of extraocular movement,
retrobulbar hematoma, ectropion, and enophthalmos.6 Therefore, careful history, physical examination, and computed tomography scans are essential for an appropriate assessment and management of patients with orbital wall fractures. Thorough ocular examination is crucial; in particular, special attention should be paid to evaluate extraocular motility and diplopia.5 The eyes normally move parallel to each other, aligned to the visual axis. If not, diplopia occurs unless there is a congenital or other early or chronic, compensated, or masked defect in eye motility. The inferior rectus muscle is the most frequently involved muscle in blow fractures, whereas the function of the superior rectus muscle can be considered normal in these injuries.3 However, disturbances in ocular motility may be determined by intraorbital tissue edema; entrapment of the extraocular muscles, tissues, orbital fat, or all, within the fractured bone; or direct damage to the extraocular muscles.4 Fractures of the orbital walls may be determined by increased orbital pressure because of hydraulic forces (hydraulic theory) or by buckling of the floor because of a direct trauma to the inferior orbital rim (buckling theory).5 In our study population, we found that most blow-out orbital fractures had been caused by assaults (37.1%), followed by falls (21.5%) and sports accidents (14.3%). However, no statistically significant associations were observed between etiological categories and the presence of diplopia, whereas a statistically significant association was curiously found between work accidents and the absence of diplopia, with no apparent explanation. As expected, orbital floor was the most common site of fracture, whereas relatively few patients presented medial wall or lateral wall fractures. Furthermore, following our statistical analysis, it was not possible to predict on the basis of the presence of diplopia per se what orbital wall had been fractured (Table 2). We observed that most patients with blow-out fractures had evidence of diplopia in all directions (78 patients), whereas complete vertical diplopia (on both eye elevation and depression) and diplopia on eye elevation were encountered in 65 and 57 patients, respectively. Our findings do not concur with previous studies where limited elevation was found to be the most common presentation.4 However, we found statistically significant associations between diplopia on eye elevation and orbital floor fractures (P G 0.05) and
TABLE 1. Etiology of Trauma in the Study Population Patients, n Cause Assault Fall Sport Motor-vehicle accident Work Bicycle Other Total
With Diplopia
Without Diplopia
Total
%
P
81 55 35 31 10 7 8 227
85 41 29 31 23 6 5 220
166 96 64 62 33 13 13 447
37.1 21.5 14.3 13.9 7.4 2.9 2.9 100
90.05 90.05 90.05 90.05 0.02* 90.05 90.05
*The category ‘‘work’’ resulted to be associated with the absence of diplopia.
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TABLE 2. Diplopia and Orbital Wall Fracture Location in the Study Population Patients, n
Floor Medial wall Lateral wall Floor + medial wall Floor + lateral wall Total
With Diplopia
Without Diplopia
Total
%
P
188 21 1 17 0 227
171 20 4 24 1 220
359 41 5 41 1 447
80.3 9.2 1.1 9.2 0.2 100
90.05 90.05 90.05 90.05 90.05
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
TABLE 3. Types of Diplopia According to Symptomatic Orbital Wall Fractures in the Study Population All Directions Floor 62 (79.2%) Medial wall 9 (11.7%) Lateral wall 1 (1.3%) Floor + 6 (7.8%) medial wall Floor + 0 lateral wall Total 78
Elevation and Depression 56 (86.1%) 2 (3.1%) 0 7 (10.8%)
Elevation
Depression Horizontal
53* (93%) 14 (87.6%) 4 (36.4%) 1 (1.7%) 1 (6.2%) 7† (63.6%) 0 0 0 3 (5.3%) 1 (6.2%) 0
0
0
0
0
65
57
16
11
*P G 0.05. †P G 0.000005.
Brief Clinical Studies
Computer-Designed Polyetheretherketone Implants Versus Titanium Mesh (TAcrylic Cement) in Alloplastic Cranioplasty: A Retrospective Single-Surgeon, Single-Center Study Zhi Yang Ng, MBChB,* Wei Jie Jensen Ang, BMedSci(Hons),Þ Irfan Nawaz, MBBS, FRCSþ
between horizontal diplopia and medial wall fractures (P G 0.000005) (Table 3).
CONCLUSIONS Our findings suggest that, in patients under evaluation for orbital trauma, the observation of diplopia on eye elevation and horizontal diplopia at presentation could be useful clinical indicators orbital floor and medial wall fractures, respectively. As the clinical investigation still remains an important indicator for open surgery, together with the radiologic investigation, posttraumatic orbital clinical signs should be precisely assessed to help in the diagnosis and surgical planning.
REFERENCES 1. Bagheri SC, Dierks EJ, Kademani D, et al. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 2006;64:408Y414 2. Folkestad L, Lindgren G, Moller C, et al. Diplopia in orbital fractures: a simple method to evaluate eye motility. Acta Otolaryngol 2007;127:156Y166 3. Gosse EM, Ferguson AW, Lymburn EG, et al. Blow-out fractures: patterns of ocular motility and effect of surgical repair. Br J Oral Maxillofac Surg 2010;48:40Y43 4. Jank S, Schuchter B, Emshoff R, et al. Clinical signs of orbital wall fractures as a function of anatomic location. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96:149Y153 5. Lee SH, Lew H, Yun YS. Ocular motility disturbances in orbital wall fracture patients. Yonsei Med J 2005;46:359Y367 6. Park MS, Kim YJ, Kim H, et al. Prevalence of diplopia and extraocular movement limitation according to the location of isolated pure blowout fractures. Arch Plast Surg 2012;39:204Y208 7. Roccia F, Boffano P, Guglielmi V, et al. Role of the maxillofacial surgeon in the management of severe ocular injuries after maxillofacial fractures. J Emerg Trauma Shock 2011;4:188Y193 8. Vriens JP, Moos KF. Morbidity of the infraorbital nerve following orbitozygomatic complex fractures. J Craniomaxillofac Surg 1995;23:363Y368 9. Boffano P, Roccia F, Gallesio C, et al. Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:275Y280 10. Roccia F, Boffano P, Bianchi FA, et al. Maxillofacial injuries due to work-related accidents in the North West of Italy. Oral Maxillofac Surg 2013;17:181Y186
Background: Polyetheretherketone (PEEK) has emerged as one of the most promising alloplastic materials for calvarial reconstruction because of a number of desirable qualities including resistance to heat and ionizing radiation, biocompatibility, biomechanically similar to native bone, and being nonferromagnetic for postoperative monitoring. We aimed to evaluate and compare the outcomes of alloplastic cranioplasty performed with PEEK, titanium mesh only (Ti-only), and titanium mesh with acrylic cement (Ti-AC); titanium mesh has previously recorded many successes with low complication rates. Methods: A retrospective, single-surgeon, single-center study for alloplastic cranioplasties was performed between January 2008 and December 2012. Titanium meshes were fashioned intraoperatively, whereas PEEK implants were prefabricated from high-resolution computed tomography scans. Patients were routinely followed up in outpatient settings. Results: Twenty-four patients (75% male) underwent delayed cranioplasty following initial craniectomy. Four Ti-only and 3 Ti-AC patients had postoperative complications including wound breakdown and implant exposure. These assumed a bimodal distribution with time postoperatively and culminated in implant removal in 6 patients, of which 4 required further plastic flap coverage. Subgroup analysis showed no significant differences in predictive factors apart from cranioplasty material with means as follows: age = 42 years, interval to surgery = 10 months, defect size = 12 9 cm, operation duration = 181 minutes, hospital stay = 13 days, follow-up = 11 months. Conclusions: Early results suggest that PEEK may be superior to Ti-only or Ti-AC as an alloplastic cranioplasty choice. Further research should include randomized trials between computer-aided,
From the *Department of Plastic Reconstructive and Aesthetic Surgery, KK Women’s and Children’s Hospital, Singapore; †College of Medicine and Veterinary Medicine, University of Edinburgh, Scotland, United Kingdom; and ‡Division of Neurosurgery, Changi General Hospital, Singapore. Received September 23, 2013. Accepted for publication December 2, 2013. Address correspondence and reprint requests to Zhi Yang Ng, MBChB, Department of Plastic Reconstructive and Aesthetic Surgery, KK Women’s and Children’s Hospital, 100 Bukit Timah Rd, Singapore 229899; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000623
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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