HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Reprinted by permission of Ann Plast Surg. 2019; 83(1):43-47.

H EAD AND N ECK S URGERY

Clinical Utility of Postoperative Computed Tomography Imaging in Orbital Floor Fracture Management Ajay N. Sharma, BS,* Ekaterina Tiourin, BS,* Derek A. Banyard, MD, MBA, MS, † Shonit N. Sharma, BS, ‡ and Wendy K. Y. Ng, MD, FRCSC †

At our institution, University of California, Irvine (UC Irvine), surgeons routinely order postoperative CT scan images for patients who sustain orbital floor fractures through trauma. Although the utility of these images for diagnosis and assessment of fracture severity has been well established, their role as a postoperative tool in medical man- agement remains unclear. 4 – 6 The goals of orbital fracture repair are to improve visual function and appearance. Incorrectly reduced orbital fractures are often detected quickly and reliably through clinical physi- cal findings such as diplopia, extraocular muscle restriction, and enophthalmos. Prior to our investigation, whether postoperative imag- ing provided an additional benefit to the management of orbital floor fracture repairs remained unknown. In this study, we analyzed 217 patients who underwent orbital floor fracture repairs to assess the clinical utility and cost-benefit of postoperative CT scans. stitutional review board at the UC Irvine (HS# 2017-3989). The authors have no conflicts of interest to declare. A retrospective chart review was conducted to identify cases of repaired orbital floor fractures performed at UC Irvine. At our institution, typical indications for orbital fracture repair were ( a ) enophthalmos or hypoglobus greater than 2 mm com- pared with the contralateral side, within the first 6 weeks after injury; ( b ) ocular entrapment; ( c ) significant fracture, defined as greater than 1 cm 2 or greater than 50% of the orbital floor; ( d ) persistent diplopia in primary visual fields 2 weeks after injury; and ( e ) blow in fractures severely constricting orbital volume. Three different surgical approaches were considered: transantral, periorbital, or a combined approach. These surgeries were encompassed by 4 different Current Procedural Terminology (CPT) codes: 21385, 21386, 21387, and 21390. Our search, which covered the 10 years of January 2008 to January 2018, captured the records of 234 patients eligible for inclu- sion in our analysis. Seventeen patients were excluded because of insuf- ficient reporting available in the archived medical records (eg, unknown mechanism of injury, surgical approach, surgical outcome), transfer of the patient to a different medical center, or if the original fracture repair was performed at an outside institution. Injury characteristics along with presurgical and postsurgical management details were carefully reviewed from each of the 217 patient charts via progress notes, discharge summa- ries, operative reports, radiology reports, and consultation letters. Extracted information included patient age, race, mechanism of injury, type of fracture, size of orbital floor defect, type of preoperative imaging done, operating surgeon, surgical approach, surgical materials used to repair orbital defect, concomitant facial injuries, number of post- operative CT scan(s) ordered, reason for postoperative CT scan, postop- erative CT scan final reads, number of postoperative follow-up physical examinations, physical examination findings, specific change in care af- ter postoperative CT scan, additional imaging, surgery complications, need for reoperation, and length of hospital stay. Patients were first categorized into 2 groups (with imaging and without imaging) and then further subclassified into those with postop- erative CT scans and those with alternative forms of imaging. Among those who received postoperative CT scans with or without alternative METHODS The protocol for this study was reviewed and approved by the in-

Background: Surgical repair of orbital floor fractures aims to improve visual function and appearance. Postoperative care often involves computed tomography (CT) imaging in addition to physical examination. It has yet to be investigated whether postoperative CT imaging influences treatment of orbital floor fractures. Methods: A retrospective chart review was conducted for all patients who underwent orbital floor fracture repair at University of California, Irvine, from 2008 to 2017. Demographics, injury characteristics, and presurgical and postsurgical management were retrospectively extracted for 217 cases. Patients who experienced a change of care following postoperative CT (n = 6) were compared with the entire patient cohort. Results: Postoperative CT imaging influenced orbital floor fracture management in 6 patients (7.2% of patients with imaging). The positive predictive value of a postoperative CT scan was 10.3%, compared with 17.6% for a physical examination. An estimated $2013.76 was spent to obtain a postoperative CT scan that revealed 1 additional patient who needed reoperation (number needed to treat = 14). Amultivar- iate regression model demonstrated no association between postoperative CT scans and change in management ( P = 0.995). Conclusions: In this patient cohort, postoperative CT imaging and its associated costs did not significantly benefit management of orbital floor fracture repair. Careful clinical physical examination should be emphasized over postoperative CT imaging to reliably determine the necessity for reoperation in orbital floor fracture management. Key Words: cost analysis, CT, CT scan, efficacy, postoperative, ophthalmology, orbit, orbital floor fracture, otolaryngology, plastic surgery, reconstruction, utility ( Ann Plast Surg 2019;83: 43 – 47) T he computed tomography (CT) scan is a revolutionary form of im- aging that provides clinicians an additional tool for diagnosis and management, but it is not without costs. Currently, more than 70 million CTexaminations are performed annually in the United States at a cost rang- ing from $100 to $500 per scan. 1 Additionally, radiation exposure from CT scans of the head is estimated to increase the lifetime risk of cancer by 0.07%. 2 Despite these considerations, CT remains a mainstay in surgical workup. The routine use of postoperative CT scans may partly be attributed to concerns that anesthesia and analgesia may mask underlying neurologi- cal and/or physical symptoms. 3 Moreover, procedures such as a postoper- ative CT scan may simply be routinely conducted in order to defend treatment plans against the potential for any future litigation. 3 With these considerations in mind, the frequency of postoperative imaging can be better understood. Received August 15, 2018, and accepted for publication, after revision October 26, 2018. From the *School of Medicine and † Department of Plastic Surgery, University of California, Irvine; and ‡ Department of Biomedical Engineering, University of California, Davis, CA. Conflicts of interest and sources of funding: none declared. Reprints: Wendy K. Y. Ng, MD, FRCSC, Department of Plastics Surgery, 200 S Manchester Ave, Suite 650, Orange, CA 92868. E-mail: wendykn@uci.edu. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal ’ s Web site (www.annalsplasticsurgery.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/19/8301 – 0043 DOI: 10.1097/SAP.0000000000001777

Annals of Plastic Surgery • Volume 83, Number 1, July 2019

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