Intraoperative computed tomography for the management of traumatic complex facial fractures: a narrative review

Abstract

Successful facial reconstruction requires accurate restoration of the concealed three-dimensional facial skeleton. The key rationale for intraoperative computed tomography (iCT) is that it facilitates the most comprehensive assessment of fracture reduction. Real-time visual feedback is now considered an essential component in hand, spine and general orthopaedic surgery. Frequently proposed as the new gold standard of care, iCT has been widely adopted in maxillofacial surgery, especially internationally. In contrast, our Australian experience is that access to iCT and therefore uptake is relatively lacking. The craniofacial skeleton is a complex structure owing to its various convexities and concavities, sinonasal elements, biomechanical buttresses, visceral and occlusal components and neurovascular structures. Classic approaches to open reduction internal fixation aim to reduce incisions to prevent complications such as ectropion, salivary leak or nerve damage. However, intraoperative assessment of fractures in minimally-invasive techniques are hindered by the limited extent of exposure, especially in the setting of complex fracture patterns or those that involve dynamic or functional endpoints. With iCT, surgeons may visualise, adjust and revise fixation without wide exposure while the patient is on the operating table. This obviates an additional operation that may be required due to an unsatisfactory fixation. iCT is cost-effective and reduces radiation exposure. Challenges in integrating iCT include competing for availability with other specialties, training staff and lack of awareness about the benefits this technology offers. This narrative review discusses the role of iCT in the modern Australian operating theatre.