Combined Orbital Floor and Medial Wall Fractures Involving the Inferomedial Strut: Repair Technique and Case Series Using Preshaped Porous Polyethylene/Titanium Implants

Abstract

The most commonly fractured walls of the orbit are the floor and medial wall, and repair is indicated in cases of extraocular muscle entrapment, diplopia, globe malposition, and significant orbital volume expansion. 1-5 Combined fractures of the floor and medial wall are more likely than isolated orbital wall fractures to require treatment due to increased volume expansion; they are often associated with compromise of the inferomedial strut at the ethmoid-maxillary junction (►Fig. 1). The large size of these fractures and the loss of internal bony support can make surgical repair particularly challenging. Several techniques have been described to deal with this fracture pattern using a variety of implant materials AbstractBackground Combined orbital floor and medial wall fractures can be technically challenging to repair, particularly when the inferomedial strut is involved. A surgical repair technique is described utilizing a single preshaped porous polyethylene/titanium implant to span both defects. Methods Retrospective interventional case series. Results Fracture repair was performed on 17 orbits (16 patients) between October 2009 and February 2012. Subsequent surgical revision was required in three cases (18%). Visual acuity was stable or improved in all cases. Of 7 patients with preoperative diplopia, 5 improved and 2 remained stable postoperatively, and there were no cases of new or worsened diplopia following surgery. Postoperative asymmetry in Hertel exophthalmometry averaged 1.0 mm (range 0 to 2 mm). Preoperatively, average orbital volume was 122.7% compared with control (range 109 to 147%, standard deviation [SD] 9.6), which improved to 100.3% postoperatively (range 92 to 110%, SD 5.7). The average decrease in orbital volume was 22.5% (range 10 to 54%, SD 11.4, p < 0.001). Conclusions With careful preoperative planning and meticulous surgical technique, combined orbital floor and medial wall fractures involving the inferomedial strut can be successfully repaired with a preshaped porous polyethylene/titanium implant through a transconjunctival/transcaruncular approach with inferior oblique disinsertion.

The accuracy of post-traumatic orbital volume correction using pre-adapted titanium mesh (randomized controlled clinical prospective study)

“…After the operation, a volume excess persists in some patients and leading to an enophthalmos, especially if the deep orbital cone area was affected or scarring occurred10. The aim of restoring the normal contours of the orbit while avoiding postoperative complications remains difficult to achieve [11] . The exact reconstruction of the complex 3D anatomy of the orbit with an individually S-shaped rise of the floor, and a retro-bulbar bulge formed by the posterior aspect of the medial wall and the floor remains a challenge for the reconstructive surgeons and takes multiple trials to achieve this goal [12] .…”

Treatment of Orbital Medial Wall Fractures with Titanium Mesh Plates Using Retrocaruncular Approach: Outcomes with Different Techniques

“…In combined medial wall and floor fractures, in particular when the inferomedial orbital strut is involved, reconstruction of this unique 3D anatomy requires the replication of slopes and curves with difficult sizing and shaping of the implant. 3 Recently, few papers, 3,4,7 combining transconjunctival retro/transcaruncular approach with the use of prebent titanium or porous polyethylene/titanium meshes and implants, reported excellent results in the treatment of medial wall fractures (isolated or combined with orbital floor fractures).…”

“…Introducing an endoscope through the incision, as described by Chen and Davies, 3 Meningaud et al, 5 and Woo et al, 6 facilitates the visualization of the margin of the fracture (►Fig. 3) and allows a precise control of the spatial relationship of the implant margins and fracture perimeter (►Fig. 4).…”

“…Recently few studies focused on medial wall fractures (isolated or combined with orbital floor fractures) presenting a treatment strategy based on transconjunctival retro/transcaruncular approach with the use of prebent titanium or porous polyethylene/titanium meshes and implants with excellent outcomes in terms of function and form. [3][4][5][6] Although these reports seem to overcome the lack of consensus on the ideal approach and materials that can be used for the repair of fractures of the medial orbital wall, treatment of these fractures is still challenging.…”

Comparative Orbital Volumes between a Single Incisional Approach and a Double Incisional Approach in Patients with Combined Blowout Fracture

“…It is possible to resolve this by widening the surgical field via disinsertion of the inferior oblique muscle. There is, however, an increased risk of developing postoperative diplopia [ 19 ].…”