Are post-operative radiographs necessary in the management of simple fractures of the zygomatic complex?

The Utility of Postoperative Computed Tomography Imaging Following Isolated Orbital Blowout Fracture Repair

Purpose

To determine the clinical utility of computed tomography (CT) imaging following isolated orbital blowout fracture (OBF) repair.

Methods

Single-center retrospective review of adult patients undergoing surgical repair of isolated OBFs between November 2008 and August 2016 who received postoperative CT scans. Preoperative and postoperative examination data, postoperative imaging reads, postoperative courses, and any reoperation documentation were collected from electronic medical records. Postoperative imaging findings were categorized as major, indeterminate, or minor by predicted impact on clinical management. Major findings indicated a need for reoperation, indeterminate a potential reoperation, and minor no reoperation.

Results

Fifty-two cases met inclusion criteria: 94.2% (n = 49) of postoperative scans included minor findings, 34.6% (n = 18) indeterminate findings, and 19.2% (n = 10) major findings. Three patients returned to the operating room (OR) for surgical revision. All 3 had a significant and concerning change on postoperative examination. Only 1 also had a major finding on postoperative imaging. The remaining 49 patients had benign postoperative examinations, despite 9 (17.3%) with major imaging findings who did not undergo reoperation.

Conclusions

In the majority of OBF repairs, postoperative CT scan findings were not predictive of a need to return to the OR for revision. Reoperation was instead largely prompted by concerning changes in the postoperative clinical examination. Our findings suggest that postoperative imaging in the absence of clinical concern should not be included in the surgical management of isolated OBFs. Instead, targeted imaging will help reduce radiation exposure and health-care costs without sacrificing patient care.

The Role of Postoperative Imaging after Orbital Floor Fracture Repair

Obtaining postoperative images of maxillofacial fractures does not affect the clinical management of asymptomatic patients; however, few studies have evaluated the role of postoperative imaging in the context of orbital floor fractures. In this study, we evaluate current practice techniques and the role of postoperative imaging in the management of orbital floor fractures in isolation and with concomitant facial fractures. Retrospective review of patients who underwent open reduction and internal fixation of orbital floor fractures between 2005 and 2015 at a single medical institution. Operative and perioperative records were reviewed to characterize postoperative imaging as routine or as indicated by concerning clinical symptoms, and to correlate clinical outcomes to postoperative imaging patterns across all identified orbital floor fractures. A total of 139 patients underwent open reduction and internal fixation of orbital floor fractures. Of these, 75 (54%) had zygomaticomaxillary (ZMC) involvement. The remaining 64 (46%) were isolated orbital floor fractures. Overall, 54 (39%) patients underwent postoperative imaging. Of these, 38 (70%) had postoperative imaging in the absence of concerning clinical symptoms. There was no observed difference in complication rates in those who underwent postoperative imaging, and those who did not. Patients with orbital + ZMC fractures underwent a significantly higher number of postoperative imaging studies ( p  < 0.001); however, there was no observed difference in complications between isolated orbital and orbital + ZMC fractures. Routine postoperative imaging is not warranted in the absence of persistent clinical symptoms following open reduction and internal fixation of orbital floor fractures.

Management of tripod fractures (zygomaticomaxillary complex) 1 point and 2 point fixations: A 5-year review

The zygomaticomaxillary complex (ZMC) plays a key role in the structure, function, and esthetic appearance of the facial skeleton. They can account for approximately 40% of mid-face fractures. They are the second most common facial bone fracture after nasal bone injuries. The fracture complex results from a direct blow to the malar eminence and results in three distinct fracture components that disrupt the anchoring of the zygoma. In addition, the fracture components may result in impingement of the temporalis muscle, trismus (difficulty with mastication) and may compromise the infraorbital foramen/nerve resulting in hypesthesia within its sensory distribution. A 4-year retrospective review of all patients treated with ZMC fractures at oral and maxillofacial surgery department, sree balaji dental college and hospital was performed. Computed tomography scans were reviewed. Demographics, treatment protocols, outcomes, complications, reoperations, and length of follow-up were identified. A total of 245 patients was identified by the Current Procedural Terminology codes for ZMC fractures. Closed or open reduction methods were performed with the goal of treatment being preservation of normal facial structure, sensory function, globe position, and mastication functionality. Unacceptably poor surgical outcomes are uncommon. Significant facial asymmetry requiring surgical revision occurs in 3-4% of patients. Postoperative infection rates are extremely low, and these infections nearly always resolve with oral antibiotics. In general, the long-term prognosis after repair of ZMC fractures is very good.

Routine Screening Radiography for Retained Wire Following Arch Bar Removal Is Not Indicated

PURPOSE

To estimate the screening test value of routine radiography after arch bar wire removal by assessing the incidence of retained wires and the importance of their sequelae.

MATERIALS AND METHODS

This was a retrospective medical record review. Records of arch bar removal procedures were examined and divided into those screened with radiography after removal (screen group) and those that were not screened (comparison group). The incidence of retained wire was calculated for each group. Study variables included wire-related radiographic or clinical findings.

RESULTS

Records of 546 mandible fractures were reviewed; 95 met the study criteria. Most exclusions were due to lack of arch bars, missing postoperative radiographs, or insufficient postoperative documentation. Of the 55 records in the screen group, 1 wire was detected (2%); of the 40 records in the comparison group, 1 wire was detected (3%). The total incidence of retained wire findings was not statistically different between the 2 groups and there were no adverse wire-related sequelae reported by any of the 95 patients.

CONCLUSION

Because of the low incidence of retained wires and wire-related sequelae, routine imaging after wire removal is probably not an effective screening test for retained wire and should be limited to situations in which there is clinical suspicion of retained wire.

Postoperative radiographs after maxillofacial trauma: Sense or nonsense?

The purpose of the present study was to investigate the necessity of routine postoperative radiographic analysis in patients with maxillofacial trauma. Between January 2000 and January 2010, 579 patients were treated surgically for 646 maxillofacial fractures including complex maxillofacial trauma. The incidence of surgical retreatments based on postoperative radiographs after maxillofacial trauma were investigated. 16 patients needed surgical retreatment. The decision to revise was based on postoperative imaging alone in one patient (0.2%). The available data in the literature concerning postoperative radiography in maxillofacial trauma was reviewed. Six useful studies concerning postoperative radiography in maxillofacial trauma were available for review. When combining these studies a total of 1377 patients underwent surgery for correction of a maxillofacial fracture. Nine patients returned to the operating theatre for correction of the initial procedure after trauma (0.7%). The present results are in line with the available literature. Routine postoperative radiography is not necessary after surgical treatment of maxillofacial trauma. Avoiding routine postoperative radiography will lead to a reduction in exposure of patients to ionizing radiation, a reduction of costs and probably a more efficient discharge.

The value of postoperative radiographs in the management of zygomatic fractures: Prospective study

It is customary in maxillofacial surgical practice for all patients who have undergone open reduction and or fixation of a fracture of the zygomatic complex to have postoperative radiographs taken before they are discharged. These radiographs are often not reviewed before the patient's departure and in many cases have no bearing on the patient's management. We prospectively reviewed over a 3-month period all patients who were treated for fractures of the zygomatic complex and had no postoperative radiographs. None of these patients had to return to the operating theatre for a further operation, which emphasises the lack of clinical evidence to support routine postoperative radiography in the management of fractures of the zygomatic complex.

An audit of the effectiveness of postoperative radiographs—do they make a difference?

We examined the impact of postoperative radiographs after repair of facial fractures on immediate postoperative management. This was completed in two parts: first we did a retrospective study from January to July 2001, and secondly a prospective observational study for the remainder of 2001. All patients who had a general anaesthetic for the treatment of a facial fracture were included. The intervention was postoperative radiographs before discharge. The outcome measure was whether the patient had to return to theatre within a month. A total of 257 patients were included of whom 3 (1.2%) returned to theatre for correction of the initial procedure. In each case this was based on the postoperative clinical findings. No patient was returned to theatre solely on the evidence of an immediate postoperative radiograph. In line with official guidelines, we suggest that postoperative radiographs must not be used routinely, but only when they are required clinically. This minimises the risk to patients, and may lead to speedier discharge and appreciable savings.

The management of zygomatic complex fractures--results of a survey

A study was undertaken to investigate the current practices in the UK in the management of zygomatic complex fractures. The results are presented and discussed with reference to recent literature on the subject.

Comparative evaluation of different radiographic projections of zygomatic complex fractures

Diagnosis of zygomaticomaxillary fractures is a major problem in radiographic interpretation. The purpose of the present study was to evaluate several radiographic examinations performed in an emergency room to diagnose zygomatic complex (ZC) fractures, in order to determine which is the single best radiographic projection for this purpose. Radiographs of 160 patients with ZC fractures were evaluated retrospectively. The modified P-A projection (10 degrees-20 degrees) provided a clear image of the frontozygomatic, infra-orbital rim and temporozygomatic fracture lines in all cases. In half the cases, the modified P-A projection also clearly demonstrated the fracture line in the zygomatic maxillary buttress. On the other hand, the Water's view demonstrated the fracture line in the zygomatic maxillary buttress and the temporozygomatic bone in all cases, but in only 65% of the cases was the fracture line in the infra-orbital rim and the frontozygomatic bones shown. The modified P-A projection was found to be the single best radiographic examination that should be performed in the emergency room to diagnose ZC fractures.

The Gillies method for fractured zygomas: an analysis of 105 cases

This prospective study analyzed 105 cases treated using the Gillies temporal approach for fractures of the zygoma. In 97 cases (92%) this was sufficient. Only eight cases required open reduction. It is suggested that the Gillies method be used more frequently, because it is associated with minimal morbidity and a short duration of general anesthesia.