PEDIATRIC/CRANIOFACIAL The Concept and Method of Closed Reduction and Internal Fixation: A New Approach for the Treatment of Simple Zygoma Fractures Hirokazu Uda, Hideaki Kamochi, Yasushi Sugawara, Syunji Sarukawa, Ataru Sunaga,
M.D. M.D. M.D. M.D. M.D.
Shimotuke, Tochigi, Japan
Background: The authors have developed a new minimally invasive surgical procedure for simple zygoma fractures, a closed reduction and internal fixation method, that uses a cannulated cortical screw system. Methods: From 2007 to 2012, 42 selected patients with simple zygoma fractures without ocular problems or shear at the zygomatic frontal portion were treated with this method. The mean age of the patients was 33 years (range, 13 to 77 years). Results: The authors achieved good repositioning, equivalent to results achieved with conventional procedures in all cases. No notable complication occurred except for minor infection in two cases. Mean operative time was 32 minutes (range, 19 to 58 minutes). Postoperative relapse was found only in the posterior direction (p < 0.001), but the distance of that was so small (mean, 0.47 mm) that it did not cause any problem clinically. Conclusions: Although further improvement might be needed, such as screw specification, the closed reduction and internal fixation method has many advantages: short operative time, less effect on soft tissue, maintenance of bone healing potential, and decreased postoperative pain and swelling. The authors concluded that this method has the potential to become a future surgical procedure for simple zygoma fractures. (Plast. Reconstr. Surg. 132: 1231, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
C
urrently, less invasive methods for the treatment of simple zygoma fractures have become available. The number of plate fixations is reduced according to the degree of dislocation and the presence of ocular problems (e.g., diplopia) and, sometimes, closed reduction with or without a Kirschner wire is performed.1–7 These approaches aim to avoid unnecessary invasion of soft tissue and avoid adverse effects such as postoperative ectropion of the lower eyelid and persistent swelling. However, a procedural dilemma also exists, which involves decreasing the number of plates or omitting rigid fixation with plates that may increase the risk of postoperative relapse. When considering the treatment of zygoma fractures, achieving anatomical repositioning by using only the closed approach and From the Department of Plastic Surgery, Jichi Medical University. Received for publication April 8, 2013; accepted May 8, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a48d8c
applying rigid internal fixation may be ideal. We have developed a minimally invasive surgical procedure based on the closed reduction and internal fixation concept. In this study, we introduce the surgical technique of the closed reduction and internal fixation method and assess its efficacy, safety, and outcome. Furthermore, we investigate the potential problems associated with the use of this method. Disclosure: None of the authors has a financial interest in companies producing or distributing products used for this study.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
1231
Plastic and Reconstructive Surgery • November 2013 PATIENTS AND METHODS Thirty-six patients with simple zygoma fractures between 2007 and 2012 were included in this study. We have previously established the inclusion criteria of our closed reduction and internal fixation method as follows: patients should have no ocular problems such as diplopia and apparent herniation of orbital contents into the maxillary sinus on preoperative multidetector computed tomography, and there should be no shearing in the zygomatic frontal portion. Surgical Procedure Thirty-eight of the patients were operated on under general anesthesia. In the remaining four patients, the dislocation of the zygoma was minimal, and surgery was performed under local anesthesia. (See Video, Supplemental Digital Content 1, which displays the closed reduction and internal fixation procedure, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A876.) First, a small (4 mm) skin stab incision was made 2 cm lateral from the lateral canthus at the level of the infraorbital rim. A Carroll-Girard screw was then used for reduction through this stab. Repositioning was confirmed by palpation of the continuity of the infraorbital rim and the frontozygomatic suture, and by inspection of the projection of the malar eminence. In later cases, especially when swelling was severe and confirmation of reduction was difficult, we used three-dimensional imaging (ARCADIS Orbic 3D;
Video 1. Supplemental Digital Content 1 displays the closed reduction and internal fixation procedure, http://links.lww. com/PRS/A876.
1232
Siemens AG, Munich, Germany) intraoperatively to check for reduction of the zygoma. If the reduction was insufficient, we sometimes performed Gillies elevation and reduction through a temporal incision. To maintain repositioning, temporary percutaneous transmalar fixation was generally performed using a 2.0-mm Kirschner wire. This transmalar fixation was occasionally omitted when the zygoma was stable after reduction. We then inserted a 3.5-mm cannulated cortical screw (TiMAX 3.5/4.5 mm Cannulated Screw System; DePuy Orthopaedics Inc., Warsaw, Ind.) through the skin stab (Fig. 1). First, an originally developed guide device (CRIF bow; Keisei Medical Industrial Co., Ltd., Tokyo, Japan), a 1.5-mm Kirschner wire that served as the guide wire, was inserted through the skin stab from the malar prominence to the edge of the roof of the hard palate between the first and second molars. The insertion of the Kirschner wire was stopped just after its tip passed through the hard palate. This procedure must be performed carefully so that the insertion of the Kirschner wire does not extend into the oral cavity (Fig. 1). By using a depth gauge, the inserted length of the Kirschner wire was then measured and the proper screw length was determined. Using the Kirschner wire as a guide, the zygoma and hard palate were drilled and tapped with a dedicated system. The screw was then inserted through the Kirschner wire and tightened using a cannulated driver (Fig. 1). Before fully inserting and tightening the screw, proper repositioning of the zygoma should be reconfirmed. A full thread screw was used, which acted as a positional screw. Therefore, the distance between the zygoma and the hard palate was maintained properly. Finally, the skin stab was sutured at the end of the procedure. The screw was removed approximately 3 months after surgery through a skin stab, under local anesthesia in an outpatient setting. Postoperative Assessment All patients underwent multidetector computed tomography before surgery (t1) and greater than 8 weeks after surgery (t2), and the repositioning of the zygoma and the changes in the orbital floor were assessed. In the latter 27 cases, we also performed multidetector computed tomography just after the operation (t1′). We expected a relapse in the early postsurgery period. Therefore, considering the effect of the masseter muscle, we assessed the inferior and posterior relapse by comparing the t1′ and t2 multidetector computed tomography scans in the latter 33
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 1. The closed reduction and internal fixation method. (Above) A 3.5-mm full-thread cannulated cortical screw. (Below, left) Using a guide device, a 1.5-mm Kirschner wire is inserted accurately. (Below, right) A screw of proper length is inserted through the Kirschner wire (the inserted length of the Kirschner wire is equal to the length of the screw).
cases. Five of the six patients with a large free segment of the orbital rim or a comminuted fracture of the zygomaticomaxillary buttress were included in these latter 33 cases. Using multidetector computed tomography, we defined distance X as the distance from the
axial plane at the height of the cribriform plate to the center of the screw head, and distance Y as the distance from the coronal plane at the posterior walls of the maxillary sinuses to the center of the screw head (Fig. 2). We then estimated the inferior relapse by using the formula Xt2 (X at t2)
Fig. 2. (Left) The distance from the axial plane at the height of the cribriform plate to the center of the screw head (X). (Right) The distance from the coronal plane at the posterior walls of the maxillary sinuses to the center of the screw head (Y).
1233
Plastic and Reconstructive Surgery • November 2013 – Xt1 (X at t1′) and the posterior relapse by the formula Yt1 (Y at t1′) – Yt2 (Y at t2). These were measured on the monitor of the picture archiving and communication system (Synapse PACS; Fuji film Medical Co., Ltd., Tokyo, Japan), and the t test was used to assess the statistical change of these distances. A value of p < 0.001 was considered to represent a significant difference. The ocular position was measured with a Hertel exophthalmometer just before screw removal, and the existence of an enophthalmos was assessed. Postoperative complications were also recorded in each case.
RESULTS The mean age of the patients was 33 years (range, 13 to 77 years), and there were 33 men and nine women. The affected side was the right side in 16 patients and the left side in 26 patients. The causes of the injuries were physical assault in 16 patients, fall in 12, sports accident in nine, and car accident in five patients. In six of the 42 patients (14.3 percent), the dislocation of the zygoma was severe and a large free segment of the orbital rim or a comminuted fracture of the zygomaticomaxillary buttress was found. All patients were operated on by a single surgeon (H.U.). The mean operative time was 32 minutes (range, 19 to 58 minutes). The length of the screw used ranged from 42 to 60 mm. Representative examples are shown in Figures 3 through 6. In the postoperative assessment of reduction, the fractures were considered perfectly reduced in 36 patients (85.7 percent). In the other six patients (14.3 percent), there was some imperfection in the reduction. In those six “imperfect” cases, three had some residual medial rotation at the sphenozygomatic suture region, two had some posterior displacement at the sphenozygomatic suture region, and one had both of the above imperfections. Concerning relapse, the mean inferior movement of the zygoma was −0.12 mm (range, −1.9 to 0.94 mm) after the operation, and no significant relapse was found (p = 0.84). In contrast, the mean posterior movement of the zygoma was 0.47 mm (range, −1.32 to 1.77) and a significant relapse existed (p < 0.01); however, it was minimal (Table 1). From the postoperative radiographic findings, no newly developed defects of the orbital floor or herniation of ocular contents into the maxillary sinus was seen in any of the 42 patients. In almost all patients, the orbital floor was restored, as the zygoma was repositioned to the anatomical position and was properly remodeled (Figs. 3
1234
through 6). In cases in which the zygoma was medially impacted before surgery, the orbital floor drooped slightly following surgery. However, no ocular problems occurred and there were no cases of enophthalmos greater than 2 mm. In two patients, minor infection occurred at the region of the skin stab, which was treated conservatively. Scar revision was then performed after the screw was removed. Other major complications such as trigeminal nerve injury, scleral show, sinusitis, diplopia, and distinct enophthalmos did not occur.
DISCUSSION To achieve good results in the treatment of zygomatic fractures, soft-tissue consideration is as important as perfect bony work.4,7 Our closed reduction and internal fixation method has the following advantages: soft-tissue damage is avoided, such as postoperative ectropion of the lower eyelid; it maintains the bone healing potential by preserving the periosteum of the fractured site; and it reduces postoperative pain and swelling while maintaining enough rigidity to keep the acquired reduction. Presently, open reduction and internal plate fixation is still the most commonly used procedure for zygoma fractures, and surgeons who prefer open reduction and internal plate fixation avoid closed reduction mainly for three presumed reasons: (1) “compared with open reduction, closed reduction is inaccurate”; (2) “despite using transmalar pinning after a closed reduction, the rigidity of the zygoma bone will weaken and relapse will easily occur without plate fixation”; and (3) “the orbital floor should be checked under direct vision intraoperatively because bony defect may occur after the reduction and it should be reconstructed to prevent ocular problems.” Is Closed Reduction Inferior to Open Reduction? Generally, the closed method is considered inferior to the open method with regard to the accuracy of the reduction.8–10 In fact, there were six cases of imperfect reduction (14.3 percent) in our series, which occurred because of insufficient intraoperative reduction. However, the claim that closed reduction is inferior to open reduction has no supporting practical evidence. Ellis and Kittidumkerng11 investigated the accuracy of open reduction of zygoma fracture and reported that inadequate repositioning was observed in 11 percent of all cases. They concluded that achieving
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 3. Case 1. A 13-year-old male patient presented with a left zygoma fracture caused by a fall. (Above) Computed tomographic scans obtained before surgery. There was also a fracture in the orbital floor; however, no herniation of ocular contents or ocular problems were observed before the surgery. (Center) Computed tomographic scans obtained 12 weeks after surgery. The zygoma was well repositioned and the orbital floor was remodeled. (Below) Postoperative scar 5 months after the operation.
accurate reduction is not easy, even with open reduction, because the operative field is narrow and noncontiguous. They also insisted that the accuracy of the reduction depends mainly on the surgeon’s skill rather than on the surgical
approach. In addition, current improvements in imaging modalities such as multidetector computed tomography allow determination of the cause of dislocation of bone fragments preoperatively, which will help to achieve good repositioning
1235
Plastic and Reconstructive Surgery • November 2013
Fig. 4. Case 2. A 51-year-old woman presented with a right zygoma fracture caused by a fall. (Left and above, right) Preoperative appearance. (Below, right) Computed tomographic scan. The free fragment of the orbital rim and the comminuted fracture of the zygomaticomaxillary buttress can be seen.
even with the closed reduction approach. Currently, intraoperative three-dimensional imaging and examination of the reduction of the zygoma on multiplanar reconstruction images are the preferred methods (Fig. 7). The accuracy of closed reduction is likely to improve further in the future because of such advances in diagnostic imaging. How about the Rigidity of the Closed Reduction and Internal Fixation Method? Our results showed that the zygoma was stable in the vertical direction and significant relapse did not occur postoperatively. However, a significant relapse was observed in the posterior direction. Nevertheless, the mean posterior relapse was only 0.47 mm, which is not clinically important. We supposed that one of the reasons for the high stability of the closed reduction and internal fixation method was that the screw is rigid and firmly fixed at the hard palate. Generally, in closed reduction with transmalar fixation with a Kirschner wire, the supporting point is the contralateral zygoma so that the moment arm is long, in addition to the fact that the Kirschner wire is easily strained. Therefore, collapse and rotation
1236
of the zygoma body occur easily.8,9 Second, the cannulated cortical screw is fully threaded. It acts as a positional screw and maintains the distance between the insertion point in the zygoma and the hard palate. Lastly, we suppose that our inclusion criteria, which restricted the selection to cases in which there was no shearing in the zygomatic frontal portion, play an important role. This area is surrounded by rigid soft-tissue structures such as the temporal muscle, temporal fascia, periosteum, and periorbita.12 Therefore, in patients with an intact zygomatic frontal portion, the reduction had high stability, especially in the vertical direction. Fujioka et al.3 analyzed the stability of oneplate fixation in the zygomaticomaxillary buttress for simple zygomatic fractures and reported its availability. Although their measurement methods were different from ours and we could not perform a simple comparison, the postoperative posterior relapse of their study was almost similar to ours. Concerning inferior relapse, the stability of our closed reduction and internal fixation method was superior to that of their method. In addition, we included unstable fracture cases (five
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 5. Case 2. Postoperative appearance and computed tomographic scan obtained 15 weeks after surgery. The zygoma was well repositioned and the “eggshell membrane phenomenon” could be seen at the free fragment of the orbital rim and the comminuted fracture of the zygomaticomaxillary buttress.
in the latter 33 cases) in which there was a large free segment in the orbital rim or a comminuted fracture of the zygomaticomaxillary buttress, and these were excluded from their criteria. Therefore, we can conclude that the closed reduction and internal fixation method has a high rigidity that is at least equal to or greater than that of the one-plate fixation method. In the closed reduction and internal fixation method, the blood circulation of the bone fragment is well maintained because the periosteum is completely preserved, which might promote early bone union. These features may also contribute to the maintenance of the acquired repositioning.7,13,14 How Do the Orbital Floor and the Free Fragment Change after Closed Reduction? How does the orbital floor change after closed reduction of a zygoma fracture? Ellis and Reddy15 investigated the orbital floor changes by using computed tomographic scans in zygomatic fracture cases with no intraoperative dissection of the orbital floor. They concluded that when there is no (or minimal) soft-tissue herniation and minimal disruption of the internal orbit on
preoperative computed tomography, zygoma reduction alone without orbit investigation is an adequate treatment. Also in our series, no cases of ocular problems such as diplopia or conspicuous enophthalmos occurred postoperatively. Therefore, we think that our inclusion criteria for the closed reduction and internal fixation method, which excluded cases with ocular problems such as diplopia and apparent herniation of orbital contents into the maxillary sinus on preoperative multidetector computed tomography, are adequate for the closed reduction approach. On retracting the preserved and continuous periosteum by reduction of the zygoma, the fragment of orbital floor was seen to be well repositioned. This can be likened to the relation of the shell and the shell membrane of a boiled egg. This “eggshell membrane phenomenon” will not be maintained if the periosteum of the orbital floor is removed from the bone segments—likened to the removal of the shell membrane from a boiled eggshell. Unnecessary dissection of the orbital floor will require reconstruction of the orbital floor. This eggshell membrane phenomenon could also be seen in other regions such as at the free orbital
1237
Plastic and Reconstructive Surgery • November 2013
Fig. 6. Computed tomographic scans of the right orbit showing the changes in the orbital floor. A comminuted fracture of the orbital wall existed just after surgery. However, it was gradually remodeled (left, just after the operation; right, 12 weeks after the operation).
rim fragment and the comminuted fracture of the zygomaticomaxillary buttress (Figs. 4 through 6). Future Tasks for the Closed Reduction and Internal Fixation Method As mentioned above, the closed reduction and internal fixation concept and method have many advantages for the treatment of simple zygoma fracture. However, some practical issues remain. We believe that the most important problem concerns the screw specifications. Basically, the screw described here is used for long (e.g., lower extremity) bone fractures and might be too large for zygoma fractures. The diameter of the
screw head is 5.5 mm, so at least a 4-mm skin stab is necessary, which could sometimes result in a visible scar. In addition, this type of screw is available in 2-mm increments when less than 50 mm in total length; however, screws greater than 50 mm are available in 5-mm increments. Generally, a 46- to 55-mm screw was often used in the closed reduction and internal fixation method, so that sometimes the choice of screw was limited. In the two cases where infection occurred, the screw was too long and the tip extended into the oral cavity. The infection occurred in tissues around the screw head through the screw cannula retrogradely. Therefore, it is preferable to
Table 1. Postoperative Relapse (n = 33) Direction of Relapse
Mean ± SD
Range
p
Inferior relapse: Xt2 − Xt1′ (mm) Posterior relapse: Yt1′ − Yt2 (mm)
–0.12 ± 0.72 0.47 ± 0.59
–1.90–0.94 –1.32–1.77
0.84 8 wk after surgery.
1238
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 7. Intraoperative multiplanar reconstruction image (ARCADIS Orbic 3D; Siemens AG, Munich, Germany).
have a specially developed screw system in the practical use of the closed reduction and internal fixation method.
PATIENT CONSENT
Patients provided written consent for the use of their images.
CONCLUSIONS
REFERENCES
The closed reduction and internal fixation method, based on the closed reduction and internal fixation concept, is still an incomplete procedure and has room for improvement. However, it has many advantages, such as its short operative time, short downtime, few soft-tissue problems, and preservation of the bone healing potential with sufficient rigidity. We think this new closed reduction and internal fixation method has the potential to become a useful alternative for the treatment of simple zygoma fractures.
1. Tarabichi M. Transsinus reduction and one-point fixation of malar fractures. Arch Otolaryngol Head Neck Surg. 1994;120:620–625. 2. Manson PN. Transcutaneous reduction and external fixation for the treatment of noncomminuted zygoma fractures: Discussion. Oral Maxillofac Surg. 1998;56:1387–1389. 3. Fujioka M, Yamanoto T, Miyazato O, Nishimura G. Stability of one-plate fixation for zygomatic bone fracture. Plast Reconstr Surg. 2002;109:817–818. 4. Yaremchuk MJ. Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures: Discussion. Plast Reconstr. Surg. 2005;115:1855–1857. 5. Yonehara Y, Hirabayashi S, Tachi M, Ishii H. Treatment of zygomatic fractures without inferior orbital rim fixation. J Craniofac Surg. 2005;16:481–485. 6. Soejima K, Sakurai H, Nozaki M, et al. Semi-closed reduction of tripod fractures of zygoma under intraoperative assessment using ultrasonography. J Plast Reconstr Aesthet Surg. 2009;62:499–505.
Hirokazu Uda, M.D. Department of Plastic Surgery Jichi Medical University 3311-1 Yakushiji Shimotuke, Tochigi 329-0498, Japan [email protected]
1239
Plastic and Reconstructive Surgery • November 2013 7. Bezuhly M, Lalonde J, Alqahtani M, Sparkes G, Lalonde DH. Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: Longterm quantitative outcomes. Plast Reconstr Surg. 2008;121: 948–955. 8. Rohrich RJ, Hollier LH, Watumull D. Optimizing the management of orbitozygomatic fractures. Clin Plast Surg. 1992;19:149–165. 9. Czerwinski M, Martin M, Lee C. Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures. Plast Reconstr Surg. 2005;115:1848–1854; discussion 1855. 10. Tajima T. Malar bone fracture. In: Treatment of Facial Fracture. 2nd ed. Tokyo: Kokuseido; 1999:110–142.
11. Ellis E III, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 1996;54:386–400; discussion 400. 12. Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremchuk M. Toward CT-based facial fracture treatment. Plast Reconstr Surg. 1990;85:202–212; discussion 213. 13. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: A review of 1,025 cases. J Oral Maxillofac Surg. 1992;50:778–790. 14. Kim YO. Transcutaneous reduction and external fixation for the treatment of noncomminuted zygoma fractures. J Oral Maxillofac Surg. 1998;56:1382–1387; discussion 1387. 15. Ellis E III, Reddy L. Status of the internal orbit after reduction of zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 2004;62:275–283.
FILLER-058
Plastic Surgery Level of Evidence Rating Scale—Therapeutic Studies
Level of Evidence I II III IV V
Qualifying Studies Highest-quality, multicentered or single-centered, randomized controlled trial with adequate power; or systematic review of these studies High-quality, randomized controlled trial; prospective cohort or comparative study; or systematic review of these studies Retrospective cohort or comparative study; case-control study; or systematic review of these studies Case series with pre/post test; or only post test Expert opinion developed via consensus process; case report or clinical example; or evidence based on physiology, bench research, or “first principles”
Find out more from the “Evidence-Based Medicine: How-to Articles” Collection at www.PRSJournal.com
1240
M.D. M.D. M.D. M.D. M.D.
Shimotuke, Tochigi, Japan
Background: The authors have developed a new minimally invasive surgical procedure for simple zygoma fractures, a closed reduction and internal fixation method, that uses a cannulated cortical screw system. Methods: From 2007 to 2012, 42 selected patients with simple zygoma fractures without ocular problems or shear at the zygomatic frontal portion were treated with this method. The mean age of the patients was 33 years (range, 13 to 77 years). Results: The authors achieved good repositioning, equivalent to results achieved with conventional procedures in all cases. No notable complication occurred except for minor infection in two cases. Mean operative time was 32 minutes (range, 19 to 58 minutes). Postoperative relapse was found only in the posterior direction (p < 0.001), but the distance of that was so small (mean, 0.47 mm) that it did not cause any problem clinically. Conclusions: Although further improvement might be needed, such as screw specification, the closed reduction and internal fixation method has many advantages: short operative time, less effect on soft tissue, maintenance of bone healing potential, and decreased postoperative pain and swelling. The authors concluded that this method has the potential to become a future surgical procedure for simple zygoma fractures. (Plast. Reconstr. Surg. 132: 1231, 2013.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
C
urrently, less invasive methods for the treatment of simple zygoma fractures have become available. The number of plate fixations is reduced according to the degree of dislocation and the presence of ocular problems (e.g., diplopia) and, sometimes, closed reduction with or without a Kirschner wire is performed.1–7 These approaches aim to avoid unnecessary invasion of soft tissue and avoid adverse effects such as postoperative ectropion of the lower eyelid and persistent swelling. However, a procedural dilemma also exists, which involves decreasing the number of plates or omitting rigid fixation with plates that may increase the risk of postoperative relapse. When considering the treatment of zygoma fractures, achieving anatomical repositioning by using only the closed approach and From the Department of Plastic Surgery, Jichi Medical University. Received for publication April 8, 2013; accepted May 8, 2013. Copyright © 2013 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3182a48d8c
applying rigid internal fixation may be ideal. We have developed a minimally invasive surgical procedure based on the closed reduction and internal fixation concept. In this study, we introduce the surgical technique of the closed reduction and internal fixation method and assess its efficacy, safety, and outcome. Furthermore, we investigate the potential problems associated with the use of this method. Disclosure: None of the authors has a financial interest in companies producing or distributing products used for this study.
Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com).
www.PRSJournal.com
1231
Plastic and Reconstructive Surgery • November 2013 PATIENTS AND METHODS Thirty-six patients with simple zygoma fractures between 2007 and 2012 were included in this study. We have previously established the inclusion criteria of our closed reduction and internal fixation method as follows: patients should have no ocular problems such as diplopia and apparent herniation of orbital contents into the maxillary sinus on preoperative multidetector computed tomography, and there should be no shearing in the zygomatic frontal portion. Surgical Procedure Thirty-eight of the patients were operated on under general anesthesia. In the remaining four patients, the dislocation of the zygoma was minimal, and surgery was performed under local anesthesia. (See Video, Supplemental Digital Content 1, which displays the closed reduction and internal fixation procedure, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links. lww.com/PRS/A876.) First, a small (4 mm) skin stab incision was made 2 cm lateral from the lateral canthus at the level of the infraorbital rim. A Carroll-Girard screw was then used for reduction through this stab. Repositioning was confirmed by palpation of the continuity of the infraorbital rim and the frontozygomatic suture, and by inspection of the projection of the malar eminence. In later cases, especially when swelling was severe and confirmation of reduction was difficult, we used three-dimensional imaging (ARCADIS Orbic 3D;
Video 1. Supplemental Digital Content 1 displays the closed reduction and internal fixation procedure, http://links.lww. com/PRS/A876.
1232
Siemens AG, Munich, Germany) intraoperatively to check for reduction of the zygoma. If the reduction was insufficient, we sometimes performed Gillies elevation and reduction through a temporal incision. To maintain repositioning, temporary percutaneous transmalar fixation was generally performed using a 2.0-mm Kirschner wire. This transmalar fixation was occasionally omitted when the zygoma was stable after reduction. We then inserted a 3.5-mm cannulated cortical screw (TiMAX 3.5/4.5 mm Cannulated Screw System; DePuy Orthopaedics Inc., Warsaw, Ind.) through the skin stab (Fig. 1). First, an originally developed guide device (CRIF bow; Keisei Medical Industrial Co., Ltd., Tokyo, Japan), a 1.5-mm Kirschner wire that served as the guide wire, was inserted through the skin stab from the malar prominence to the edge of the roof of the hard palate between the first and second molars. The insertion of the Kirschner wire was stopped just after its tip passed through the hard palate. This procedure must be performed carefully so that the insertion of the Kirschner wire does not extend into the oral cavity (Fig. 1). By using a depth gauge, the inserted length of the Kirschner wire was then measured and the proper screw length was determined. Using the Kirschner wire as a guide, the zygoma and hard palate were drilled and tapped with a dedicated system. The screw was then inserted through the Kirschner wire and tightened using a cannulated driver (Fig. 1). Before fully inserting and tightening the screw, proper repositioning of the zygoma should be reconfirmed. A full thread screw was used, which acted as a positional screw. Therefore, the distance between the zygoma and the hard palate was maintained properly. Finally, the skin stab was sutured at the end of the procedure. The screw was removed approximately 3 months after surgery through a skin stab, under local anesthesia in an outpatient setting. Postoperative Assessment All patients underwent multidetector computed tomography before surgery (t1) and greater than 8 weeks after surgery (t2), and the repositioning of the zygoma and the changes in the orbital floor were assessed. In the latter 27 cases, we also performed multidetector computed tomography just after the operation (t1′). We expected a relapse in the early postsurgery period. Therefore, considering the effect of the masseter muscle, we assessed the inferior and posterior relapse by comparing the t1′ and t2 multidetector computed tomography scans in the latter 33
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 1. The closed reduction and internal fixation method. (Above) A 3.5-mm full-thread cannulated cortical screw. (Below, left) Using a guide device, a 1.5-mm Kirschner wire is inserted accurately. (Below, right) A screw of proper length is inserted through the Kirschner wire (the inserted length of the Kirschner wire is equal to the length of the screw).
cases. Five of the six patients with a large free segment of the orbital rim or a comminuted fracture of the zygomaticomaxillary buttress were included in these latter 33 cases. Using multidetector computed tomography, we defined distance X as the distance from the
axial plane at the height of the cribriform plate to the center of the screw head, and distance Y as the distance from the coronal plane at the posterior walls of the maxillary sinuses to the center of the screw head (Fig. 2). We then estimated the inferior relapse by using the formula Xt2 (X at t2)
Fig. 2. (Left) The distance from the axial plane at the height of the cribriform plate to the center of the screw head (X). (Right) The distance from the coronal plane at the posterior walls of the maxillary sinuses to the center of the screw head (Y).
1233
Plastic and Reconstructive Surgery • November 2013 – Xt1 (X at t1′) and the posterior relapse by the formula Yt1 (Y at t1′) – Yt2 (Y at t2). These were measured on the monitor of the picture archiving and communication system (Synapse PACS; Fuji film Medical Co., Ltd., Tokyo, Japan), and the t test was used to assess the statistical change of these distances. A value of p < 0.001 was considered to represent a significant difference. The ocular position was measured with a Hertel exophthalmometer just before screw removal, and the existence of an enophthalmos was assessed. Postoperative complications were also recorded in each case.
RESULTS The mean age of the patients was 33 years (range, 13 to 77 years), and there were 33 men and nine women. The affected side was the right side in 16 patients and the left side in 26 patients. The causes of the injuries were physical assault in 16 patients, fall in 12, sports accident in nine, and car accident in five patients. In six of the 42 patients (14.3 percent), the dislocation of the zygoma was severe and a large free segment of the orbital rim or a comminuted fracture of the zygomaticomaxillary buttress was found. All patients were operated on by a single surgeon (H.U.). The mean operative time was 32 minutes (range, 19 to 58 minutes). The length of the screw used ranged from 42 to 60 mm. Representative examples are shown in Figures 3 through 6. In the postoperative assessment of reduction, the fractures were considered perfectly reduced in 36 patients (85.7 percent). In the other six patients (14.3 percent), there was some imperfection in the reduction. In those six “imperfect” cases, three had some residual medial rotation at the sphenozygomatic suture region, two had some posterior displacement at the sphenozygomatic suture region, and one had both of the above imperfections. Concerning relapse, the mean inferior movement of the zygoma was −0.12 mm (range, −1.9 to 0.94 mm) after the operation, and no significant relapse was found (p = 0.84). In contrast, the mean posterior movement of the zygoma was 0.47 mm (range, −1.32 to 1.77) and a significant relapse existed (p < 0.01); however, it was minimal (Table 1). From the postoperative radiographic findings, no newly developed defects of the orbital floor or herniation of ocular contents into the maxillary sinus was seen in any of the 42 patients. In almost all patients, the orbital floor was restored, as the zygoma was repositioned to the anatomical position and was properly remodeled (Figs. 3
1234
through 6). In cases in which the zygoma was medially impacted before surgery, the orbital floor drooped slightly following surgery. However, no ocular problems occurred and there were no cases of enophthalmos greater than 2 mm. In two patients, minor infection occurred at the region of the skin stab, which was treated conservatively. Scar revision was then performed after the screw was removed. Other major complications such as trigeminal nerve injury, scleral show, sinusitis, diplopia, and distinct enophthalmos did not occur.
DISCUSSION To achieve good results in the treatment of zygomatic fractures, soft-tissue consideration is as important as perfect bony work.4,7 Our closed reduction and internal fixation method has the following advantages: soft-tissue damage is avoided, such as postoperative ectropion of the lower eyelid; it maintains the bone healing potential by preserving the periosteum of the fractured site; and it reduces postoperative pain and swelling while maintaining enough rigidity to keep the acquired reduction. Presently, open reduction and internal plate fixation is still the most commonly used procedure for zygoma fractures, and surgeons who prefer open reduction and internal plate fixation avoid closed reduction mainly for three presumed reasons: (1) “compared with open reduction, closed reduction is inaccurate”; (2) “despite using transmalar pinning after a closed reduction, the rigidity of the zygoma bone will weaken and relapse will easily occur without plate fixation”; and (3) “the orbital floor should be checked under direct vision intraoperatively because bony defect may occur after the reduction and it should be reconstructed to prevent ocular problems.” Is Closed Reduction Inferior to Open Reduction? Generally, the closed method is considered inferior to the open method with regard to the accuracy of the reduction.8–10 In fact, there were six cases of imperfect reduction (14.3 percent) in our series, which occurred because of insufficient intraoperative reduction. However, the claim that closed reduction is inferior to open reduction has no supporting practical evidence. Ellis and Kittidumkerng11 investigated the accuracy of open reduction of zygoma fracture and reported that inadequate repositioning was observed in 11 percent of all cases. They concluded that achieving
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 3. Case 1. A 13-year-old male patient presented with a left zygoma fracture caused by a fall. (Above) Computed tomographic scans obtained before surgery. There was also a fracture in the orbital floor; however, no herniation of ocular contents or ocular problems were observed before the surgery. (Center) Computed tomographic scans obtained 12 weeks after surgery. The zygoma was well repositioned and the orbital floor was remodeled. (Below) Postoperative scar 5 months after the operation.
accurate reduction is not easy, even with open reduction, because the operative field is narrow and noncontiguous. They also insisted that the accuracy of the reduction depends mainly on the surgeon’s skill rather than on the surgical
approach. In addition, current improvements in imaging modalities such as multidetector computed tomography allow determination of the cause of dislocation of bone fragments preoperatively, which will help to achieve good repositioning
1235
Plastic and Reconstructive Surgery • November 2013
Fig. 4. Case 2. A 51-year-old woman presented with a right zygoma fracture caused by a fall. (Left and above, right) Preoperative appearance. (Below, right) Computed tomographic scan. The free fragment of the orbital rim and the comminuted fracture of the zygomaticomaxillary buttress can be seen.
even with the closed reduction approach. Currently, intraoperative three-dimensional imaging and examination of the reduction of the zygoma on multiplanar reconstruction images are the preferred methods (Fig. 7). The accuracy of closed reduction is likely to improve further in the future because of such advances in diagnostic imaging. How about the Rigidity of the Closed Reduction and Internal Fixation Method? Our results showed that the zygoma was stable in the vertical direction and significant relapse did not occur postoperatively. However, a significant relapse was observed in the posterior direction. Nevertheless, the mean posterior relapse was only 0.47 mm, which is not clinically important. We supposed that one of the reasons for the high stability of the closed reduction and internal fixation method was that the screw is rigid and firmly fixed at the hard palate. Generally, in closed reduction with transmalar fixation with a Kirschner wire, the supporting point is the contralateral zygoma so that the moment arm is long, in addition to the fact that the Kirschner wire is easily strained. Therefore, collapse and rotation
1236
of the zygoma body occur easily.8,9 Second, the cannulated cortical screw is fully threaded. It acts as a positional screw and maintains the distance between the insertion point in the zygoma and the hard palate. Lastly, we suppose that our inclusion criteria, which restricted the selection to cases in which there was no shearing in the zygomatic frontal portion, play an important role. This area is surrounded by rigid soft-tissue structures such as the temporal muscle, temporal fascia, periosteum, and periorbita.12 Therefore, in patients with an intact zygomatic frontal portion, the reduction had high stability, especially in the vertical direction. Fujioka et al.3 analyzed the stability of oneplate fixation in the zygomaticomaxillary buttress for simple zygomatic fractures and reported its availability. Although their measurement methods were different from ours and we could not perform a simple comparison, the postoperative posterior relapse of their study was almost similar to ours. Concerning inferior relapse, the stability of our closed reduction and internal fixation method was superior to that of their method. In addition, we included unstable fracture cases (five
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 5. Case 2. Postoperative appearance and computed tomographic scan obtained 15 weeks after surgery. The zygoma was well repositioned and the “eggshell membrane phenomenon” could be seen at the free fragment of the orbital rim and the comminuted fracture of the zygomaticomaxillary buttress.
in the latter 33 cases) in which there was a large free segment in the orbital rim or a comminuted fracture of the zygomaticomaxillary buttress, and these were excluded from their criteria. Therefore, we can conclude that the closed reduction and internal fixation method has a high rigidity that is at least equal to or greater than that of the one-plate fixation method. In the closed reduction and internal fixation method, the blood circulation of the bone fragment is well maintained because the periosteum is completely preserved, which might promote early bone union. These features may also contribute to the maintenance of the acquired repositioning.7,13,14 How Do the Orbital Floor and the Free Fragment Change after Closed Reduction? How does the orbital floor change after closed reduction of a zygoma fracture? Ellis and Reddy15 investigated the orbital floor changes by using computed tomographic scans in zygomatic fracture cases with no intraoperative dissection of the orbital floor. They concluded that when there is no (or minimal) soft-tissue herniation and minimal disruption of the internal orbit on
preoperative computed tomography, zygoma reduction alone without orbit investigation is an adequate treatment. Also in our series, no cases of ocular problems such as diplopia or conspicuous enophthalmos occurred postoperatively. Therefore, we think that our inclusion criteria for the closed reduction and internal fixation method, which excluded cases with ocular problems such as diplopia and apparent herniation of orbital contents into the maxillary sinus on preoperative multidetector computed tomography, are adequate for the closed reduction approach. On retracting the preserved and continuous periosteum by reduction of the zygoma, the fragment of orbital floor was seen to be well repositioned. This can be likened to the relation of the shell and the shell membrane of a boiled egg. This “eggshell membrane phenomenon” will not be maintained if the periosteum of the orbital floor is removed from the bone segments—likened to the removal of the shell membrane from a boiled eggshell. Unnecessary dissection of the orbital floor will require reconstruction of the orbital floor. This eggshell membrane phenomenon could also be seen in other regions such as at the free orbital
1237
Plastic and Reconstructive Surgery • November 2013
Fig. 6. Computed tomographic scans of the right orbit showing the changes in the orbital floor. A comminuted fracture of the orbital wall existed just after surgery. However, it was gradually remodeled (left, just after the operation; right, 12 weeks after the operation).
rim fragment and the comminuted fracture of the zygomaticomaxillary buttress (Figs. 4 through 6). Future Tasks for the Closed Reduction and Internal Fixation Method As mentioned above, the closed reduction and internal fixation concept and method have many advantages for the treatment of simple zygoma fracture. However, some practical issues remain. We believe that the most important problem concerns the screw specifications. Basically, the screw described here is used for long (e.g., lower extremity) bone fractures and might be too large for zygoma fractures. The diameter of the
screw head is 5.5 mm, so at least a 4-mm skin stab is necessary, which could sometimes result in a visible scar. In addition, this type of screw is available in 2-mm increments when less than 50 mm in total length; however, screws greater than 50 mm are available in 5-mm increments. Generally, a 46- to 55-mm screw was often used in the closed reduction and internal fixation method, so that sometimes the choice of screw was limited. In the two cases where infection occurred, the screw was too long and the tip extended into the oral cavity. The infection occurred in tissues around the screw head through the screw cannula retrogradely. Therefore, it is preferable to
Table 1. Postoperative Relapse (n = 33) Direction of Relapse
Mean ± SD
Range
p
Inferior relapse: Xt2 − Xt1′ (mm) Posterior relapse: Yt1′ − Yt2 (mm)
–0.12 ± 0.72 0.47 ± 0.59
–1.90–0.94 –1.32–1.77
0.84 8 wk after surgery.
1238
Volume 132, Number 5 • Repair of Simple Zygoma Fractures
Fig. 7. Intraoperative multiplanar reconstruction image (ARCADIS Orbic 3D; Siemens AG, Munich, Germany).
have a specially developed screw system in the practical use of the closed reduction and internal fixation method.
PATIENT CONSENT
Patients provided written consent for the use of their images.
CONCLUSIONS
REFERENCES
The closed reduction and internal fixation method, based on the closed reduction and internal fixation concept, is still an incomplete procedure and has room for improvement. However, it has many advantages, such as its short operative time, short downtime, few soft-tissue problems, and preservation of the bone healing potential with sufficient rigidity. We think this new closed reduction and internal fixation method has the potential to become a useful alternative for the treatment of simple zygoma fractures.
1. Tarabichi M. Transsinus reduction and one-point fixation of malar fractures. Arch Otolaryngol Head Neck Surg. 1994;120:620–625. 2. Manson PN. Transcutaneous reduction and external fixation for the treatment of noncomminuted zygoma fractures: Discussion. Oral Maxillofac Surg. 1998;56:1387–1389. 3. Fujioka M, Yamanoto T, Miyazato O, Nishimura G. Stability of one-plate fixation for zygomatic bone fracture. Plast Reconstr Surg. 2002;109:817–818. 4. Yaremchuk MJ. Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures: Discussion. Plast Reconstr. Surg. 2005;115:1855–1857. 5. Yonehara Y, Hirabayashi S, Tachi M, Ishii H. Treatment of zygomatic fractures without inferior orbital rim fixation. J Craniofac Surg. 2005;16:481–485. 6. Soejima K, Sakurai H, Nozaki M, et al. Semi-closed reduction of tripod fractures of zygoma under intraoperative assessment using ultrasonography. J Plast Reconstr Aesthet Surg. 2009;62:499–505.
Hirokazu Uda, M.D. Department of Plastic Surgery Jichi Medical University 3311-1 Yakushiji Shimotuke, Tochigi 329-0498, Japan [email protected]
1239
Plastic and Reconstructive Surgery • November 2013 7. Bezuhly M, Lalonde J, Alqahtani M, Sparkes G, Lalonde DH. Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: Longterm quantitative outcomes. Plast Reconstr Surg. 2008;121: 948–955. 8. Rohrich RJ, Hollier LH, Watumull D. Optimizing the management of orbitozygomatic fractures. Clin Plast Surg. 1992;19:149–165. 9. Czerwinski M, Martin M, Lee C. Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures. Plast Reconstr Surg. 2005;115:1848–1854; discussion 1855. 10. Tajima T. Malar bone fracture. In: Treatment of Facial Fracture. 2nd ed. Tokyo: Kokuseido; 1999:110–142.
11. Ellis E III, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 1996;54:386–400; discussion 400. 12. Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremchuk M. Toward CT-based facial fracture treatment. Plast Reconstr Surg. 1990;85:202–212; discussion 213. 13. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic fractures: A review of 1,025 cases. J Oral Maxillofac Surg. 1992;50:778–790. 14. Kim YO. Transcutaneous reduction and external fixation for the treatment of noncomminuted zygoma fractures. J Oral Maxillofac Surg. 1998;56:1382–1387; discussion 1387. 15. Ellis E III, Reddy L. Status of the internal orbit after reduction of zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 2004;62:275–283.
FILLER-058
Plastic Surgery Level of Evidence Rating Scale—Therapeutic Studies
Level of Evidence I II III IV V
Qualifying Studies Highest-quality, multicentered or single-centered, randomized controlled trial with adequate power; or systematic review of these studies High-quality, randomized controlled trial; prospective cohort or comparative study; or systematic review of these studies Retrospective cohort or comparative study; case-control study; or systematic review of these studies Case series with pre/post test; or only post test Expert opinion developed via consensus process; case report or clinical example; or evidence based on physiology, bench research, or “first principles”
Find out more from the “Evidence-Based Medicine: How-to Articles” Collection at www.PRSJournal.com
1240
