Subcaruncular approach for the reconstruction of blowout fractures of medial orbital walls

To obtain a wide and clean operative field for anatomic reconstruction of medial orbital blowout fractures, an alternative method called the subcaruncular approach has been performed. Between March 2008 and June 2010, this method was applied to the orbits of 41 patients with isolated pure medial orbital blowout fractures. A medial half conjunctival incision was made and extended meticulously to the subcaruncular area through preseptal plane under direct vision. Pre- and postoperative computed tomographic scans and ophthalmic examinations were performed, and clinical results were assessed. Postoperatively, computed tomographic scans revealed anatomic reduction of orbital soft tissues and the reconstructed medial orbital wall to be in proper position in all cases, and diplopia and eyeball motility limitation were resolved in most patients. There were no complications except severe chemosis in one case. We believe that this method can be a useful alternative option for the anatomic reconstruction of medial orbital blowout fractures.     

A combined lateral and medial orbitotomy for exposure of the optic nerve and orbital apex.

A technique for exposure and direct visualization of the optic nerve and medial apex of the orbit is presented. The technique involves an initial lateral orbitotomy or Kr?nlein procedure followed by a nasal conjunctival peritomy, detachment of the medial rectus muscle, and outward rotation of the globe to expose the optic nerve and apex of the orbit. With relaxing incisions in the conjunctiva, the globe can be rotated approximately 45 degrees with visualization of the optic nerve from its exit from the globe to its disappearance into the origin of the rectus muscles. This technique may be used for exposure of the optic nerve and orbital apex for the optic nerve decompression for chronic papilledema in indicated cases, biopsy of lesions of the orbital apex, or excisional biopsies of tumors of the optic nerve.     

Medial microsurgical approach to the orbit: an anatomic study.

The authors have identified and described three medial approaches to the intraorbital portion of the optic nerve in cadavers. The structures exposed via the superior, inferior or central approaches were approached through the medial orbital wall. The superior approach in which the medial rectus muscle is retracted inferiorly exposes the superomedial aspect of the orbit. The inferior approach in which the medial rectus muscle is retracted superiorly, provided the inferomedial aspect of the optic nerve from the globe to the muscle cone. The central approach in which the ethmoidectomy was performed and the medial rectus muscle was disinserted and retracted, provided excellent exposure of the structures of the medial part of the orbit and the optic nerve. There were no structures blocking access to the two third anterior optic nerve and medial surface of the globe. The structures encountered in these approaches are demonstrated under magnification in cadavers, and the exposure of the optic nerve is discussed.     

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

ObjectivesWe determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.MethodsWe performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.ResultsOur study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k = 0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054–8.849) for superior wall fractures, 0.459 (95% CI: 0.152–1.389) for inferior wall fractures, 2.286 (95% CI: 1.062–4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215–1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR) = 12.01, P = 0.011), and medial or inferior wall fracture was a protective factor (adjusted OR = 0.14, P = 0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).ConclusionAmong patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.     

The volume of muscles of mastication in patients receiving mandibular contouring surgery: a comparative study.

PURPOSE: As the management of prominent mandibular angle and masseter muscle hypertrophy becomes increasingly popular, proper understanding of the volumetric component of the related structures becomes important but is currently lacking. MATERIALS AND METHODS: Three-dimensional computed tomographic (CT) scans of 18 female and eight male adult patients with square-face appearance were used for volumetric measurement of the osseous hemi-mandible, masseter, medial and lateral pterygoid muscles. CT scans of 28 female and 17 male adult patients without square-face appearance were selected from the imaging laboratory archive to serve as controls. RESULTS: Compared with the sex-matched controls, the square-faced patients had significantly higher volume of the osseous hemi-mandible as well as the masseter and medial pterygoid muscles. There was no significant difference in the volume of the lateral pterygoid muscle between the two groups. This study confirms a significantly greater volume in the osseous mandible and masseter muscle in patients complaining of square-face appearance. The implication of this information on treatment is discussed.     

Reconstruction of the medial canthus

The keystone for successful reconstruction of the medial canthal area is adequate positioning of the medial canthal complex to maintain proper intercanthal distance and apposition of the lids to the globe. This requires an understanding of the dynamics of the tripartite insertion of the MCT and its relationship to the medial orbital wall. We have previously described a technique for transnasal wiring based on anatomic studies that is anatomically and physiologically precise and that is applicable to a variety of clinical situations. Soft-tissue problems need to be dealt with on an individual basis with grafts, flaps, or a combination of these modalities.     

Pathoanatomy of posterior malleolar fractures of the ankle

BACKGROUND: The functional outcome following ankle fractures that involve a posterior malleolar fragment is often not satisfactory, and treatment of this type of fracture remains controversial. Thorough knowledge of the pathologic anatomy of the posterior malleolar fracture is essential for planning appropriate treatment. Thus, we conducted a computed tomographic study to clarify the pathologic anatomy of the posterior malleolar fracture. METHODS: Between 1999 and 2003, fifty-seven consecutive patients with a unilateral ankle fracture with one or more posterior fragments were managed at our hospital. We reviewed the patients' preoperative computed tomographic scans to determine (1) the ratio of the posterior fragment area to the total cross-sectional area of the tibial plafond and (2) the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. Each fracture was categorized according to the location of the major fracture line on the computed tomographic image at the level of the tibial plafond. RESULTS: The fifty-seven fractures were categorized into three types: (1) the posterolateral-oblique type (thirty-eight fractures; 67%), (2) the medial-extension type (eleven fractures; 19%), and (3) the small-shell type (eight fractures; 14%). Two of the eleven medial-extension fractures extended to the anterior part of the medial malleolus. A total of nine of the eleven medial-extension fractures actually consisted of two fragments [corrected] The conditions are not exclusive of one another; for example, in the case of one of the fractures exhibiting two fragments, the fracture also extended to the anterior part of the medial malleolus [corrected] The average area of the fragment comprised 11.7% of the cross-sectional area of the tibial plafond for posterolateral-oblique fractures and 29.8% for medial-extension fractures. In the cases of seven of the nine fractures that comprised >25% of the tibial plafond, the fracture line extended to the medial malleolus. The angles between the bimalleolar axis and the major fracture line of the posterior malleolus varied. CONCLUSIONS: The fracture lines associated with posterior malleolar fractures appear to be highly variable. A large fragment extending to the medial malleolus existed in almost 20% of the posterior malleolar fractures in the current study, and some fragments involved almost the entire medial malleolus. Because of the great variation in fracture configurations, preoperative use of computed tomography may be justified. The information obtained from this study will be helpful for conducting basic research of this condition and for determining appropriate surgical approaches.     

Severe orbital floor fractures: repair with a titanium implant

Summary Fractures of the orbital floor which require exploration are usually treated with an alloplastic floor implant or an autogenous bone graft. When large portions of the orbital floor, together with the lower parts of lateral and medial walls, are destroyed there may be no possibility of providing a conventional orbital floor reconstruction. In this situation, a titanium orbital floor implant may well be required to support the globe. 4 cases of traumatic orbital floor blow-out fractures are described. Clinically, all patients had diplopia, enophthalmos and radiological evidence of extensive loss of the orbital floor. A titanium orbital floor implant was molded and secured to the infraorbital rim with miniscrews to reconstruct the orbital floor and to reconstitute the orbital volume. No additional bone grafting was performed. Complications were minimal. From this experience, in severe orbital floor fractures, good results are obtained by supporting the globe using only a titanium implant.     

Axial or coronal CT scan; which is more accurate in detection of open globe injury?

PurposeTo evaluate and compare the accuracy of axial versus coronal computerized tomography (CT) scan in detection of open globe injury.MethodIn this retrospective study, records of 61 patients with open and 72 patients with closed globe injury were reviewed. One experienced ophthalmologist and one neuroradiologist read the orbital CT scans and accuracy of the axial and coronal planes in detecting open globe injuries were compared. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated and compared for axial and coronal planes.ResultThe most common CT finding reported by the readers through the interpretation chart was scleral irregularity (70%), followed by dislocation of the crystalline lens (54%) and vitreous hemorrhage (51%). The sensitivity of axial, coronal and combined CT planes were 74%, 65%, and 79%, respectively. There was no significant difference between axial and coronal CT scans for detecting open globe injuries (P value=0.075), independent of the type and the location of the globe injury. For posterior injuries and sharp trauma, the sensitivity of coronal plane in detecting open globe injury was significantly lower, compared to axial and combined readings (P value=0.012 and 0.015, respectively). There was a near perfect agreement between readers for all CT scan readings with a Kappa value of 0.9.ConclusionAxial CT reading may be as adequate as a multiplanar reading in detection of open globe injury in emergency setting, where timely diagnosis matters. Without clinical and surgical findings, CT cannot provide adequate accuracy for detecting open globe injuries.     

Navigation-aided reconstruction of medial orbital wall and floor contour in cranio-maxillofacial reconstruction

The reconstruction of the anterio-posterior inclination of the medial aspect of the orbital floor, despite a wide 360 degrees exposure, including coronal and conjunctival incisions, is a challenging task in severe injuries of the orbit with massive comminution and complete displacement of the medial orbital wall and orbital floor. Out of a total of 20 patients with orbital fractures, five underwent a surgical intervention of repositioning the medial aspect of the orbital floor and especially the transition area between the orbital floor and medial orbital wall, using navigation-aided procedures. Using the mirroring tool of the Stryker-Leibinger STN-system, post-operative CTs indicated an average difference of the globe position of -4.9% between the operated side and the unaffected side, depending on the position of the medial aspect of the orbital floor. Navigation-aided procedures proved to be an essential precondition for achieving precise and predictable results in orbital reconstruction. In such cases, unlike those with an intact medial orbital wall remnant as a surgical target, bone grafts for reconstruction of the orbital floor cannot be implanted as onlay grafts.     

结合扩张术的重度眶距增宽症矫正术

目的 在传统颅内外径路眶距增宽矫正手术的基础上,通过术前眶周软组织扩张并改进术中眶间结构的处理,进一步提高术后效果.方法 对2例重度眶距增宽症患者术前3周进行眶周软组织扩张术,双侧颞部各置入100 ml软组织扩张器,于术前获得充足的眶外侧软组织量,然后进行传统颅内外径路眶周截骨两侧眶内移矫正术,术后进行内眶距大体测量和三维CT检查随访.结果 2例患者内眶距分别由术前的4.4 cm和3.2 cm矫正到术后的2.0 cm和1.4 cm;内眦间距分别由术前的6.7 cm和4.8 cm矫正到术后的5.0 cm和3.8 cm.结论 术前眶周软组织扩张和眶间结构的精确重建可以使眶距增宽症术后效果得到明显提高.     

The microsurgical anatomy of the ciliary ganglion and its clinical importance in orbital traumas: an anatomic study.

The ciliary ganglion can easily be injured during surgery for the repair of orbital fractures and laterally situated intraorbital mass lesions. The aim of this study is to elucidate the microsurgical anatomy of the ciliary ganglion and to emphasize its clinical importance in orbital traumas and surgeries. The orbits of 10 adult cadavers were fixed with 10 % formalin and dissected under the microscope with special attention to the presence and location of the ciliary ganglion. The motor (parasympathetic), sympathetic, and sensory roots, and the short ciliary nerves were exposed. Its relationship with other intraorbital neural and vascular structures were investigated. Some anatomic landmarks were determined and the distances between these landmarks were measured. The ciliary ganglion is an intraorbital neural structure approximately 3 mm in size, situated near the orbital apex, posterolateral to the globe in loose areolar tissue between the optic nerve and lateral rectus muscle. The mean distance between the ganglion and the optic nerve was 2.9 mm (range: 2.70 - 3.10 mm) and the mean distance between the lateral rectus muscle and the ganglion was 10.4 mm (range: 9.20 - 11.20 mm). Six to 10 short ciliary nerves arise from the ganglion and run forward in a curving manner with the ciliary arteries above and below the optic nerve. The ciliary ganglion should be taken into the account especially during lateral approaches to the orbit and the patients should be warned before the surgery about possible mydriatic or tonic pupils as a complication.     

A comparison of computed tomographic techniques in the diagnosis of Graves' ophthalmopathy

We performed CT scans on 24 patients with clinically typical Graves' ophthalmopathy to compare the advantages of various scanning techniques. Scans were performed before and after intravenous contrast material infusion, and the contrast-enhancement of abnormal muscles was compared with that of known orbital tumors. Images were also obtained using 5-mm and 8-mm collimators, and the diagnostic value of these collimators was compared. Sagittal and coronal scans were performed in some of the cases, using a new direct technique for the sagittal plane. In general, the 5-mm collimators provided sharper definition of the ocular muscles and optic nerves. Contrast-enhancement alone was not helpful in differentiating enlarged muscles from orbital tumors because of the great overlap of attenuation coefficients. Sagittal and coronal images were helpful in confirming muscle enlargement suspected from axial scans, and were most useful in showing enlarged superior and/or inferior recti in cases with normal medial and lateral recti. The advantages of our method of obtaining sagittal scans through the long axis of the orbit and the potential application of this technique to orbital CT scanning are discussed.     

Endoscopic transnasal approach for the treatment of isolated medial orbital blow-out fractures: a prospective study of preoperative and postoperative orbital volume change

Endoscopic transnasal reduction is a safe and effective technique for the treatment of blow-out fractures of the medial orbital wall. However, because this approach does not use rigid permanent material for reconstruction of the fractured medial orbital wall, some degree of herniation of the orbital contents may occur after the intraethmoidal packing material is removed. The purpose of this study was to evaluate the change in orbital volume in patients with medial orbital wall fractures treated through an endoscopic transnasal approach. This study was a prospective analysis that includes 20 patients who underwent endoscopic transnasal reduction of medial orbital wall fractures between April 2007 and December 2008. Computer-assisted orbital volume measurements were made using axial computed tomography. The mean (standard deviation [SD]) volume increase was 2.00 (0.92) cm(3) and the mean (SD) dimension of the fractured orbital wall was 2.76 (0.83) cm(2). After endoscopic surgery, an average (SD) volume decrease of 2.15 (0.91) cm(3) was achieved with ethmoid sinus packing. After removal of the packing materials, 1.14 (0.78) cm(3) increase of the orbital volume was observed. The dimension of the orbital wall fracture significantly correlated with the increased preoperative orbital volume (P = 0.002, r = 0.609); the preoperative increase in the orbital volume also significantly correlated with volume relapse after removal of the packing (P = 0.023, r = 0.452). These findings suggest that in broad orbital wall fractures, reconstruction of the orbital wall by rigid materials or prolongation of the packing period should be considered, because orbital volume can increase again after packing removal, and may thus lead to postoperative complications.     

Medial orbital wall fracture with concomitant medial longitudinal fasciculus lesions

Isolated orbital fractures are rare and may cause entrapment of intraocular muscles. The medial longitudinal fasciculus extending bilaterally through the brainstem establish connections between III, VI, VIII, and XIth cranial nerves. Lesions of these fasciculi may cause clinical findings similar to those seen in orbital fractures leading to muscle entrapment. A 9-year-old girl suffered a crush trauma. She had a limited inward gaze of left eye and complaints of diplopia. Findings were thought to be secondary to a left medial orbital wall fracture detected by cranial computed tomography, there was also entrapment of the medial rectus muscle. The patient was evaluated for the presence of any intracranial pathology as nystagmus developed. Antioedema therapy was initiated. Cranial magnetic resonance imaging revealed multiple millimeter-sized lesions at the medial longitudinal fasciculus MLF of the pons. There was a dramatic improvement in clinical findings on the 17th day of antioedema therapy; a diagnosis of internuclear ophthalmoplegia was made, and the operation was canceled. The authors emphasize that clinical findings due to orbital fractures may also be signs of a concomitant intracranial lesion, and that this possibility should be considered in differential diagnosis     

Clinical analysis of orbital blowout fractures caused by a globe-to-wall contact mechanism

Computed tomograms of blowout fractures of the pure medial and inferomedial wall that showed that the size of the orbital displacement exactly fitted the shape of the globe in many cases were investigated. To examine the veracity of a "globe-to-wall contact mechanism", we have analysed our own cases of medial or inferomedial blowout fractures (and also the charts of presumptive cases in which this mechanism was suspected), for the clinical information. The size of the displacement of the orbital wall exactly fitted the globe in 20/45 patients (44%). All fractures occurred in the inferomedial area of the orbital wall. In our study, serious complications such as corneal laceration, global rupture, paralysis of the cranial nerve, and ophthalmic nerve neuropathy were seen more often than in other studies.     

Graves’ exophthalmos: Volumetric assessment of orbital expansion

INTRODUCTION:

Graves’ ophthalmopathy is characterized by an increase in the volume of orbital soft tissue contents and an associated increase in intraorbital pressure. Surgical expansion of bony orbital volume is therefore an effective method of treating moderate to severe exophthalmos. Numerous correlations between specific decompression procedures and reduction of proptosis have been made. The main emphasis of the majority of these studies, however, appears to be of a qualitative nature rather than quantitative.

OBJECTIVES:

To quantitatively examine the consequences of surgical orbital decompression in the treatment of severe Graves’ exophthalmos, with respect to changes in ocular globe projection and orbital soft tissue and bony volume.

MATERIAL AND METHODS:

A series of three patients (five orbits) with severe exophthalmos were evaluated. All patients were operated on by a single surgeon using a standard technique of orbitozygmatic osteotomy in conjunction with three-wall orbital decompression and release of periorbita. Data obtained from standardized preoperative and three-month postoperative computed tomography scans were transferred to an offline computer workstation. Scalar and volumetric parameters were quantitatively analyzed to determine changes in globe projection in relation to intraorbital volume differences.

RESULTS:

Following surgery, mean globe retrodisplacement from the lateral orbital rim and from the optic foramen were 6.7 mm and 3.3 mm, respectively. Osteotomy and decompression were effective in producing an 18.6% increase in bony orbital volume. However, the volume of intraorbital soft tissues increased substantially following surgery, with a 23.4% increase in orbital fat volume and a 12.2% increase in neurovascular tissue volume.

CONCLUSIONS:

The degree of globe retrodisplacement achieved by surgical expansion of the bony orbital cavity in patients with Graves’ ophthalmopathy may be less than anticipated, due to a post-operative increase in the intraorbital soft tissue volumes.     

Course of the innervation supply of medial head of triceps muscle and anconeus muscle at the posterior aspect of humerus (anatomical study)

Introduction In elbow surgery; posterior side of joint has been described as the front door for accessing the elbow pathologies. Triceps splitting, triceps reflection, posterolateral Kocher, posteromedial Bryan-Morrey, modified MacAusland transolecranon approaches are the well known posterior surgical approaches. In the English literature, release and transposition of ulnar nerve on the medial side was fully described in posterior approaches. We believe that there was a need to identify the structures at the lateral aspect of the elbow while an iatrogenic injury may inversely effect an excellent radiological result. Therefore, we exposed the detailed innervation supply to the anconeus muscle and medial head of triceps muscle and tried to show possible denervation sites of these two structures during posterior approaches.Materials and methods This study was performed on 14 elbows in formalin-preserved 7 cadavers. We exposed the course of the innervation supply to the medial head of triceps muscle and anconeus muscle and tried to show possible denervation sites of these two structures during posterior approaches. The branching pattern of radial nerve innervating anconeus muscle and its deriving level from radial nerve was identified. Distance from a vertical line which is passing through lateral epicondyle to branching point was measured.Results The mean distance of the branching point of the nerve to medial head of triceps muscle and anconeus was 168.3 mm (range 130.36–185.4). The nerve to anconeus muscle ran along the posterior aspect of the humerus from the horizontal line passing through lateral epicondyle at a distance of 142.20 mm (range 153.72–136.41) medial to olecranon and at a distance of 47.45 mm (range 77.13–30.14) lateral to olecranon.Conclusion Although splitting the fibers of triceps proximaly increases the exposure of the posterior humerus, innervation of the lateral portion of the medial head of triceps muscle and anconeus muscle may be jeoparadized. Therefore, surgeons who have interest in elbow surgery; (1) should revise the course of the nerve to medial head of triceps and anconeus muscle, (2) be aware of possible iatrogenic injury of the extensor muscles of the elbow via transtricipital approaches, (3) try to choose a more conservative posterior surgical approach.     

Further experience with the medial circumflex femoral(GRACILIS) perforator free flap

The microsurgical transfer of the medial groin skin territory previously required this to be part of a transverse-oriented gracilis musculocutaneous free flap. As the concept of muscle perforator flaps has evolved, avoidance of muscle bulk and/or retention of muscle function here is also possible with the careful intramuscular dissection of the gracilis musculocutaneous perforators back to the usual medial circumflex femoral source vessel. This so-called medial circumflex femoral (GRACILIS) [MCF (GRACILIS)] perforator free flap has been successfully used seven times in six patients with minimal complications. The MCF (GRACILIS) muscle perforator flap may well represent the ideal skin flap: no muscle function is sacrificed; a reliable skin territory of large size is available; the dominant vascular pedicle is consistent in location; the flap may be harvested with the patient in a supine position; a combined conjoint flap including the gracilis muscle is optional; closure of the donor site leaves a medial groin scar that can be readily concealed; and flap dissection in this region is already very familiar to most microsurgeons.     

Ocular motility complications after endoscopic sinus surgery with powered cutting instruments.

OBJECTIVE: The purpose of this study was to describe 2 unique cases of ocular motility dysfunction after powered endoscopic sinus surgery and identify potential risk factors for extraocular muscle injury. STUDY DESIGN: Interventional case series. RESULTS: Patient 1 developed a restrictive global ophthalmoplegia after inadvertent entry into the medial orbit during powered endoscopic sinus surgery. Patient 2 had complete loss of adduction of the left eye as a result of transection of the medial rectus muscle by a powered cutting instrument. CONCLUSIONS: Despite advances in endoscopic sinus surgery technique and instrumentation, serious ophthalmic complications may still occur. Inadvertent entry into the medial orbital wall can result in ocular motility complications. Furthermore, it is possible that attraction of orbital contents into the tip of a powered cutting instrument may occur without significant entry into the orbital cavity. SIGNIFICANCE: It is important for endoscopic sinus surgeons to be aware of the intimate anatomical relationship between the orbit and sinuses, as well as the potential risks of the current instruments used in endoscopic sinus surgery.