Kos Marcin, Brusco Daniel, Engelke Werner
Klinika Chirurgii Szczekowo-Twarzowej.
Polim Med. 2006;36(4):31-6.
Orbital fractures are one of the most frequent consequences following midfacial trauma. If not treated they can lead to serious optical complications as: double vision (diplopia), restriction of ocular motility, eyeball sinking (enophthalmos). Autogenic bone grafts although still wide and effectively used for reconstruction of the fractured orbital walls present some disadvantages. This is morbidity of the donor site, unforeseen resorption, time-consuming procedure and longer postoperative care. Because of that introduction of new materials for orbital reconstruction seems to be desirable. The aim of the work was to evaluate usefulness of the polydioxanone sheets (PDS) as a reconstructive material for orbital floor fractures.
From 1. 09. 2004 to 1. 02. 2006 111 patients with orbital fractures were treated in the Department of Maxillofacial Surgery Klinikum Minden. Age of the patients was between 15- 89 years (mean 43 y.); m:w ratio 78:33. There were 54 isolated orbital floor fractures (in 3 cases with additional medial wall fracture) and 57 zygomatico-orbito-maxillary fractures. The diagnosis was based on the clinical picture and coronal CT scans. The patients were operated through a transconjunctival (72%) or an infraorbital-Mustarde (28%) access and the orbital floor (medial orbital wall) was reconstructed with PDS sheet. Control examination was performed immediately, 1 moth and 6 months after the operative treatment.
There were 47% true "blow-out", 34% "trap-door" and 19% "en-clapet" fractures. The most important preoperative symptom was double vision (23%), restriction of ocular motility (18%), enophthalmos (3,6%), impairment of function of the infraorbital nerve (41%). Size of the defect was 3+/-1,13 cm(2) in "blow out" fracture, 1,8 +/-0,9 cm(2) in "trap-door" and 2+/-0,5 cm(2) in ,"en-clapet" ones. The primary reconstruction was successful in 97,3% of the cases. Any inflammation or reaction against implant was noted. Persistent double vision was present in 2,7%, restriction of ocular motility in 1,8% and enophthalmos in 0,9% after the primary procedure. These patients were submitted to reoperation. In 1 case badly positioned PDS sheet causing diplopia was removed. In another one, eyeball movement restriction was due to adhesions between the sheet and periorbital tissue. Visual status of this patient has improved after adhesiolysis. In 1 patient with a large bony destruction reconstruction only with PDS sheet was an inadequate treatment. In 7,2% of patients disturbances in the field of innervation of the infraorbital nerve were present 6 months after the surgery.
Alloplastic, resorbable PDS sheets in most cases were a valuable material for the reconstruction of the orbital floor (medial orbital wall). Mechanical properties of PDS seem to be not sufficient for the reconstruction of extremely large bony defects. In these cases use of autogenic bone grafts or a titanium mesh should be rather considered.
眼眶骨折是面中部创伤后最常见的后果之一。若不进行治疗，可能会导致严重的眼部并发症，如复视、眼球运动受限、眼球内陷（眼球凹陷）。自体骨移植虽然仍被广泛且有效地用于眼眶骨折壁的重建，但存在一些缺点。这包括供区的发病率、不可预见的吸收、耗时的手术过程以及较长的术后护理。因此，引入用于眼眶重建的新材料似乎是必要的。这项工作的目的是评估聚二氧杂环己酮片（PDS）作为眼眶底骨折重建材料的实用性。
2004年9月1日至2006年2月1日，明登市立医院颌面外科对111例眼眶骨折患者进行了治疗。患者年龄在15至89岁之间（平均43岁）；男女比例为78:33。其中有54例单纯眼眶底骨折（3例伴有额外的内侧壁骨折）和57例颧骨 - 眶 - 上颌骨折。诊断基于临床表现和冠状位CT扫描。患者通过经结膜入路（72%）或眶下 - 穆斯塔德入路（28%）进行手术，并用PDS片重建眼眶底（内侧眶壁）。在手术治疗后立即、1个月和6个月进行对照检查。
真性“爆裂性”骨折占47%，“活板门”骨折占34%，“夹钳”骨折占19%。最重要的术前症状是复视（23%）、眼球运动受限（18%）、眼球内陷（3.6%）、眶下神经功能障碍（41%）。“爆裂性”骨折的缺损大小为3±1.13平方厘米，“活板门”骨折为1.8±0.9平方厘米，“夹钳”骨折为2±0.5平方厘米。初次重建在97.3%的病例中成功。未发现任何针对植入物的炎症或反应。初次手术后，持续性复视发生率为2.7%，眼球运动受限为1.8%，眼球内陷为0.9%。这些患者接受了再次手术。1例因PDS片位置不当导致复视被取出。另一例中，眼球运动受限是由于该片与眶周组织粘连所致。该患者在粘连松解后视力状况有所改善。1例有大面积骨质破坏的患者仅用PDS片重建治疗不足。术后6个月，7.2%的患者存在眶下神经支配区域的紊乱。
在大多数情况下，异体可吸收PDS片是用于眼眶底（内侧眶壁）重建的有价值材料。PDS的机械性能似乎不足以重建极大的骨缺损。在这些情况下，应考虑使用自体骨移植或钛网。
