Accepted Manuscript Reconstruction of Orbital Floor Blow-out Fractures with Autogenous Iliac Crest Bone: A Retrospective Study including Maxillofacial and Ophthalmology perspectives John Edward O’Connell , MB, BDS, FFD RCSI, Claire Hartnett , Marie Hickey-Dwyer , Gerard J. Kearns PII:

S1010-5182(14)00307-2

DOI:

10.1016/j.jcms.2014.11.001

Reference:

YJCMS 1910

To appear in:

Journal of Cranio-Maxillo-Facial Surgery

Received Date: 19 February 2014 Revised Date:

3 November 2014

Accepted Date: 4 November 2014

Please cite this article as: O’Connell JE, Hartnett C, Hickey-Dwyer M, Kearns GJ, Reconstruction of Orbital Floor Blow-out Fractures with Autogenous Iliac Crest Bone: A Retrospective Study including Maxillofacial and Ophthalmology perspectives, Journal of Cranio-Maxillo-Facial Surgery (2014), doi: 10.1016/j.jcms.2014.11.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title: Reconstruction of Orbital Floor Blow-out Fractures with Autogenous Iliac Crest Bone: A Retrospective Study including Maxillofacial and Ophthalmology perspectives Authors:

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John Edward O’Connell*, Claire Hartnett§, Marie Hickey-Dwyer§, Gerard J Kearns*. §

Corresponding author: John Edward O’Connell MB, BDS, FFD RCSI

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Email: [email protected] Tel: 00353 (0) 1 4162352

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Department of Oral and Maxillofacial Surgery, St James Hospital, James’ St, Dublin 8, Ireland

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Department of Ophthalmology, Mid Western Regional Hospital, Limerick, Ireland. *Department of Oral and Maxillofacial Surgery, St James Hospital, Dublin, Ireland.

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Keywords: trauma; orbital blow-out; orbital reconstruction; iliac crest graft.

ACCEPTED MANUSCRIPT

Captions for figures and images (in the order submitted)

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Abstract This is a 10-year retrospective study of patients with an isolated unilateral orbital floor fracture reconstructed with an autogenous iliac crest bone graft. The following inclusion criteria applied: isolated orbital floor fracture without involvement of the orbital rim or other craniofacial injuries, pre/post-operative ophthalmological/orthoptic follow-up, pre-operative CT. Variables recorded were patient age and gender, aetiology of injury, time to surgery, follow-up period, surgical morbidity, diplopia pre- and post-operatively (Hess test), eyelid position, visual acuity, and the presence of en-/ or exophthalmos (Hertel exophthalmometer). Twenty patients met the inclusion criteria. The mean age was 29 years. The mean follow up period was 26 months. No patient experienced significant donor site morbidity. There were no episodes of post-operative infection or graft extrusion. Three patients had diplopia in extremes of vision post-operatively, but no interference with activities of daily living. One patient had post-operative enophthalmos. Isolated orbital blow-out fractures may be safely and predictably reconstructed using autogenous iliac crest bone. The rate of complications in the group of patients studied was low. The value of pre- and post-operative ophthalmology consultation cannot be underestimated, and should be cosidered the standard of care in all patients with orbitozygomatic fractures, in particular those with blow-out fractures.

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Figure 1: Coronal CT, with orbital floor fracture and herniation of orbital contents into left maxillary antrum Figure 2: Post-operative Coronal CT, with iliac crest graft in situ

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Photo 1: Pre-operative photograph, demonstrating restriction of upward gaze Photo 2: Post-operative photograph with resolution of restriction

ACCEPTED MANUSCRIPT Introduction Blow-out fractures of the orbit, most commonly involving the floor and/or the medial wall, can occur following blunt trauma to the face. They may result in an increased incidence of ocular injuries relative to other orbito-zygomatic complex fractures (Barry et al., 2008). A number of theories have been proposed to explain the mechanism of injury. The “hydraulic theory” (Koornneef, 1982; Converse and

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Smith, 1960) proposes that retropulsion of the globe, when directly struck by an object, elevates the intra-orbital pressure transmitting force to the orbital walls. The thinner areas, namely the floor and medial wall, fracture into the adjacent sinuses. Soft tissues may become entrapped in the defect and

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may be damaged or undergo necrosis. A number of authors advocate this theory (Jolies and Evans, 1967; Green et al., 1990). The second theory, the “buckling theory”, suggests that direct trauma to the rigid orbital rim causes the orbital wall to buckle, creating a compression fracture of the orbital floor

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(Fujino and Makino, 1980). Several studies also support this hypothesis (Fujino and Makino, 1980; Kersten 1987).

The sequelae of orbital blow-out fractures include infra-orbital nerve sensory deficit, and diplopia secondary to extra-ocular muscle involvement (entrapment, ischaemia, haemorrhage, nerve injury

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[Burnstein, 2002]). If the orbital volume is increased relative to the volume of the intra-orbital soft tissue contents, enophthalmos may occur. Hypophthalmos, where the globe sinks downward, may also occur. It has been suggested that medial wall displacement may carry the greatest risk of enophthalmos

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(Yab et al., 1997). Whitehouse et al described a linear relationship between orbital volume and enophthalmos, which changed over twenty days as oedema resolved. In addition to these

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complications, direct soft tissue damage within the orbit can lead to scar contracture, globe dystopia, and dysmotility (Siddique and Mathog, 2002). Periorbital ecchymosis, subcutaneous emphysema, subconjunctival haemorrhage, epistaxis, pupillary dilation and lacrimal system damage may also be seen clinically.

It has been reported that the clinical presentation may be more subtle in children due to a different fracture pattern (Soll and Poley, 1965; deMan, 1991; Jordan et al., 1998; Egbert at al., 2000; Hatton et al., 2001; Kwon et al., 2005). Greater elasticity in the facial bones of children may result in a linear or “trapdoor” orbital floor/wall fracture, with entrapment of orbital soft tissues (Grant et al., 2002; Tse et

ACCEPTED MANUSCRIPT al., 2007). The relative paucity of clinical signs associated with this type of fracture led to the term “white-eye” blow-out fracture, owing to the absence of a subconjunctival haemorrhage or periorbital ecchymosis. The paucity of clinical signs may lead to a delayed diagnosis resulting in a suboptimal outcome. However, a number of authors (Kwon at al., 2005; Ethunandan and Evans, 2011) have shown that this type of fracture can also occur in adults. Autonomic symptoms may be more common in

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patients with linear “trapdoor” type fractures. The presence of nausea, vomiting, or bradycardia along with a painful restriction in ocular motility should arouse suspicion for a linear orbital fracture, even in the absence of classical symptoms such as subconjunctival haemorrhage (Sires et al., 1998; Bansagi

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and Meyer, 2000). These autonomic features may be the result of increased vagal tone secondary to soft tissue entrapment. The most serious autonomic complication is the oculocardiac reflex and is characterized by bradycardia and syncope. This presentation is an indication for emergency

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intervention as there is a risk of fatal arrhythmia (Sires et al., 1998).

Acute enophthalmos is rare, and late enophthalmos may not manifest for many months. Whilst some authors have attempted to predict those patients at risk for the development of late enophthalmos following a blow-out fracture (Whitehouse et al., 1994), it is not always possible to predict clinically or

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radiographically this potential complication, despite the widespread use of computed tomography Increasingly, orbital defects are repaired early in an attempt to prevent enophthalmos (Ellis and Tan, 2003). First described by Smith and Regan in 1957, the management of isolated orbital blow-out

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fractures remains controversial. There are no clear guidelines regarding the indications for surgery, the timing of treatment, and the choice of grafting material to use if required. Some surgeons immediately

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repair orbital floor fractures based on CT and ophthalmology findings, whilst others treat their patients conservatively and monitor for the development of enophthalmos and diplopia.

Orbital reconstruction is not without risk and the surgeon must be cognisant of potential complications, including blindness, mydriasis, infection and/or migration of implanted material, epiphoria, and persistent or worsening diplopia (Bodker et al., 1993; Biesman et al., 1996; Liu, 1994; Folkstad and Westin, 1999; Jordan et al., 1992). Putterman et al, in 1974, suggested non-surgical management of orbital blow-out fractures. In contrast, Hawes and Dortzbach advocated early repair in patients with large fractures or those with significant extra-ocular muscle dysfunction secondary to entrapment.

ACCEPTED MANUSCRIPT Millman et al described the use steroids immediately after a blow-out fracture to facilitate early decision making. A number of situations require early intervention. Immediate intervention is required when soft tissue entrapment stimulates the oculocardiac reflex (Sires et al., 1998). Prolapse of the globe into the maxillary sinus should also be treated promptly (Berkowitz et al., 1981; Smit et al., 1990). Jordan et al advocated early intervention in pediatric patients with so-called “white-eye” blow-out

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fractures, in order to avoid late muscle damage and contracture. Bansagi and Meyer, in a report on 34 patients aged 18 or younger, described earlier surgical repair resulting in improved outcomes. The

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findings of Egbert et al, and Wachler and Holds supported these findings.

Enophthalmos may present early if greater than half the orbital floor is involved in a fracture, and this may also prompt early intervention (Hawes and Dortzbach, 1983). However, in the absence of those

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situations that require immediate intervention, a two-week period of observation is often followed to allow for resolution of oedema and haemorrhage. Disturbance of ocular motility may not only be caused by entrapment of extra-ocular muscles and associated soft tissues (Burnstein, 2002) but also motor nerve palsy, muscle oedema, and haemorrhage may all lead to motility deficits (Wonjo, 1987; IIliff et al., 1999; Levine et al., 1998), and these deficits may resolve over time without surgical

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intervention. Nishida et al, in an attempt to identify those cases of blow-out fractures where ocular motility will return naturally, concluded that recovery can be expected in an eye without muscle entrapment and with movement of more than 10 or 20 degrees on each Hess chart. The presence of

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significant enophthalmos is difficult to assess in the early post-traumatic period, due to soft tissue oedema and haemorrhage. Indeed, oedema and haemorrhage may cause proptosis on the affected side.

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However, it is important to remember that fibrosis of orbital soft tissues occurs soon after trauma, often making late surgical intervention challenging and suboptimal. Some authors report that the treatment of established enophthalmos is significantly more difficult than its prevention (Ellis and Tan, 2003). The advent of computed tomography (CT) scans has increased the ability to assess fracture size and soft tissue involvement, and therefore help to inform the decision to intervene surgically. Jin et al reported that enophthalmos of 2mm or more could be expected when the size of the fracture is 1.9cm2 or more, or when the volume of herniated orbital soft tissue is 0.9ml or more. Also, Manson et al suggested that as little as a 5% change in orbital volume might result in enophthalmos. However, despite the fact that there is no absolute consensus regarding the indications for, and timing of surgical treatment, the goal

ACCEPTED MANUSCRIPT of treatment is to support of orbital contents, free entrapped tissue, and especially, restore the original orbital volume to prevent late enophthalmos.

Lang, in 1889, first described some of the materials available for reconstruction of orbital fractures and since then a myriad of materials has been proposed. The ideal material for orbital reconstruction would

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be chemically inert, biocompatible, non-allergenic, and non-carcinogenic (Potter and Ellis, 2004). In addition, it should be easy to handle and shape, allow for fixation if necessary, promote osteoconduction, be visible on radiographs, and sterilizable if alloplastic. Also, it should be easy to

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remove if necessary. None of the available materials fulfill all of these criteria. A number of considerations may influence the choice of graft used. Size and location of the defect, medical status of the patient, risk of further trauma, early or late repair, availability of grafting material, and surgeon

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training and experience, are all factors that may determine the material used.

Autogenous bone remains the standard by which all other grafting materials are measured. Its advantages include a relative resistance to infection, incorporation into new bone, absence of a foreign body reaction, and a decreased incidence of extrusion (Potter and Ellis, 2004). A number of potential

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donor sites including the iliac crest, calvarium, and mandible have been proposed. Yesiloglu et al, have recently proposed the Olecranon bone graft as a further option for the repair of orbital floor defects. However, all autogenous grafts require a second surgical site thereby increasing patient morbidity and

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operation time. Also, resorption of the grafted material, in particular cancellous bone, is accepted (Ozaki and Buchman, 1998). Cartilage (Li, 1997) [nasal septum, conchal] is another autogenous

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material available for orbital reconstruction. In addition, it can be difficult to adequately shape autogenous graft materials so that they conform to the contour of the internal orbit.

Allogenic materials such as lyophilized fascia (Chen et al., 1992), and homologous bone and cartilage (Ellis and and Sinn, 1993) have also been used. However, concern regarding antigenicity and transmission of infectious disease, such as Creutzfeld-Jakob disease (Thadani et al., 1988), has seen the use of these materials decline (Potter and Ellis, 2004). Alloplastic materials such as metallic mesh (Ellis and Messo, 2004), high-density porous polyethylene (Romano et al., 1993), silicone (Morrison et al., 1995), and also resorbable alloplasts such as polylactide (Cordewener et al., 1996), and

ACCEPTED MANUSCRIPT polydioxanone [PDS] (Iizuka et al., 1991) are widely used. The authors of a recent paper, reporting the medium to long-term results with a biodegradable osteo-inductive co-polymer grafting material, advocate its use in linear and trap-door type fractures (Morotomi et al., 2014). The advantages of alloplasts include their availability, and elimination of a second surgical donor site and its associated morbidity. However, these materials may elicit a foreign body reaction with or without extrusion.

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Birkenfeld and colleagues in a recent cadaveric study where orbital reconstruction materials, namely PDS and collagen, were artificially aged, demonstrated that thinner designs may provide adequate support for the orbital contents.

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At present, most graft materials are shaped intra-operatively following inspection of the bony defect. However, the use of patient specific implants in becoming more widespread (Lieger et al., 2010;

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Mustafa et al., 2011; Stoor P et al., 2014, Kozakevicz et al., 2013; Gander et al., 2014).

The purpose of this study was to assess the outcome, from both a surgical and ophthalmology perspective, for patients with a unilateral isolated orbital blow-out fracture treated with autogenous

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iliac crest bone grafts.

ACCEPTED MANUSCRIPT Patients and Methods

PATIENTS This is a 10-year retrospective study of all patients who underwent reconstruction of a unilateral isolated pure orbital blow-out fracture with autogenous iliac crest bone at a regional oral and

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maxillofacial surgery unit.

METHODS

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The following inclusion criteria applied: “pure” orbital floor fracture, pre-and post-operative ophthalmological and orthoptic follow-up, pre-operative CT, availability of detailed clinical and operation notes, reconstruction with autogenous iliac crest. The following variables were recorded:

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patient age and gender, aetiology of the injury, time from injury to surgery, length of hospital stay, follow-up period, surgical and donor site morbidity (including sensory nerve deficit, pain, aesthetics, and mobility), pre- and post-operatively diplopia (Hess test), eyelid position, visual acuity, and the postoperative en or exophthalmos (Hertel exophthalmometer). All information was obtained from patient medical records and operation reports. In addition all pre- and post-operative CT scans were

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Results (Table.1)

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reviewed. Post-operative CT scans were not taken routinely.

DEMOGRAPHICS

Two hundred and ninety nine orbito-zygomatic-complex fractures were surgically treated during the 10 year study period. Of these, twenty patients (6.7%) met the study inclusion criteria (as outlined above). Patients (18 male, 2 female) underwent reconstruction of the orbital floor fracture with autogenous iliac crest bone. The mean age at the time of surgery was 29 (19 - 57) years. Sporting injury was the most common cause of injury, accounting for 55% (n=11) of the fractures, followed by assault (40%, n=8), and an accidental fall (5%, n=1). Fourteen fractures were on the left side, and 5 on the right. The mean time from injury to surgery was 11 (5 - 19 ) days.The mean follow up period was 26 (2 to 120) months.

ACCEPTED MANUSCRIPT SURGICAL PERSPECTIVE The orbital floor was approached using a standard subcilliary incision and a stepped blunt dissection to the infra orbital rim. The orbital floor was explored and orbital fat and any involved muscle removed from the maxillary sinus by blunt dissection and repositioned within the orbital cavity. The anterior iliac crest was approached using an incision lateral to the crest and the corticocancellous block graft

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harvested from the medial aspect of the ilium using an osteotome. There were no intra-operative orbital complications such as excessive bleeding or optic nerve damage. No patient suffered a retrobulbar

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haemorrhage.

One patient was returned to theatre from the recovery room with ocular pain and periorbital swelling. The subciliary incision was re-opened, however there was no haematoma or active bleeding.There was

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no donor site morbidity associated the the iliac crest harvest, specifically: no patients experienced neurosensory disturbance, excessive scarring, post-operative infection or gait disturbance. There were no episodes of post-operative infection or graft extrusion at the surgical site. Two patients reported subjective parasthesia in the distribution of the infra-orbital branch of the trigeminal nerve 6 months post-operatively. However, objective sensory examination using direction, temperature and two point

show.

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discrimination showed no objective sensory defecit. There were no cases of ectropion or excess scleral

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OPHTHALMOLOGY PERSPECTIVE

All patients underwent an ophthalmologic and orthoptic examination pre- and post-operatively.

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Nineteen (95%) patients had diplopia pre-operatively, (confirmed by a Hess Test), which interfered with normal daily activities. Two patients had enophthalmos pre-operatively (both 3mm), one of whom also had hypoglobus. Post-operative enophthalmos, (defined as greater than 2mm of difference in projection [Lahbabi et al., 1999]), varied from 0 to 3mm, with only 1 patient having a value greater than 2mm. Three patients had residual diplopia post-operatively. The first had limitation of depression in extreme gaze only (objectively measured with Hess test) but had no interference with daily activities, and was unaware of the limitation. The second patient had a restriction in both downward and lateral gaze 6 months post-operatively. This improved over time and at 14 months the patient was unaware of the restriction, except in extreme lateral gaze. The third patient had diplopia, in extreme left

ACCEPTED MANUSCRIPT upward gaze, five months post-operatively. This was an objective finding, and the patient had no functional restriction.

Table.1 Summary of results

Age

Gender

Aetiology

Investigations

of Injury

1

28

M

Assault

CT, Hess

Graft

Donor

Follow-

Material

site

Up

problems

(months)

None

36

None

120

Iliac

2

22

M

Sport

CT, Hess

Iliac Crest

57

M

Fall

CT, Hess

Iliac

Post-op (mm)

No

0

Limitation

1

of dep

None

3

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3

Enophtalmos

Post-op

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Crest

Diplopia

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Patient

No

2

Crest

4

19

M

Sport

CT, Hess

Iliac

None

115

No

0

None

19

No

0

None

60

No

0

None

18

Limitation

3

Crest

5

23

M

Assault

CT, Hess

Iliac

Crest

6

29

M

Assault

CT, Hess

Iliac

7

36

M

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crest

Sport

CT, Hess

Iliac

Crest

8

40

M

Assault

CT, Hess

Iliac

of dep None

4

No

0

None

60

No

1

None

4

No

1

None

6

No

2

None

36

No

0

None

6

Extreme

0

10

11

12

19

39

M

M

Sport

Sport

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9

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Crest

24

21

M

M

Assault

Assault

CT, Hess

CT, Hess

Iliac crest Iliac Crest

CT, Hess

Iliac Crest

CT, Hess

Iliac Crest

13

31

M

Sport

CT, Hess

Iliac Crest

14

32

F

Sport

CT, Hess

Iliac Crest

Up None

6

No

0

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25

M

Sport

CT, Hess

Iliac

None

13

No

0

None

4

No

0

None

7

No

0

None

2

No

1

None

2

None

3

Crest 16

37

M

Sport

CT, Hess

Iliac Crest

17

27

M

Assault

CT, Hess

Iliac

18

28

F

Sport

CT, Hess

Iliac Crest

19

23

M

Assault

CT, Hess

Iliac

20

25

M

Sport

CT, Hess

Iliac Crest

0

No

0

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Abbreviations: M, Male; Dep, depression; CT, computed tomography.

No

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Crest

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Crest

Discussion

Prevention of enophthalmos, release of entrapped soft tissues, preservation of normal ocular motility and support of the orbital contents are the objectives of orbital blow-out reconstructive surgery.

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Numerous grafting materials have been described. The choice of material is influenced by a number of factors including the specific characteristics of the injury and the training/experience of the surgeon. The purpose of this study was to retrospectively review isolated orbital floor blow-fractures

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reconstructed using autogenous iliac crest bone.

Autogenous bone was one of the first materials used in orbital reconstruction (Converse et al., 1967)

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and remains a popular choice (Siddique and Mathog, 2002; Ellis and Tan, 2003). It has a number of advantages when compared with alloplastic materials, including biocompatibility, lower potential for extrusion, decreased foreign body reactions, and less infection risk (Sakakibara et al, 2009). Nevertheless, resorption of the grafted bone remains a concern whenever this material is used. Kontio et al in a CT/MRI follow-up study reported up to 80% resorption of iliac crest grafts but this coincided with 75% concurrent new bone formation. This serves to highlight the potential for resorption and also the osteo-conductive potential of autogenous bone. Another disadvantage of autogenous bone is the requirement of a second surgical site. This increases patient morbidity. Reported complications include acute and chronic pain, gait disturbance, infection, sensory nerve disturbance, fracture, and haematoma

ACCEPTED MANUSCRIPT (Barone et al., 2011; Swan and Goodacre, 2006; Kim et al., 2009). However, in the group of patients highlighted in this study, there were no long-term donor site complications. Indeed, the increased morbidity associated with harvesting autogenous bone appears to be minimal (Potter and Ellis, 2004; Sakakibara et al, 2009). Banwart et al, in a study on iliac crest bone graft harvest donor site morbidity, revealed that none of the 261 patients studied had significant peri-operative complications, and none of

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the 225 followed up long-term had severe late complications. Ahlmann et al, reported similar results. In a recent retrospective review, Stam et al evaluated the morbidity associated with harvesting the inner cortical plate of the iliac crest for reconstruction of the orbit. They found that all complications were

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temporary. Schaaf et al, in another retrospective analysis of donor site morbidity after bone harvesting from the anterior iliac crest found that 6.7% of patients reported subjective persistent sensory nerve deficits in the distribution of the lateral cutaneous femoral nerve. However, objective measurement

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demonstrated that only 1.85% of patients had a sensory nerve disturbance.

The Hess test was used in all patients to record pre- and post-operative diplopia. An advantage of the Hess test is the ability to objectively express the ocular motility in a numerical value and also to evaluate the over-action of the unaffected eye (Furuta et al., 2006). Three (15%) patients in this study

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had diplopia 6 months post-operatively. This residual diplopia may be related to extra-ocular muscle damage at the time of trauma. Two of these patients had no subjective findings and were unaware of the deficit, however the Hess test revealed a restriction of extreme downward gaze. The third patient

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was aware of a restriction in extreme lateral gaze, confirmed by Hess testing. However, this did not disrupt the patients’ daily activities. Baumann et al, in a retrospective review of orbital reconstruction

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with an alloplastic resorbable polydioxanone sheet, found that 25.8% of patients had diplopia in extreme gaze post-operatively. Zunc et al, in a similar study, reported that 18.75% of patients had residual diplopia at 7 months post-operatively. Gunarajah and Samman systematically reviewed 55 papers that reported the use and outcomes of a variety of implant materials for the management of orbital blow-out fractures. They found that of those patients with pre-operative diplopia, 18.3% had post-operative diplopia. Gosau and colleagues retrospectively reviewed 189 patients who underwent reconstruction of orbital floor fractures with a variety of materials including polydioxanone sheets, ethisorb dura, and titanium mesh. They found consistent diplopia in 3.2% of patients, and an overall

ACCEPTED MANUSCRIPT complication rate of 19%. Morotomi et al, in a review of 7 patients treated with a biodegradable osteoinductive co-polymer, reported diplopia in one (14.3%) patient.

One of the patients (8%) in this study had post-operative enophthalmos, measured with a Hertel exophthalmometer. These findings compare favorably to other similar studies (Siddique and Mathog,

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2002). Folkestad and Westin reported an enophthalmos rate of 7% among 84 patients treated with a variety of graft materials. Herzog et al found that 10% of patients, treated with a number of materials, had post-operative enophthalmos. Dempf et al used calvarial and iliac crest grafts to reconstruct orbital

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fractures and found that 7 (20%) of the 34 patients followed-up had enophthalmos. Gunarajah and Samman found that of those patients with pre-operative enophthalmos, 29.8% had post-operative enophthalmos. Gierloff et al, in an evaluation of orbital floor reconstruction with polydioxanone (PDS)

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implants found that 2% of patents experienced enophthalmos at 6 months following surgery. Wajih et al, compared the outcomes of patients managed with autogenous and porous polyethylene (Medpor). They reported that post-operative enophthalmos was found in 11.4% of patients reconstructed with autogenous bone, and in 15.3% of those reconstructed with Medpor.

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Ellis and Tan, in an assessment of blow-out fractures reconstructed with both titanium mesh and cranial bone, found that the titanium mesh may provide more accurate reconstructions than bone grafts due to the ease with which it can be contoured to fit the shape of the internal orbit. However, this study did

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not report on post-operative ocular motility, enophthalmos, or biological response to the titanium. The authors concluded that if these variables are considered, titanium mesh might not prove to be the most

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appropriate material. The likelihood of future trauma and the potential for posterior displacement of the graft material should also be considered when choosing a material for orbital repair. One recent study (Kozakiewicz et al., 2011) did however consider ophthalmology outcomes in patients managed with titanium implants. It was also interesting for the fact that it compared pre-bent titanium implants to patient specific implants. They reported better outcomes in relation to binocular vision, upgaze, and globe position for the patient specific implants. Gander and colleagues, in a paper looking at 12 patients managed with patient specific titanium implants reported that 5 (42%) patients had temporary post-operative diplopia, but none had permanent diplopia.

ACCEPTED MANUSCRIPT Graft displacement is another concern irrespective of the material used. This may lead to extrusion of the graft, restriction of gaze, loss of vision, enophthalmos, and lacrimal duct obstruction (Mauriello et al., 1987; Brown and Banks, 1993; Wolfe, 1981). Fixation of the graft has been shown to reduce the graft displacement. A number of authors have reported that implant displacement is directly related to the method of fixation, and screws have been shown to be a reliable method (Haugh et al., 1993;

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Browning, 1967; Aronowitz, 1986). The patients in this study routinely had grafts placed in the internal orbits and fixed with screw and/or plate fixation. No patient developed graft extrusion or displacement,

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as evidenced clinically and radiographically (post-operative CT).

Conclusion

Isolated orbital blow-out fractures may be safely and predictably reconstructed using autogenous

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corticocancellous iliac crest bone. The rate of complications (surgical and ophthalmological) in the group of patients studied was low. The value of pre- and post-operative ophthalmology consultation cannot be underestimated, and should be considered the standard of care in all patients with

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Bansagi ZC, Meyer DR. Internal orbital fractures in the pediatric age group: characterization and management. Ophthalmology 107:829–36, 2000

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polydioxanone implants. J Craniofac Surg. Jan;23(1):161-4, 2012 Gosau M, Schöneich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures-complications, outcome, and review of literature. Clin Oral Investig. Jun;15(3):305-13, 2011

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