2017-18 HSC Section 4 Green Book

Evidence-Based Facial Fracture Management

and extracranial compartments. Recent advances and new surgical techniques have permitted tradi- tional obliteration and cranialization techniques to be replaced by more conservative manage- ment. 39,40 These newer methods use endoscopic sinus surgery to preserve the frontal sinus and avoid complications. Given the low incidence of these injuries and an even lower rate of complica- tions, an evidence-based approach to determine if or when obliteration or cranialization is appropriate would take decades. Skull base fractures and other infrequent facial injuries point to some of the limitations inherent in relying on high-level evidence gained by ran- domized trials to answer important facial trauma questions. These relatively rare events may be bet- ter studied with other methods. Although the RCT is the preferred experimental design, significant obstacles limit reliance on these studies to determine the best practices for facial trauma. Injuries that occur infrequently and injuries that have many concurrent variables make RCTs impractical or impossible. Several other areas of medicine have developed expanded clinical regis- tries that allow auditing of clinical standards and quality assessments. 41,42 These registries com- bined with the electronic medical record can pro- vide a large amount of observational data. These data are used to supplement the conclusions drawn and allow researchers to identify topic areas for which a focused RCT is needed. Finally, registries also help overcome some of the short- falls of randomized trials by allowing accrual of clinical data at multiple sites prospectively. Because results from small RCTs are accentuated in meta-analysis, data from a heterogynous popu- lation help offset some of the problems encoun- tered for conditions that are so infrequent that a trial is not possible. There has been interest in es- tablishing registries for facial trauma. Several Eu- ropean trauma centers recently joined together and are prospectively compiling facial trauma de- mographic data. 43 This European Maxillofacial Trauma (EUMAT) project is attempting to combine resources to better identify future clinical and research priorities. Such efforts are certain to improve the quality of the facial trauma literature. FUTURE DIRECTIONS

and technique papers that focus on these frac- tures. The plating requirements for these injuries are still dictated by the experience of the treating surgeon. The goal of treatment of a ZMC fracture is to restore the bone to its preinjury location and main- tain orbital volume, thereby enhancing both the functional and cosmetic outcome. 37 There is debate about how much hardware is needed to accomplish this goal. Surgeons have observed that 3-point fixation of the ZMC (frontal-zygomatic suture, inferior orbital rim, and zygomaticomaxil- lary buttress) provides the greatest stability. How- ever, some surgeons contend that fixation with 2 plates (fronto-zygomatic suture and zygomatico- maxillary buttress), and even 1 plate, can be suffi- cient if properly applied. A limited surgery with less hardware can result in shorter operative times, lower costs, and fewer complications. Like nearly all other aspects of facial trauma, there is limited evidence to direct the surgeon in this matter. In the only randomized study of zygoma fractures, Rana and colleagues 38 compared 2-point internal fixation to 3-point internal fixation. In this study of 100 subjects undergoing zygoma fracture repair, better malar projection and less vertical dystopia was seen after 3-point fixation. They also deter- mined that the 3-point constructs were much more likely to be deemed stable. Based on these findings, the investigators recommended 3 points of fixation for all displaced ZMC fractures. Because this is the only study, additional work is needed to corroborate these results. Until then, clinical management will continue to be guided by surgeon experience. Frontal sinus and naso-orbital ethmoid fractures are among the most challenging in facial trauma. Given a lower overall incidence, the management of these fractures has not been investigated by clinical trials. Instead, the literature consists almost entirely of case series and case studies in which management continues to be debated. There are many proposed algorithms to treat these complex injuries and avoid potentially cata- strophic complications. There is no consensus for surgical indications, surgery timing, method of repair, or postoperative surveillance for frontal sinus fracture. The basic goal is creation of a safe sinus. Surgeons try to reestablish the frontal bony contour and maintain normal sinus function, which includes patent sinus outflow. When an injury makes assuring the patency of sinus outflow unlikely, it becomes necessary to eradicate the si- nus and create a barrier between the intracranial Skull Base Fractures

SUMMARY

There is limited higher level evidence available to surgeons treating facial trauma management. Although there have been improvements in the quality and level of evidence, it is still

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