Journal of Cranio-Maxillo-Focia/ Surgery (1992) 20, 303-304 © 1992 European Association for Cranio-Maxilio-Facial Surgery
E x t r u s m n ot a mJcroplate: an unusual complication ol osteosynthesls Stephen P. R. Macleod, Roger Bainton
Maxillofacial Unit (Head." Mr R. Bainton FDS RCS, FRCS Ed), Aberdeen Royal Infirmary, Aberdeen, UK
S U M M A R Y . A case is presented o f an unusual complication o f internal fixation of a midfaeial fracture; the spontaneous extrusion o f a microplate. KEY WORDS: Microplates - Vitallium - Midfacial trauma - Internal fixation - Complications
fractures of the midface and cranium (Kellman and Schilli, 1987). The complications of plate osteosynthesis of mandibular and midfacial fractures
INTRODUCTION Open reduction and internal fixation of facial fractures is becoming the accepted method of treatment. Technical developments have led to the introduction of smaller plates allowing accurate reduction and fixation of small bone fragments. A case is reported of the use of microplates, one of which subsequently extruded cutaneously. Case Report
A 44-year-old man was admitted to the Maxillofacial Unit of Aberdeen Royal Infirmary following an assault in which he sustained bilateral fractures of the zygomatic complexes, the orbital floors, the maxillary buttresses, the naso-ethmoid complex, and left body of mandible. He also sustained a significant head injury. Following stabilisation of his neurological condition definitive repair of his facial injuries was performed via a bicoronal flap. The zygomatic fractures were reduced and plated at the frontozygomatic suture with miniplates. The zygomatic arches were reduced and fixed with microplates. The maxillary buttress was exposed using a Le Fort I incision and stabilised using miniplates. The nasoethmoid complex and infra-orbital rims were reduced and fixed with microplates (Fig. 1). The orbital contents were restored and the defects in the walls repaired. Four months postoperatively, the patient presented complaining of painful swelling over the root of the nose. An infection at the site of one or more of the microplates was suspected and their removal recommended. This was declined and the swelling was managed conservatively with antibiotics. Eight months postoperatively the patient contacted the unit stating that one of the plates had worked its way to the surface and had come out spontaneously (Figs 2 and 3). There have been no further episodes of discomfort.
Fig. l - Postoperative radiograph showing the use of mini and
micro-plates. The plate which was extruded is marked (arrow).
D I S C U S S I O N AND C O N C L U S I O N S Plate osteosynthesis of facial fractures is a well documented technique and is the treatment of choice (Cawood, 1985; Luhr t987). The development of increasingly smaller plates has led to their use in
Fig. 2 - Photograph of the tract through which the plate was extruded. 303
304 Journal of Cranio-Maxillo-Facial Surgery true for fractures elsewhere in the maxillofacial skeleton, although it seems unlikely that midfacial structures above the Le Fort I level which are not part of the buttress system would be subjected to movement due to occlusal forces. It is the opinion of Michelet et al. (1973) that a two hole plate is sufficient. Failure due to corrosion must be considered, but Luhr (1987) reports that Vitallium ~ is highly resistant to corrosion and can remain in vivo for an indefinite period. The resolution of symptoms following the extrusion of the plate would support the removal of symptomatic plates. Fig. 3 - Photograph showing the plate which was extruded. References
include; wound dehiscence, infection of the wound a n d / o r plate, fracture of the plate and delayed union (Champy et al., 1986). Some authors have considered that the open reduction of fractures brings complications regardless of the method of fixation. The problems mentioned are: creation of larger incisions, wide periosteal dissection and extreme retraction of wound edges bringing the potential for unfavourable scarring (Davidson et al., 1990). Other problems unique to osteosynthesis of the midface include conduction of cold on to bone by plates, giving rise to discomfort particularly in the zygomaticofrontal region (KelIman and Schilli, 1987). White (1949) reports a late breakdown of the skin of the upper eyelid overlying a Vitallium ® cranioplasty plate in a patient who picked at a prominent plate edge, however, spontaneous extrusion of an osteosynthesis plate, in the maxillofacial skeleton or elsewhere, does not appear to have been recorded in the literature, (Langhamer and Ackroyd, 1990). The reasons for this complication are not clear. Failure to use at least two screws on each side of the fracture line has been cited as a cause of delayed infection due to inadequate immobilisation of the fragments (Champy et al., 1986). This observation was made on mandibular fractures but presumably holds
Cawood, J.. Small plate osteosynthesis of mandibular fractures.
Br. J. Oral Maxillofac. Surg. 23 (1985) 77 Charnpy, M., H-D. Pape, K. Gerlach, J. P. Lodde : Mandibular
fractures, 8. The Strasbourg miniplate osteosynthesis. In: Schilli W., E. Kruger, (eds). Oral and maxillofacial traumatology Vol 2. Quintessence Publishing Co, Chicago, 1986, pp 19-43 Davidson, J., D. Nickerson, B. Nickerson : Zygomatic fractures: comparison of methods of internal fixation. Plast. Reconstr. Surg. 86 (1990) 25 Kellman, R. M., W. Schilli: Plate fixation of fractures of the mid and upper face. Otolaryngol. Clin. North Am. 20 (1987) 559 Langhamer, V. G., C. E. Ackroyd: Removal of forearm plates: review of complications. J. Bone Joint Surg. 76 (1990) 601 Luhr, H. G. : Vitallium Luhr system in the reconstruction of the facial skeleton. Otolaryngol. Clin. North Am. 20 (1987) 573 Michelet, F. X., or. Deymes, B. Dessus." Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J. Max. Fac. Surg. 1 (1973) 79 White, J. C. : Late complications following eranioplasty with alloplastic plates. Ann. Surg. 128 (1949) 743
Mr S. P. R. MacLeod
Maxillofacial Unit Aberdeen Royal Infirmary Foresterhill Aberdeen AB9 2ZB UK Paper received 3 March 1992 Accepted 9 April 1992
E x t r u s m n ot a mJcroplate: an unusual complication ol osteosynthesls Stephen P. R. Macleod, Roger Bainton
Maxillofacial Unit (Head." Mr R. Bainton FDS RCS, FRCS Ed), Aberdeen Royal Infirmary, Aberdeen, UK
S U M M A R Y . A case is presented o f an unusual complication o f internal fixation of a midfaeial fracture; the spontaneous extrusion o f a microplate. KEY WORDS: Microplates - Vitallium - Midfacial trauma - Internal fixation - Complications
fractures of the midface and cranium (Kellman and Schilli, 1987). The complications of plate osteosynthesis of mandibular and midfacial fractures
INTRODUCTION Open reduction and internal fixation of facial fractures is becoming the accepted method of treatment. Technical developments have led to the introduction of smaller plates allowing accurate reduction and fixation of small bone fragments. A case is reported of the use of microplates, one of which subsequently extruded cutaneously. Case Report
A 44-year-old man was admitted to the Maxillofacial Unit of Aberdeen Royal Infirmary following an assault in which he sustained bilateral fractures of the zygomatic complexes, the orbital floors, the maxillary buttresses, the naso-ethmoid complex, and left body of mandible. He also sustained a significant head injury. Following stabilisation of his neurological condition definitive repair of his facial injuries was performed via a bicoronal flap. The zygomatic fractures were reduced and plated at the frontozygomatic suture with miniplates. The zygomatic arches were reduced and fixed with microplates. The maxillary buttress was exposed using a Le Fort I incision and stabilised using miniplates. The nasoethmoid complex and infra-orbital rims were reduced and fixed with microplates (Fig. 1). The orbital contents were restored and the defects in the walls repaired. Four months postoperatively, the patient presented complaining of painful swelling over the root of the nose. An infection at the site of one or more of the microplates was suspected and their removal recommended. This was declined and the swelling was managed conservatively with antibiotics. Eight months postoperatively the patient contacted the unit stating that one of the plates had worked its way to the surface and had come out spontaneously (Figs 2 and 3). There have been no further episodes of discomfort.
Fig. l - Postoperative radiograph showing the use of mini and
micro-plates. The plate which was extruded is marked (arrow).
D I S C U S S I O N AND C O N C L U S I O N S Plate osteosynthesis of facial fractures is a well documented technique and is the treatment of choice (Cawood, 1985; Luhr t987). The development of increasingly smaller plates has led to their use in
Fig. 2 - Photograph of the tract through which the plate was extruded. 303
304 Journal of Cranio-Maxillo-Facial Surgery true for fractures elsewhere in the maxillofacial skeleton, although it seems unlikely that midfacial structures above the Le Fort I level which are not part of the buttress system would be subjected to movement due to occlusal forces. It is the opinion of Michelet et al. (1973) that a two hole plate is sufficient. Failure due to corrosion must be considered, but Luhr (1987) reports that Vitallium ~ is highly resistant to corrosion and can remain in vivo for an indefinite period. The resolution of symptoms following the extrusion of the plate would support the removal of symptomatic plates. Fig. 3 - Photograph showing the plate which was extruded. References
include; wound dehiscence, infection of the wound a n d / o r plate, fracture of the plate and delayed union (Champy et al., 1986). Some authors have considered that the open reduction of fractures brings complications regardless of the method of fixation. The problems mentioned are: creation of larger incisions, wide periosteal dissection and extreme retraction of wound edges bringing the potential for unfavourable scarring (Davidson et al., 1990). Other problems unique to osteosynthesis of the midface include conduction of cold on to bone by plates, giving rise to discomfort particularly in the zygomaticofrontal region (KelIman and Schilli, 1987). White (1949) reports a late breakdown of the skin of the upper eyelid overlying a Vitallium ® cranioplasty plate in a patient who picked at a prominent plate edge, however, spontaneous extrusion of an osteosynthesis plate, in the maxillofacial skeleton or elsewhere, does not appear to have been recorded in the literature, (Langhamer and Ackroyd, 1990). The reasons for this complication are not clear. Failure to use at least two screws on each side of the fracture line has been cited as a cause of delayed infection due to inadequate immobilisation of the fragments (Champy et al., 1986). This observation was made on mandibular fractures but presumably holds
Cawood, J.. Small plate osteosynthesis of mandibular fractures.
Br. J. Oral Maxillofac. Surg. 23 (1985) 77 Charnpy, M., H-D. Pape, K. Gerlach, J. P. Lodde : Mandibular
fractures, 8. The Strasbourg miniplate osteosynthesis. In: Schilli W., E. Kruger, (eds). Oral and maxillofacial traumatology Vol 2. Quintessence Publishing Co, Chicago, 1986, pp 19-43 Davidson, J., D. Nickerson, B. Nickerson : Zygomatic fractures: comparison of methods of internal fixation. Plast. Reconstr. Surg. 86 (1990) 25 Kellman, R. M., W. Schilli: Plate fixation of fractures of the mid and upper face. Otolaryngol. Clin. North Am. 20 (1987) 559 Langhamer, V. G., C. E. Ackroyd: Removal of forearm plates: review of complications. J. Bone Joint Surg. 76 (1990) 601 Luhr, H. G. : Vitallium Luhr system in the reconstruction of the facial skeleton. Otolaryngol. Clin. North Am. 20 (1987) 573 Michelet, F. X., or. Deymes, B. Dessus." Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. J. Max. Fac. Surg. 1 (1973) 79 White, J. C. : Late complications following eranioplasty with alloplastic plates. Ann. Surg. 128 (1949) 743
Mr S. P. R. MacLeod
Maxillofacial Unit Aberdeen Royal Infirmary Foresterhill Aberdeen AB9 2ZB UK Paper received 3 March 1992 Accepted 9 April 1992
