Abstract
This retrospective cohort study examines the rates and outcomes of concomitant orbital floor fracture repair during zygomaticomaxillary complex fracture reduction.
Orbital floor (OF) fractures are, by definition, a component of zygomaticomaxillary complex (ZMC) fractures. The need for concurrent OF repair during ZMC repair remains a topic of discussion. Current evidence in the literature favors a more selective approach to exploring and repairing the OF during repair of ZMC fractures.1,2,3,4 Proponents of selective OF exploration advocate that precise ZMC reduction corrects orbital volume without the need for OF exploration in most concurrent ZMC and OF fractures. Unnecessary OF exploration increases potential morbidity and adds to costs. We sought to determine if surgeons’ operative trends in clinical practice paralleled recommendations in the literature regarding concomitant OF exploration and repair during ZMC fracture reduction.
Methods
The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) databases were used as a means to analyze current clinical practice trends. The ACS NSQIP databases were reviewed for the years 2010 through 2016. The 2012 Current Procedural Terminology (CPT) codes for ZMC fracture repair (21355, 21356, 21360, 21365, 21366) were queried. Within the ZMC fracture repair codes, we queried CPT codes (21385, 21386, 21387, 21390, 21395, 21400, 21401, 21406, 21407, 21408) for patients who also underwent OF repair. The relative rate of concomitant OF repair with ZMC fracture reduction was examined by operative year. Data were analyzed using SPSS statistical software, version 25 (IBM Corporation). Continuous variables are presented using the median and interquartile range, and comparisons were performed using Mann-Whitney tests. Categorical data were compared using χ2 and Fisher-exact tests. This study was deemed exempt by the institutional review board at the University of Kansas Medical Center, waiving patient written informed consent. This was deemed nonhuman research, and no protected health information or data were collected or analyzed.
Results
A total of 1396 patients who underwent ZMC repair were identified. Of those patients, 260 had a concomitant OF repair. Patient demographics, operative factors, and outcomes were compared (Table 1). Concomitant OF repair occurred with varying frequency among races and was more commonly performed for complex ZMC fractures, as defined by CPT code. White patients underwent OF repair more frequently than patients of other races, including African American patients (182 [71.7%] vs 32 [12.6%]; P < .001). Mean operative time was longer in those who underwent concomitant OF repair (145 vs 68 minutes; P < .001). Hospital length of stay and complications were similar between the groups. Relative OF repair rates for concomitant OF and ZMC fractures from 2010 through 2016 have remained constant (Table 2).
Table 1. Patient Demographics.
| Characteristic | ZMC Repair, No. (%) | P Value | |
|---|---|---|---|
| Without OF Repair (n = 988) | With OF Repair (n = 254) | ||
| Age, mean (range), y | 37 (27-50) | 38 (26-53) | .56 |
| Male sex | 783 (79.3) | 197 (77.6) | .51 |
| BMI, mean (range) | 24.4 (21.8-27.5) | 24.5 (22.1-27.6) | .19 |
| Race | |||
| White | 571 (57.8) | 182 (71.7) | <.001 |
| African American | 121 (12.2) | 32 (12.6) | |
| Other | 50 (5.1) | 8 (3.1) | |
| Unknown | 246 (24.9) | 32 (12.6) | |
| CPT code | |||
| 21355 | 32 (3.2) | 5 (2.0) | <.001 |
| 21356 | 369 (37.3) | 51 (20.1) | |
| 21360 | 117 (11.8) | 35 (13.8) | |
| 21365 | 460 (46.6) | 157 (61.8) | |
| 21366 | 10 (1.0) | 6 (2.4) | |
| Operative factors | |||
| Operative time (IQR), min | 68 (32-118) | 145 (100-205) | <.001 |
| Hospital LOS (IQR), d | 0 (0-1) | 1 (0-1) | <.001 |
| Outcomes | |||
| Any readmission | 17 (1.7) | 6 (2.4) | .44 |
| Reoperation | 12 (1.2) | 7 (2.8) | .09 |
| Mortality | 2 (0.2) | 0 | >.99 |
| Surgical site infection | |||
| Superficial | 8 (0.8) | 1 (0.4) | .70 |
| Deep | 0 | 0 | |
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CPT, current procedural terminology; IQR, interquartile range; LOS, length of stay; ZMC, zygomaticomaxillary complex.
Table 2. Zygomaticomaxillary Complex (ZMC) Fracture Repair Trends by Year.
| Repair Type | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | Total |
|---|---|---|---|---|---|---|---|---|
| ZMC | ||||||||
| All ZMC repair | 121 | 129 | 143 | 146 | 191 | 224 | 288 | 1396 |
| Without orbital floor repair | 96 | 107 | 113 | 123 | 153 | 173 | 223 | 1136 |
| With orbital floor repair | 25 | 22 | 30 | 23 | 38 | 51 | 65 | 260 |
| With orbital floor repair per ZMC without orbital floor repair, % | 26 | 21 | 27 | 19 | 25 | 30 | 29 | 23 |
Discussion
A growing body of literature supports observation alone for most OF fractures occurring with ZMC fractures. Selective computed tomography–based criteria have been described in order to assist with OF repair decision making.2 Wilde and colleagues4 demonstrated that only 2 of 19 (10%) concurrent ZMC and OF fractures required OF exploration and reduction based on intraoperative computed tomography findings after ZMC reduction alone. Of the 1396 patients in the present study who underwent ZMC reduction, 23% of these patients underwent concomitant OF repair. Despite evidence supporting increased OF observation, this study demonstrates that from 2010 through 2016, there was no correlating clinical practice decrease in the rate of OF repair.
We also identified a statistically significant race discrepancy regarding OF management. White patients underwent concomitant repair in 71.7% of cases while African American patients underwent repair in 12.6% of cases. Race inequalities have been specifically identified among trauma patients.5,6 This finding may be accounted for by mechanism of injury or hospital setting; however, the wide disparity between these groups suggests the need for further investigation.
The ACS-NSQIP database captures 32% of surgeries nationally and allows for a useful estimation of procedure frequency. Limitations of this methodology are inherent to cross-sectional analysis of national patient databases and have potential for selection bias. This study suggests discordance between clinical practice and current evidence for management of concomitant OF repair and ZMC fracture reduction. This discordance may be increasing cost of care and operative time, as well as putting patients at unnecessary risk for complications.
References
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