2017-18 HSC Section 4 Green Book

Doerr

and fracture location should be repaired. This re- view looked at 231 studies that included more than 15,000 subjects. It found that 94% of the pub- lications were retrospective studies describing a single institution’s experience or were noncon- trolled descriptions of a single treatment. The outcome measures were generally varied and sub- jective. Description of orbital fracture size and location were not clearly specified and many arti- cles did not discuss complications. The review was able to identify only 14 prospective trials totaling 380 orbital fractures. Among these 14 studies, just 5 were controlled clinical trials, 4 of which were randomized. There was significant het- erogeneity in the types and sizes of orbital frac- tures reported with only 1 randomized study describing both defect size and fracture location. Because of the small sample size of the studies and the poor descriptions of the fractures, the re- view could not draw any evidence-based conclu- sions for a defect-driven reconstruction. The question of what size and location of fractures require treatment remains unanswered in the literature. There are also varying opinions as to what mate- rial is best for orbital repair. Generally, the fracture size (area of the defect or the orbital volume change) is the key element in choosing an orbital implant. Although small defects can heal with scar, larger defects probably require more rigid support to maintain or restore orbital volume and avoid enophthalmos. However, there are few sug- gestions in the literature concerning orbital repair materials and clinical outcomes to help guide the surgeon treating these injuries. There has also been recent interest in incorporating preoperative planning and intraoperative imaging and naviga- tion into the management of orbital fracture repair. There are no prospective studies to determine if the benefits of these technologies warrant the increased cost. Until better evidence is available from the literature, surgeons will continue to rely on clinical experience and the available lower level studies to determine treatment. Injuries of the central third of the face are relatively common and include Le Fort type maxillary frac- tures and zygomatico-maxillary complex fractures (ZMC). The management of these fractures has evolved greatly during the past 3 decades because lower profile miniplates allowing stable fixation of precisely reduced fractures became available. There is virtually no higher level literature to guide the surgeon in treatment of these Le Fort fractures. There are only retrospective case series Midface Fractures

is optimal for repair of these fractures. There is some evidence gained through a meta-analysis of retrospective studies that eyelid complications are increased with subciliary approaches to the orbit compared with the transconjunctival approach. 34 There are certain orbital fractures for which the indication for prompt surgery is agreed. However, in most other instances the need for sur- gery is less clear. In deciding whether to repair an orbital fracture, the surgeon takes into account several factors, including vision, ocular motility, diplopia, and cosmesis. The clinician must decide which patients can safely be observed and re- paired later if is still necessary. Important in this process is deciding whether motility is reduced by mechanical entrapment, swelling, or contused ocular muscles. These factors can influence patient outcomes. In 2014, Dubois and colleagues 35 conducted a systematic review of the orbital trauma literature to identify any controlled clinical trials on posttrau- matic orbital reconstruction with a focus on the timing, or delay, of surgery. From this review, a to- tal of 17 studies with 1579 subjects with orbital in- juries were identified. This included a single RCT of 21 subjects that compared nasal septal and conchal cartilage for orbital blowout repair. That study found repair before 4 weeks had a positive effect on postoperative enophthalmos. However, the timing of surgery was not randomized and it was unclear what factors influenced earlier inter- ventions. In the only other prospective study, 24 subjects undergoing orbital fracture repair were followed for more than 6 months with no correla- tion between surgery timing and postoperative diplopia identified. With the prospective literature not sufficiently answering the question of timing, the investigators systematically examined retro- spective studies comparing surgical timing. Fifteen studies were found that reported on surgi- cal timing and various clinical outcomes. Of the 9 adult studies, 4 showed a significant positive effect on clinical outcomes (enophthalmos and ocular motility) with earlier surgery, whereas 5 others were inconclusive. In the pediatric orbital fracture studies, 1 showed a significant correlation between surgery within 3 weeks and diplopia long- term, whereas 5 others were not conclusive. The review showed that the available data were insufficient to provide guidelines for the timing of orbital repair. It concluded that the evidence for early posttraumatic repair was limited to low- level evidence. The investigators called for quality prospective studies to help answer the important clinical question of the timing of repair. In a companion systematic review, Dubois and colleagues 36 tried to identify which fracture size

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