Reoperation in Zygomatico-orbital Trauma: A Review of Patients With Suboptimal Outcomes Following Initial Repair

Abstract

Introduction:

Treatment to restore anatomy, function, and aesthetics after trauma should involve as little surgical insult as possible. As such, repeated procedures may suggest failed initial management. To date, no predictive factors for failure of primary surgery have been identified.

Objectives:

The aim of this review was to identify factors affecting the requirement for reoperation following treatment of zygomatico-orbital injuries.

Study Design and Methods:

A retrospective review of patients undergoing surgery for zygomatico-orbital fractures between 2011 and 2019 in a single UK major trauma center was undertaken. All operative notes and imaging were reviewed independently by 2 authors to classify the fracture patterns for both zygomatic and orbital components of the injury. For all cases, the mode of preoperative imaging the grade of operating surgeon, materials used for fixation, and the surgical approaches were recorded.

Results:

Coding data identified 432 patients who underwent surgery for zygomatico-orbital fractures. In total, 116 cases were treated with closed reduction and 316 with open reduction and internal fixation; 20 cases required reoperation. There were no significant differences identified between cases requiring reoperation and those who did not.

Conclusions:

A need for repeated surgery is rare. However, this review identified an increased risk of infection of fixation when an intraoral approach was used and highlights the potential benefits that can be achieved by open reduction and internal fixation when more conservative approaches fail to achieve the desired outcome.

Introduction

Adequate reduction of facial fractures should restore anatomy and avoid the requirement for further surgery. A need for reoperation after surgical treatment may suggest failure of initial management. Research on indications for reoperation is scarce and no predictive factors have been identified to date. Identification of factors that may increase the likelihood of need for reoperation or surgical difficulty could help to plan more effectively. We reviewed 8 years of zygomatico-orbital trauma, managed at a UK major trauma center to identify cases which required multiple operations in an attempt to identify themes and reoperative factors.

Methods

This retrospective project was registered with the hospital clinical effectiveness unit as a service evaluation and therefore ethical approval was not required. Clinical coding data were used to identify all patients undergoing surgery for zygomatico-orbital fractures between December 2011 and June 2019. Operative notes were reviewed for all patients and full case notes were reviewed for those undergoing repeated procedures. Patients having further surgery for conditions unrelated to their injury were excluded. Preoperative imaging was reviewed independently by 2 authors to anatomically classify the fracture patterns for both zygomatic and orbital components using the Knight and North¹ and Jacquiery² classifications, respectively. For all cases, the grade of operating surgeon (consultant/trainee), materials used for any fixation, and the surgical approaches involved were recorded (transoral, transcutaneous, transconjunctival, coronal, indirect), and what form of preoperative imaging (computed tomography [CT] vs plain film) was recorded. For patients who required a return to theatre, full clinical records, including clinical notes, clinical correspondence, and any subsequent imaging, were reviewed independently by 2 authors to identify common themes.

Results

A total of 432 patients underwent surgery for zygomatico-orbital trauma in 8-year study period. There was a mean follow-up period of 4.7 years, with 65% of cases followed up for 4 or more years, and 97% of cases followed up for minimum of 12 months postoperatively, with a minimum of 3 months; 92% of cases treated in this period were male, with just 34 cases involving female patients. The average age of patients in the study period was 36 years (range 16-87 years). In our region, children are treated in a dedicated Children’s Hospital and are therefore not included within the scope of this article.

In total, 116 cases were treated with closed reduction and 316 with open reduction and internal fixation; 20 cases were identified as having returned to theatre for reoperation (see Table 1). There were no significant differences between those requiring repeated surgery and those who did not in terms of fracture pattern or grade of operating surgeon (consultant vs trainee). The average age of the return to theatre group was also 36 years, with a range of 21 to 82 years. All patients who required reoperation were male.

Table 1.

Return to Theatre Breakdown.

	Case #	Diagnosis	Fracture classification	First operation	Summary of issues leading to RTT	Further procedure at RTT	Time between ops (days)
Complications related to fixation	1	Fractured zygomatic complex	Knight and North—3	ORIF zygoma (buttress)	Chronic sinusitis, recurrent infections buttress plate	Second removal of infected buttress late and sinus washout. Third middle meatal antrostomy	109
	2	Fractured zygomatic complex	Knight and North—5a	ORIF zygoma (I/o rim + buttress)	Recurrent infections buttress plate	Removal of infected buttress plate	221
	3	Fractured zygomatic complex	Knight and North—3	ORIF Zygoma (buttress)	Recurrent infections buttress plate	Removal of infected buttress plate and sinus washout	910
	4	Fractured zygomatic complex	Knight and North—4a	ORIF zygoma (buttress)	Recurrent infections buttress plate	Removal of infected buttress plate and sinus washout	293
	5	Fractured zygomatic complex	Knight and North—4a	ORIF zygoma (I/o rim + buttress)	Prominent plate	Removal of prominent plate/screws	83
Failure of primary surgery	6	Isolated orbital floor fracture	Jacquiéry—3	Exploration and repair orbital floor—difficulty accessing medial wall	No improvement in eye movements postop, malpositioned plate	Repeat procedure with transcaruncular approach to access medial wall	3
	7	Fractured zygomatic complex with orbital floor defect	Knight and North—3 Jacquiéry—3	ORIF zygoma and exploration and repair orbital floor	Severely malpositioned plate, significant ophthalmoplegia	Re-exploration of orbital floor, repositioning of plate using endoscopic guidance	2
	8	Fractured zygomatic complex	Knight and North—3	Gillies’ temporal zygomatic lift	Fracture unstable and depressed	Reoperation, ORIF	6
	9	Fractured zygomatic complex	Knight and North—3	Gillies’ temporal zygomatic lift	Fracture unstable and depressed	Reoperation, ORIF zygoma (buttress plate)	1
	17	Fractured zygomatic complex	Knight and North—6	Gillies’ temporal zygomatic lift	Fracture unstable and depressed	Re-operation, Gillies’ temporal lift, + oral approach pack inserted under arch given degree of comminution, plating was not possible without a coronal approach	11
	18	Fractured zygomatic arch	Knight and North—2	Gillies’ temporal zygomatic lift	Fracture unstable and depressed	Re-operation, Gillies’ temporal lift—failed again, Pt accepted residual deformity (refused coronal approach)	6
	19	Fractured zygomatic arch	Knight and North—2	Gillies’ temporal zygomatic lift	Fracture unstable and depressed (Pt refused coronal approach for first operation	ORIF R zygomatic arch via coronal approach	14
Development of delayed deformity	10	Isolated orbital floor fracture	Jacquiéry—3	Exploration and repair orbital floor	Residual enophthalmos and diplopia	Rerepair using CT-guided navigation and patient specific implant	202
	11	Fractured zygomatic complex with orbital floor defect	Knight and North—4a Jacquiéry—3	ORIF zygoma and exploration and repair orbital floor	Residual enophthalmos and diplopia. Facial contour well restored	Rerepair orbital floor using CT-guided navigation and patient-specific implant	300
	12	Fractured zygomatic complex with orbital floor defect	Knight and North—4a Jacquiéry—2	ORIF zygoma	Residual malar flatness	Restoration of facial contour using custom PEEK implant	504
	13	Fractured zygomatic complex	Knight and North—4a	ORIF zygoma	Residual malar flatness	Restoration of facial contour using patient-specific PEEK implant	170
	14	Fractured zygomatic complex with orbital floor defect	Knight and North—5b Orbit missed preop	Gillies’ temporal zygomatic lift	Developed late onset enophthalmos and diplopia. CT demonstrated orbital component	Return to theatre for exploration and repair of orbital floor	349
	15	Fractured zygomatic complex with orbital floor defect	Knight and North—4a Jacquiéry—3	Repair R orbital floor with PDS sheet + ORIF zygoma	Residual enophthalmos and diplopia, residual malar flatness	Restoration of facial contour using patient-specific PEEK implant	364
	16	Fractured zygomatic complex with orbital floor defect	Knight and North—5a	ORIF zygoma	Developed enophthalmos and diplopia, residual malar flatness	Return to theatre for exploration and rerepair of orbital floor and malar profile with interlocking Medpor implant	304
Reinjury	20	Fractured zygomatic arch	Knight and North—2	Gillies’ temporal zygomatic lift	Patient walked into a door—depressed fracture	Repeat Gillies’ temporal zygomatic lift	36

Abbreviations: CT, computed tomography; I/o, Intra oral; Ops, Operation; ORIF, open reduction internal fixation; RTT, Return to theatre; postop, postoperative; preop, preoperative; PDS, Polydioxanone; PEEK, polyetheretherketone; Pt, patient;.

Five patients required removal of fixation, 4 of which were due to infection. Patients who had a buttress plate placed were significantly more likely to develop an infection than those who had open reduction and internal fixation without an oral approach (Fisher exact P = .042).

Seven patients required reoperation within 2 weeks of the primary procedure. Five of these were failures of initial attempts at closed reduction, with instability of the fractures resulting in repeated displacement, while 2 were due to inadequate fracture reduction at the initial open reduction and internal fixation.

Seven patients developed late deformity requiring delayed further surgery (mean 313 days after primary surgery). Five of these had late development of enophthalmos and hypoglobus, while 2 had late soft tissue atrophy leading to flattening and asymmetry.

One patient sustained a further injury displacing the original fracture and requiring repeat surgery.

Discussion

In South Yorkshire, all patients with midface or zygomatico-orbital trauma are assessed according to a regional protocol with follow-up dependent on clinical urgency. Those with clinical muscle entrapment or reduced visual acuity detected by the referring physician are evaluated immediately; those with displaced fractures, trismus, globe displacement, diplopia, or altered facial sensation are reviewed within 72 hours; and those with radiographic signs of injury but no clinical signs are reviewed within 2 weeks. Decisions regarding specific timing and nature of surgery, including approach, utilization of 3-dimensional planning, or navigation, are at the discretion of the operating surgeon.

Previous reviews of orbital trauma complications have focused on areas such as biomaterials³ and timing⁴ in relation to outcomes, and there is little in the literature regarding those with posttraumatic, postsurgical poor outcomes requiring further surgery. Wolfe et al⁵ evaluated 240 such patients in the setting of a single surgeon’s referral practice with a wide range of midfacial trauma requiring reoperation but included an additional 77 patients undergoing primary surgery. They describe indications for repeat surgery but did not draw any conclusions about the reasons for failure of the primary procedures. The most common symptom in those having repeated surgery in their series was enophthalmos (47%), with malar flatness close behind (33%).

In our series, 4 main themes were identified in those patients who required reoperation: complications related to fixation materials, failure of the initial surgery, development of delayed deformity, and reinjury (see Table 1).

Of those having complications related to fixation materials, 1 patient requested removal of an infraorbital plate as it was palpable and causing anxiety. The 4 who had infection all did so in plates placed via an oral approach, which is unsurprising given the exposure of the metalwork to the oral bacterial flora at the time of insertion. The overall rate of hardware removal due to infection in our series is low (0.9% requiring hardware removal due to infection), a previous systematic review of the removal of hardware placed in the treatment of trauma found that 3.5% of cases resulted in hardware removal due to infection.⁶ In all cases, the fractures had fully united before the requirement for removal of metalwork, and no further fixation was required.

Seven patients required reoperation within 2 weeks of their primary procedure. We consider these to represent failure of the initial surgery. Five had undergone a “closed” approach with zygomatic elevation via a Gillies’ temporal approach and no fixation. Three required open reduction and internal fixation, while 2 refused open reduction. Both of these patients underwent a further elevation, one accepting the residual deformity while the other was treated with an antral pack to provide stability (Figure 1) and achieved a satisfactory outcome.

Figure 1.

A, Result after primary surgery—note the depressed right zygomatic arch. B, Result immediately after secondary procedure with antral pack in situ. C, Final postoperative result after removal of antral pack.

The 2 patients who underwent primary open reduction and internal fixation and required return to theatre warrant further review.

In 1 case, the fracture involved a significant part of the medial orbital wall and having restored the contour of the orbital floor, forced duction revealed residual muscular tethering. The surgery was abandoned with the floor repaired, with a plan to return to theatre for a navigation-assisted transcaruncular approach to the medial wall as a joint case with oculoplastic ophthalmic colleagues (see Figure 2). The patient was notified immediately postoperatively and returned to theatre 3 days later for the planned procedure.

Figure 2.

A, Result after primary surgery, note the mispositioned plate and medial wall defect. B, Result after reoperation with navigation and transcaruncular access as oculoplastic ophthalmology joint case.

In the other case, a large lateral and orbital floor defect was inadequately reduced, with difficulty obtaining optimal position of the orbital plate and residual entrapment of the ocular muscles. Postoperative imaging demonstrated malposition of the plate and the patient returned to theatre 2 days later, with endoscopic guidance via the maxillary antrum to confirm adequate plate positioning.

In both cases, a satisfactory outcome was achieved following the second procedure.

This group of patients demonstrate that satisfactory outcomes can be achieved for almost all patients with zygomatico-orbital trauma, provided that adequate exposure can be achieved, and occasionally necessitating the use of navigation or other adjuncts (such as endoscopic approaches) to provide on-table confirmation of position. Navigation is available at the discretion of the individual surgeon planning the case, whereas intraoperative CT which may have a role in such situations is not available in our institution at present.

Development of late enophthalmos is a well-recognized complication after orbital surgery⁷ and occurred in 2 cases in our series (see Table 1, cases 14 + 16). Of note, neither patient who developed late enophthalmos had orbital reconstruction as their initial procedure, having both undergone surgery on the zygoma. Soft tissue atrophy resulting in malar flatness following trauma is less well understood.⁸ This subset of patients were treated with patient-specific implants and had satisfactory outcomes.

As interpersonal violence is the most common cause of facial trauma in the United Kingdom,⁹ it was surprising that only 1 patient required repeat surgery due to re-injury, and in that patient the mechanism was accidental collision with a door-frame, not related to interpersonal violence.

There are several limitations to our study. It is a retrospective analysis, and as such our ability to fully evaluate the decision-making process for those requiring reoperation is limited to a review of the clinical records. A prospective review would however prove challenging given the low incidence. In addition, due to the retrospective nature of this study, there are patients who have been operated on within the study period (2011-2019) who have been treated more recently than others, the mean duration of follow-up is 4.7 years. Therefore, it is possible that there may be a small number of patients who ultimately develop delayed deformity due to soft tissue changes long term, who have not currently been represented here. Further to this, we were only able to identify patients who returned to theatre in our institution. It is possible that some patients may have gone on to have surgery elsewhere, but we would expect such numbers to be small, as our institution is a Major Trauma Centre and provides services over a wide geographical area.

Overall while the need for repeated surgery in patients with zygomatico-orbital trauma is low, in some cases, it may reflect failure of conservative treatment, and a low threshold for open reduction and internal fixation may be warranted where optimal reduction and/or fracture stability cannot be achieved through a closed approach.