Going beyond the limitations of the non-patient-specific implant in titanium reconstruction of the orbit

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Abstract

Reconstruction of post traumatic orbital defects has undergone a stepwise evolution following developments in reconstructive materials and surgical techniques. Advances in communication between surgical teams and design technicians have allowed provision of bespoke surgical plates with a high degree of accuracy and surgical relevance in an appropriate timeframe. We present a case series of 41 consecutive patients treated in London and BernBern Switzer between March 2019 and September 2020 with extensive defects reconstructed with patient specific orbital plates. Complexity of fracture was risk adjusted using the Jaquiery scale with one patient (J3), 14 patients (J4), and 26 Patients (J5). Outcome was assessed by accuracy of fit at the surgical margins and was 94.5%. The study group was statistically tested against a previous series by the same group and was statistically different with respect to the case complexity (p < 0.001) and accuracy of fit (p < 0.001) (Fisher’s exact test). Complications included the removal on one plate due to patient choice, with perfect surgical position and resolving diplopia. Only one plate articulation was poor, this mitigated by the size of the defect and the orbital soft tissue swelling which prohibited seating the implant. The patient remains well with acceptable function and satisfactory aesthetics. We present design considerations including the use two part plates, and surgical pearls to achieve predictable placement. We believe that the use of custom plates for reconstruction of Jaquiery 4 and 5 should be considered. We regard this technology as a game changer in surgical management of the complex high risk orbit.

Introduction

Reconstruction of large orbital defects remains a surgical challenge with respect to surgical access, plate placement, and postoperative morbidity. The evolution of biomaterials together with increased experience and confidence in surgical exposure of the orbit have made significant development into the quality and outcomes of surgical reconstructions. The use of patient specific implants represents the logical extension in titanium reconstruction of the orbit allowing for near perfect reconstruction of complex three-dimensional anatomy within a realistic preoperative timeframe.

Whilst the revision rate is variable using traditional orbital plates between 17%1 and 87%2 the improvements observed using a preformed plate are significant. We reported a 6% revision rate in 81 consecutive orbits in a 12-month period.3 The results were risk adjusted against the Jaquiery staging, poorer results were achieved in multiple wall fractures. In all revision cases the plate size was simply not big enough for the planned surgical defect. Following this study our protocol for managing these lager defect has changed to the use of patient specific implants.

The purpose of this study was to compare the accuracy of surgical positioning in a series of patients treated with patient specific implants compared with the previously described case series.

Section snippets

Patients and methods

The retrospective cohort study was conducted at level I trauma centres at the Royal London Hospital in Whitechapel, London, UK and Inselspital, Bern University Hospital, Bern, Switzerland. All patients included in the series underwent surgical procedures for fractures of the floor and/or medial wall using a standardised approach in London between March 2019 and December 2020, and in Bern from March 2019 to September 2020 (Table 1).

Inclusion criteria included patients requiring treatment for an

Results

In the case series there were 41 cases who fulfilled clinical requirements. The mean age at presentation was 35 years old and 28 were male. The left side was injured slightly more than the right side with (n = 23).

With respect to mechanism, the majority of the fractures were caused by assault (n = 21), followed by road traffic accidents (n = 7), sporting injuries (n = 8) and falls (n = 4). One patient had a postoperative silent sinus syndrome (Swiss series).

The results were then compared with the results

Discussion

This retrospective analysis was conducted on a case series of 41 patients presenting with multiple wall complex defects reconstructed with patient specific implants.

The complexity scores between the groups were statistically different (p < 0.001) with the test group having a higher complexity score with a large number of defects extending to the skull base – Jaquiery 5, and beyond.

Titanium orbital reconstruction has now become industry standard for orbital reconstruction of large defects

Conclusion

Orbital reconstruction using titanium implants has evolved significantly and the use of custom implants, facilitated by improved communication between surgeon and technician has improved the predictability in complex defects. The case series illustrates significantly improved results that the matrix plate case series reported in 2020. It remains our view that the custom plate should be considered for Jaquiery 4 and 5 fracture patterns.

Conflict of interest

We have no conflicts of interest.

Ethics statement/confirmation of patients’ permission

This study followed the Declaration of Helsinki on medical protocol and ethics. Furthermore, the regional Ethical Review Board of Bern, Switzerland, approved the study. Patient permission was obtained for the CT scan illustration.

Acknowledgements

(1) Materialise NV, 3001 Leuven, Belgium. PSI for Synthes; (2) Planmeca OY, FI-00880 Helsinki, Finland; (3) KLS, Tuttlingen, Baden-Wurtemberg 78532, DE.

References (15)

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