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A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures
Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
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A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures Tymour Forouzanfar*, Erik Salentijn, Gina Peng, Bart van den Bergh Department of Oral and Maxillofacial Surgery/Oral Pathology (Head: Tymour Forouzanfar), VU University Medical Center, Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 26 September 2011 Accepted 11 December 2012
Despite many publications on the epidemiology, incidence and aetiology of zygomatic complex (ZC) fractures there is still a lack of information about a consensus in its treatment. The aim of the present study is to investigate retrospectively the Amsterdam protocol for surgical treatment of ZC fractures. The 10 years results and complications are presented. The study population consisted of 236 patients (170 males, 66 females, 210 ZC fractures, 26 solitary zygomatic arch fractures) with a mean age of 39.3 (SD: 15.6) years (range 4e87 years). The mean cause of injury was traffic accident followed by violence and fall. A total of 225 plates and 943 screws were used. Twenty-eight patients presented with complications, including wound infection (9 patients) and transient paralysis of the facial nerve (one patient). Seven patients (2.8%) needed surgical retreatment of whom four patients needed secondary orbital floor reconstruction as these patients developed enophthalmos and diplopia. In conclusion this report provides important data for reaching a consensus for the treatment of these types of fractures. Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Maxillofacial trauma Zygomatic complex fractures Protocol Consensus
1. Introduction Maxillofacial fractures account for a substantial proportion of traumatic injuries (Calderoni et al., 2011; Katarzyna and Piotr, 2010). The incidence of maxillofacial fractures varies with geographical area, socioeconomic trends, incidence of road traffic accidents, alcohol abuse, drug abuse and by season. The pattern of maxillofacial fractures presentation varies depending on the aetiology of the injury. Common causes of maxillofacial fractures include road traffic accidents (including motorcycle, automobile, bicycle, pedestrian), assaults, falls, stumbling, sports, industrial/ work related accidents and other miscellaneous causes (e.g. gunshot injuries, pathological fractures) (Calderoni et al., 2011; Naveen Shankar et al., 2011; van den Bergh et al., 2011b). An understanding of these factors may guide clinical research into the development of more effective prevention and treatment of these injuries (Calderoni et al., 2011). Several authors have noted that the zygomatic complex and maxilla are the most common maxillofacial fracture sites (Bogusiak and Arkuszewski, 2010; van den Bergh et al., 2011b). As with other maxillofacial bone fractures the prevalence of zygomatic complex
* Corresponding author. Tel.: þ31 204441031. E-mail addresses: [email protected] (T. Forouzanfar), b.vandenbergh@ vumc.nl, [email protected] (B. van den Bergh).
fractures is related to different conditions (Calderoni et al., 2011; Olate et al., 2010; Trivellato et al., 2011; van den Bergh et al., 2011b). Adequate reduction of the fracture is a constant challenge for surgeons due to the anatomical position of the complex. The zygomatic complex consists of 4 pillars attached by 4 suture lines. It includes the part of the orbital floor lateral to the infraorbital fissure, therefore a fracture of this complex is always accompanied by an orbital floor fracture. The aim of a treatment is reduction of the zygomatic bone, orbital floor and zygomatic arch (He et al., 2007; Hwang, 2010; Wang et al., 2008). In the past wire fixation was a treatment modality for zygomatic complex fractures (Lund, 1971; Pozatek et al., 1973). The introduction of rigid internal fixation using miniplates has lead to greater stability and less complications. The use of miniplates is now state of the art (Olate et al., 2010). There is no consensus on the best surgical access to the orbito-zygomatic complex. The majority of authors prefer to initially use the lower lid and lateral brow approach. On the other hand, some authors use the intraoral approach as first choice, because it results in a more stable reduction with a lower complication rate (Calderoni et al., 2011). Despite various publications on the epidemiology, incidence and aetiology of zygomatic complex fractures there remains no consensus agreement regarding treatment. The aim of this study was to retrospectively investigate the outcomes and complications of patients surgically treated for a zygomatic complex fracture according to our treatment protocol
1010-5182/$ e see front matter Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2012.12.004
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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2. Materials and methods
postoperatively). Osteosynthesis material was also removed for age related reasons. The material was removed 6e12 months after surgery for patients younger than 18 years old to prevent any possible growth restriction of the zygomatic complex due to the presence of the osteosynthesis material.
2.1. Data collection
2.3. Statistics
Hospital and outpatient records of patients surgically treated for zygomatic complex fractures from January 2000 to January 2010 were reviewed and analysed retrospectively. The patients were identified using the hospital database. All types of zygomatic complex fracture surgically treated by open or closed reduction were included. Patients with panfacial trauma and solitary blow-out fractures were excluded. Data collected included gender, age, cause of injury, pre and postoperative radiographical analysis, type of zygomatic complex fracture, treatment modality and complications.
Data was analysed using the Statistical Package for Social Sciences (SPSS) version 15.0. For parametric data Student t-test and for non-parametric data chi square tests were performed.
over a 10-year period. We hope that our study will contribute towards the formation of a consensus view on the treatment of zygomatic complex fractures.
2.2. Treatment protocol Zygomatic complex fractures were diagnosed on presentation to the Outpatient Department or Emergency Ward, using a combination of clinical and radiographic examination. Radiographic analysis included submentovertex and occipitomental views or a (conebeam) CT scan. If necessary an ophthalmology opinion was obtained pre- and postoperatively to record enophthamos and/or eyemovement disturbances. Patients were treated according to the department’s protocol demonstrated in Fig. 1. The fracture reduction was performed using a hook and if necessary the fractured bones were fixed. The preferred site of fixation was the lateral orbital rim. Where the reduction was unstable a second miniplate was placed at the zygomatico-alveolar crest. If necessary a third miniplate was placed at the infraorbital margin. KLS Martin 2.0 mm and/or 1.5 mm plates were used. As a training unit the departmental policy was to adhere to the treatment protocol, however the surgeon had the option to deviate from the protocol if necessary. During the surgical procedure a forced duction test was performed twice, before and after reduction of the zygomatic complex. If ocular movements were restricted and entrapment of the rectus inferior muscle was suspected, the orbital floor was explored. Another reason for exploration was the detection of a comminuted orbital floor fracture on the CT images. Where necessary the orbital floor was reconstructed using Medpor, titanium or autologous bone. The reconstructive material was chosen by the operating surgeon. Postoperatively all patients received standard analgesics (diclofenac 50 mg three times daily or paracetamol with codeine 1000/20 mg four times daily). Patients received prophylactic antibiotics for one week if either the zygomatico-alveolar crest or the infraorbital margin was used for fixation (either clindamycin 600 mg three times daily or amoxicillin-clavulanate 625 mg three times daily). Patients also received prophylactic antibiotics after orbital floor reconstruction. Postoperatively conventional radiographs (submentovertex and occipitomental views) were performed to assess the reduction, for teaching and medicolegal reasons. If the reduction was performed suboptimally and there were clinical signs of a malpositioned zygomatic complex, the patient was retreated. All patients were followed up weekly for the first 3 weeks postoperatively, then at 3 and 6 months as per the department’s protocol. Osteosynthesis material was only removed in cases of persistent infection that did not respond to oral antibiotics (after 2e3 months
3. Results The study population consisted of 170 males and 66 females with a mean age of 39.3 (SD: 15.6) years (range 4e87 years). In 210 patients the zygomatic complex was fractured, whereas 26 patients presented with a solitary zygomatic arch fracture. Fig. 2 demonstrates the cause of the fractures. The fractures were mainly the result of vehicle accidents, followed by violence. The left side was more affected (145 patients) than the right side (91 patients). There were no significant differences between males and females. The clinical signs and symptoms are shown in Table 1. Most patients presented with paraesthesia in the infraorbital nerve distribution (47.0%), followed by malar depression (37.3%) and haematomas/ecchymosis (36.0%). 3.1. Radiographical analysis The type of pre and postoperative analysis was divided into conventional radiographs, consisting of submentovertex and occipitomental views or a (conebeam) CT scan. In total 413 preoperative radiographic analyses were performed. Postoperatively 361 radiographs were taken. 3.2. Treatment modalities and operation duration All 26 patients with solitary zygomatic arch fractures were treated by reduction via the Gillies approach which was consistent with the department’s protocol. The mean operation time was 31.0 (SD: 8.9) min. Postoperative radiographs consisted of submentovertex and occipitomental views. No CT scans were performed. Of the 210 patients with zygomatic complex fractures 33 patients were treated with reduction without fixation. The remaining 177 patients underwent reduction and fixation using 225 plates (22 1.5 mm Martin-plates and 203 2.0 mm Martinplates) and 943 screws. The distribution and localisation of the plates is demonstrated in Fig. 3 and Fig. 4. The mean operation time for all zygomatic complex fractures was 65.9 (SD: 3.7) min. In 141 patients only one plate was placed. One hundred and thirty seven plates were placed on the lateral orbital rim. The plate was positioned on the zygomatico-alveolar crest in 2 patients. The surgeons felt that the zygomatic complex was most displaced at the zygomatico-alveolar crest in these patients as this approach gives better control of the reduction at this location. The infraorbital margin was used for fixation in 2 other patients. In both patients it was clear preoperatively that an orbital floor reconstruction was necessary. Two plates were required in 29 patients. In 26 patients the first plate was placed on the lateral orbital rim and in 3 patients on the zygomatico-alveolar crest. The second plate was fixed on the zygomatico-alveolar crest in 15 patients and on the infraorbital margin in 14 patients.
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
T. Forouzanfar et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
Fig. 1. Treatment protocol (s.r: stable reposition; i.r: instable reposition; s.f: stable fixation; i.f: instable fixation).
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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120
Patients
100 80 60 40 20 0 Fall
Violence Vehicle Sport accident accident
Other
Missing
Fig. 2. Mechanism of the injury.
Table 1 Clinical signs and symptoms.
Oedema Pain Hematomas/ecchymosis Malar depression Palpable bone deformity e intraoral Palpable bone deformity e extraoral Paraesthesia Mouth opening limitation Diplopia Enophthalmos
N (%)
Missing files (%)
64 62 85 88 37 72 111 32 20 10
38 173 23 108 136 115 69 88 68 78
(27.1) (26.3) (36.0) (37.3) (15.7) (30.5) (47.0) (13.6) (8.5) (4.2)
160
(16.1) (73.3) (9.7) (45.8) (57.6) (48.7) (29.2) (37.3) (28.8) (33.1)
Patients
140 120 100 80 60 40 20 0 0
1
2
3
4
5
Fig. 3. Used osteosynthesis plates.
Patients
3.3. Complications and retreatment As demonstrated in Table 2 the main complication consisted of a suboptimal reduction of the fracture (15 patients), of whom 12 patients needed no retreatment. The second most noted complication was wound infection (9 patients). In all patients the infection developed within 2e3 weeks of surgery. In 8 patients the infection was intraoral at the zygomatico-alveolar crest, whereas in one patient the infection was in the region of the lateral orbital rim. In the latter patient the osteosynthesis material was removed 5 weeks after surgery. All other patients were treated successfully with amoxicillin-clavulanate 625 mg, three times daily for one week. In total 7 patients needed secondary treatment. Two patients were retreated during their hospital stay. The first was treated for a solitary zygomatic complex fracture. After open reduction with fixation clinical analysis demonstrated a displaced zygomatic complex which required further treatment. The second patient presented with a displaced zygomatic arch fracture. Following closed reduction the radiographic analysis demonstrated a suboptimally performed reduction. The patient underwent successful surgical retreatment. Four patients underwent surgical retreatment after discharge. One of these patients had been treated for a fracture of the zygoma by closed reduction. This patient presented with clinical signs of a displaced zygomatic complex one week after discharge and further treatment was required. Retrospective review of the postoperative radiographs taken prior to discharge showed no malposition or indication for further surgery. The remaining 3 patients were retreated surgically between 2 and 4 weeks after discharge. These patients needed secondary correction of the orbital floor following a fracture of the zygomatic complex. The orbital floor was not initially treated during the reduction of the zygomatic bone, as these patients initially did not show clinical signs that could justify a primary orbital reconstruction (according to our department’s protocol, Fig. 1). The pre- and postoperative radiographs were simple plain views (submentovertex and occipitomental radiographs) which showed no displacement. The seventh patient underwent correction of an orbital floor reconstruction one month after the initial treatment. The inserted PDS-sheet had dislodged anteriorly. The fracture was part of a zygomatic complex fracture. Despite the primary reconstruction and retreatment the patient developed late enophthalmos and diplopia. A further successful reconstruction with a Medpor implant was necessary.
200
4. Discussion
150
There is considerable information available on the epidemiology and mechanism of injury for zygomatic bone fractures, however, there is a lack of information regarding treatment protocols and there is still no consensus on the treatment of these fractures. This retrospective analysis was performed to investigate our department’s protocol. In doing so we hope to contribute to the development of a consensus on the treatment of zygomatic complex fractures.
100 50 0 Lateral orbital rim
ZM buttress
Infraorbital rim
Para-nasal
Zygomatic arch
Fig. 4. Location of the osteosynthesis plates. Table 2 Postoperative complications.
Three patients needed fixation at all three buttresses. A 1.5 mm plate was placed paranasally in 3 patients in addition to the 3 buttresses. One patient was treated with 5 osteosynthesis plates: 3 on the buttresses, 1 paranasally and 1 on the zygomatic arch. Orbital floor reconstruction was performed in 13 patients using PDS-sheets (8 patients) and Medpor-implants (5 patients).
N (%) Wound infection Suboptimal reduction e no retreatment Suboptimal reduction e retreatment Secondary orbital reconstruction e retreatment Facial nerve damage e transient
9 12 3 4 1
(3.8) (5.1) (1.3) (1.7) (0.4)
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
T. Forouzanfar et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
In the last 10 years 236 patients with a fracture of the zygomatic complex were admitted to our department for surgical treatment. The main cause of injury was vehicle accidents, followed by violence and falls. These results are consistent with the literature as traffic accidents are frequently seen as the most frequent cause of maxillofacial trauma in many countries (Calderoni et al., 2011; Naveen Shankar et al., 2011; van den Bergh et al., 2011b). In recent years interpersonal violence has increased and it has surpassed traffic accident as the main causative event (van den Bergh et al., 2011b). Others point out an etiological transition tendency towards a rise in aggression over traffic accidents (Gomes et al., 2006; Hwang et al., 2009; Lee, 2009; Lee and Antoun, 2009; van Beek and Merkx, 1999). Twenty-six patients were diagnosed with a solitary fracture of the zygomatic arch. All of these patients were treated using the Gillies approach. In seven patients the reduction was not satisfactory on clinical analysis or following review of the postoperative radiographs. Thirty-three of 210 patients with zygomatic complex fractures were treated with reduction without fixation. The remaining patients were treated with reduction and fixation. As plate osteosynthesis has become state of the art in the treatment of facial fractures, all remaining fractures (N ¼ 177) were fixed with plates (Alkan et al., 2007; de Matos et al., 2010; Ellis et al., 1985). A total of 225 plates were used. Recent studies have stated that standard postoperative radiographical analysis of maxillofacial fractures is not necessary. Radiographs are taken routinely after treatment of maxillofacial trauma for several reasons, including surgical treatment evaluation, detection of defects after surgery before the patient is discharged, identification of the osteosynthesis material for future removal, for teaching and medicolegal reasons (Durham et al., 2006; Jain and Alexander, 2009; van den Bergh et al., 2011a). 413 preoperative and 361 postoperative radiographs were analysed in the treatment of 236 patients. This issue has to be investigated further and will not be discussed further as it is out of the scope of this study. In the author’s opinion performing routine postoperative radiographs is of questionable value considering that 361 postoperative radiographs were performed and only 1 patient was retreated on the basis of this evidence. Several authors (Jarrahy et al., 2011; Kaufman et al., 2008) propose a CT scan as the gold standard in diagnosing and planning zygomatic complex fractures. Our department’s protocol uses conventional radiographs to diagnose fractures although a CT scan is performed when required for treatment planning. Conventional radiographs have the advantage of being more cost effective and expose the patient to less irradiation. Figs. 5 and 6 demonstrate a zygomatic complex fracture with minimal displacement on conventional radiographs (submentovertex and occipitomental views). In this case a CT scan would not be necessary. Figs. 7 and 8 show conventional postoperative images after reduction with a hook. A CT scan may be advantageous for treatment planning in cases with comminuted orbital floor fractures, as demonstrated in Fig. 9. Fig. 10 demonstrates a postoperative coronal CT-image of a comminuted orbital floor fracture which was reconstructed with a Medpor-titanium implant. Irrespective of the increased cost and irradiation we have to admit that the decision to perform a scan is much easier nowadays following the introduction of the conebeam CT. Markowitz and Manson showed that the frontozygomatical area is not a good reference point for fracture reduction and that a second or perhaps even a third area of evaluation can be beneficial (Markowitz and Manson, 1989). Habal demonstrated good reduction by their sequential surgical approach using the zygomaticomaxillary buttress as first approach, followed by the infraorbital
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Fig. 5. Preoperative submentovertex radiograph of a zygomatic complex fracture on the right side.
Fig. 6. Preoperative occipitomental radiograph of a zygomatic arch fracture on the right side.
rim and frontozygomatical area in the third place (Habal, 2010; Ridgway et al., 2009). Ellis advised the zygomaticomaxillary approach as the first choice, followed by the infraorbital rim and lateral orbital rim (Ellis and Kittidumkerng, 1996). In contrast, in our department the lateral orbital rim approach is the first choice, followed by the zygomaticomaxillary buttress and the infraorbital
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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Fig. 9. Preoperative CT-image of a comminuted orbital floor fracture on the left side.
Fig. 7. Postoperative submentovertex radiograph of a zygomatic complex fracture on the right side. Fixation was not necessary.
Fig. 10. Postoperative CT-image of a reconstructed orbital floor on the left side. A Medpor-titanium implant was used for the reconstruction.
Fig. 8. Postoperative occipitomental radiograph of a zygomatic arch fracture on the right side.
rim as the latter approach is associated with higher complication rates (Bahr et al., 1992; Ridgway et al., 2009). During surgery the reduction is assessed by palpating the infraorbital rim and the zygomaticomaxillary buttress. If the fracture is adequately reduced, fixation is performed using a plate at the frontozygomatical suture. The development of the department’s approach was clarified by interviewing the senior surgeons. In the past fixation was performed by wiring and the best location for fixation with wires proved to be the frontozygomatical region. Following the introduction of osteosynthesis the department decided to use the same
approach, therefore the same approach is still used in the present protocol. This study did not demonstrate any differences in the incidence of infection between different fixation sites, this is in line with the literature. Recently Knepil and Loukota (Knepil and Loukota, 2010) described the type of contamination during surgery. Most fractures of the zygomatic complex may be classified as clean or cleancontaminated, depending on whether the surgical approach is transcutaneous or transoral. Clean operations in healthy patients have a low risk of infection, and therefore antibiotic prophylaxis is not indicated. Avoiding a transoral approach converts a cleancontaminated operation into a clean operation, which makes the use of prophylactic antibiotics unnecessary. Published data regarding the effectiveness of prophylactic antibiotics in the surgical treatment of maxillofacial fractures and especially zygomatic bone fractures is scarce, and the level of evidence is low (Zhang et al., 2010). The authors of the present study only used prophylactic antibiotics according to the department’s protocol. This protocol states that patients only receive prophylactic
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
T. Forouzanfar et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
antibiotics if either the zygomatico-alveolar crest or the infraorbital margin is used for fixation. As we did not investigate the patients’ opinion on the formation of scar tissue at the lateral orbital rim, we are not able to draw firm conclusions about this important subject. Although our results are in line with the literature, the extraoral approach is questionable if the same results can be achieved using an intraoral approach. 5. Conclusion This study gives an overview of 236 patients who underwent surgical treatment for a zygomatic complex fracture according to the “Amsterdam” protocol. Twenty-eight patients presented with complications, including wound infection (9 patients) and transient paralysis of the facial nerve (1 patient). Seven patients (2.8%) needed surgical retreatment, four of whom needed secondary orbital floor reconstruction for enophthalmos and diplopia. This report demonstrates important data that may improve the treatment of the zygomatic complex fractures and contribute towards reaching a consensus opinion on the management of this type of fracture. Funding No grants were used. References Alkan A, Celebi N, Ozden B, Bas B, Inal S: Biomechanical comparison of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104: 752e756, 2007 Bahr W, Bagambisa FB, Schlegel G, Schilli W: Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: a retrospective study. Plast Reconstr Surg 90: 585e591, 1992 Bogusiak K, Arkuszewski P: Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 21: 1018e1023, 2010 Calderoni DR, Guidi Mde C, Kharmandayan P, Nunes PH: Seven-year institutional experience in the surgical treatment of orbito-zygomatic fractures. J Craniomaxillofac Surg 39: 593e599, 2011 de Matos FP, Arnez MF, Sverzut CE, Trivellato AE: A retrospective study of mandibular fracture in a 40-month period. Int J Oral Maxillofac Surg 39: 10e15, 2010 Durham JA, Paterson AW, Pierse D, Adams JR, Clark M, Hierons R, et al: Postoperative radiographs after open reduction and internal fixation of the mandible: are they useful? Br J Oral Maxillofac Surg 44: 279e282, 2006 Ellis 3rd E, el-Attar A, Moos KF: An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 43: 417e428, 1985 Ellis 3rd E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 54: 386e400,1996, discussion 400e401 Gomes PP, Passeri LA, Barbosa JR: A 5-year retrospective study of zygomaticoorbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg 64: 63e67, 2006
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Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures Tymour Forouzanfar*, Erik Salentijn, Gina Peng, Bart van den Bergh Department of Oral and Maxillofacial Surgery/Oral Pathology (Head: Tymour Forouzanfar), VU University Medical Center, Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 26 September 2011 Accepted 11 December 2012
Despite many publications on the epidemiology, incidence and aetiology of zygomatic complex (ZC) fractures there is still a lack of information about a consensus in its treatment. The aim of the present study is to investigate retrospectively the Amsterdam protocol for surgical treatment of ZC fractures. The 10 years results and complications are presented. The study population consisted of 236 patients (170 males, 66 females, 210 ZC fractures, 26 solitary zygomatic arch fractures) with a mean age of 39.3 (SD: 15.6) years (range 4e87 years). The mean cause of injury was traffic accident followed by violence and fall. A total of 225 plates and 943 screws were used. Twenty-eight patients presented with complications, including wound infection (9 patients) and transient paralysis of the facial nerve (one patient). Seven patients (2.8%) needed surgical retreatment of whom four patients needed secondary orbital floor reconstruction as these patients developed enophthalmos and diplopia. In conclusion this report provides important data for reaching a consensus for the treatment of these types of fractures. Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Maxillofacial trauma Zygomatic complex fractures Protocol Consensus
1. Introduction Maxillofacial fractures account for a substantial proportion of traumatic injuries (Calderoni et al., 2011; Katarzyna and Piotr, 2010). The incidence of maxillofacial fractures varies with geographical area, socioeconomic trends, incidence of road traffic accidents, alcohol abuse, drug abuse and by season. The pattern of maxillofacial fractures presentation varies depending on the aetiology of the injury. Common causes of maxillofacial fractures include road traffic accidents (including motorcycle, automobile, bicycle, pedestrian), assaults, falls, stumbling, sports, industrial/ work related accidents and other miscellaneous causes (e.g. gunshot injuries, pathological fractures) (Calderoni et al., 2011; Naveen Shankar et al., 2011; van den Bergh et al., 2011b). An understanding of these factors may guide clinical research into the development of more effective prevention and treatment of these injuries (Calderoni et al., 2011). Several authors have noted that the zygomatic complex and maxilla are the most common maxillofacial fracture sites (Bogusiak and Arkuszewski, 2010; van den Bergh et al., 2011b). As with other maxillofacial bone fractures the prevalence of zygomatic complex
* Corresponding author. Tel.: þ31 204441031. E-mail addresses: [email protected] (T. Forouzanfar), b.vandenbergh@ vumc.nl, [email protected] (B. van den Bergh).
fractures is related to different conditions (Calderoni et al., 2011; Olate et al., 2010; Trivellato et al., 2011; van den Bergh et al., 2011b). Adequate reduction of the fracture is a constant challenge for surgeons due to the anatomical position of the complex. The zygomatic complex consists of 4 pillars attached by 4 suture lines. It includes the part of the orbital floor lateral to the infraorbital fissure, therefore a fracture of this complex is always accompanied by an orbital floor fracture. The aim of a treatment is reduction of the zygomatic bone, orbital floor and zygomatic arch (He et al., 2007; Hwang, 2010; Wang et al., 2008). In the past wire fixation was a treatment modality for zygomatic complex fractures (Lund, 1971; Pozatek et al., 1973). The introduction of rigid internal fixation using miniplates has lead to greater stability and less complications. The use of miniplates is now state of the art (Olate et al., 2010). There is no consensus on the best surgical access to the orbito-zygomatic complex. The majority of authors prefer to initially use the lower lid and lateral brow approach. On the other hand, some authors use the intraoral approach as first choice, because it results in a more stable reduction with a lower complication rate (Calderoni et al., 2011). Despite various publications on the epidemiology, incidence and aetiology of zygomatic complex fractures there remains no consensus agreement regarding treatment. The aim of this study was to retrospectively investigate the outcomes and complications of patients surgically treated for a zygomatic complex fracture according to our treatment protocol
1010-5182/$ e see front matter Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2012.12.004
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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2. Materials and methods
postoperatively). Osteosynthesis material was also removed for age related reasons. The material was removed 6e12 months after surgery for patients younger than 18 years old to prevent any possible growth restriction of the zygomatic complex due to the presence of the osteosynthesis material.
2.1. Data collection
2.3. Statistics
Hospital and outpatient records of patients surgically treated for zygomatic complex fractures from January 2000 to January 2010 were reviewed and analysed retrospectively. The patients were identified using the hospital database. All types of zygomatic complex fracture surgically treated by open or closed reduction were included. Patients with panfacial trauma and solitary blow-out fractures were excluded. Data collected included gender, age, cause of injury, pre and postoperative radiographical analysis, type of zygomatic complex fracture, treatment modality and complications.
Data was analysed using the Statistical Package for Social Sciences (SPSS) version 15.0. For parametric data Student t-test and for non-parametric data chi square tests were performed.
over a 10-year period. We hope that our study will contribute towards the formation of a consensus view on the treatment of zygomatic complex fractures.
2.2. Treatment protocol Zygomatic complex fractures were diagnosed on presentation to the Outpatient Department or Emergency Ward, using a combination of clinical and radiographic examination. Radiographic analysis included submentovertex and occipitomental views or a (conebeam) CT scan. If necessary an ophthalmology opinion was obtained pre- and postoperatively to record enophthamos and/or eyemovement disturbances. Patients were treated according to the department’s protocol demonstrated in Fig. 1. The fracture reduction was performed using a hook and if necessary the fractured bones were fixed. The preferred site of fixation was the lateral orbital rim. Where the reduction was unstable a second miniplate was placed at the zygomatico-alveolar crest. If necessary a third miniplate was placed at the infraorbital margin. KLS Martin 2.0 mm and/or 1.5 mm plates were used. As a training unit the departmental policy was to adhere to the treatment protocol, however the surgeon had the option to deviate from the protocol if necessary. During the surgical procedure a forced duction test was performed twice, before and after reduction of the zygomatic complex. If ocular movements were restricted and entrapment of the rectus inferior muscle was suspected, the orbital floor was explored. Another reason for exploration was the detection of a comminuted orbital floor fracture on the CT images. Where necessary the orbital floor was reconstructed using Medpor, titanium or autologous bone. The reconstructive material was chosen by the operating surgeon. Postoperatively all patients received standard analgesics (diclofenac 50 mg three times daily or paracetamol with codeine 1000/20 mg four times daily). Patients received prophylactic antibiotics for one week if either the zygomatico-alveolar crest or the infraorbital margin was used for fixation (either clindamycin 600 mg three times daily or amoxicillin-clavulanate 625 mg three times daily). Patients also received prophylactic antibiotics after orbital floor reconstruction. Postoperatively conventional radiographs (submentovertex and occipitomental views) were performed to assess the reduction, for teaching and medicolegal reasons. If the reduction was performed suboptimally and there were clinical signs of a malpositioned zygomatic complex, the patient was retreated. All patients were followed up weekly for the first 3 weeks postoperatively, then at 3 and 6 months as per the department’s protocol. Osteosynthesis material was only removed in cases of persistent infection that did not respond to oral antibiotics (after 2e3 months
3. Results The study population consisted of 170 males and 66 females with a mean age of 39.3 (SD: 15.6) years (range 4e87 years). In 210 patients the zygomatic complex was fractured, whereas 26 patients presented with a solitary zygomatic arch fracture. Fig. 2 demonstrates the cause of the fractures. The fractures were mainly the result of vehicle accidents, followed by violence. The left side was more affected (145 patients) than the right side (91 patients). There were no significant differences between males and females. The clinical signs and symptoms are shown in Table 1. Most patients presented with paraesthesia in the infraorbital nerve distribution (47.0%), followed by malar depression (37.3%) and haematomas/ecchymosis (36.0%). 3.1. Radiographical analysis The type of pre and postoperative analysis was divided into conventional radiographs, consisting of submentovertex and occipitomental views or a (conebeam) CT scan. In total 413 preoperative radiographic analyses were performed. Postoperatively 361 radiographs were taken. 3.2. Treatment modalities and operation duration All 26 patients with solitary zygomatic arch fractures were treated by reduction via the Gillies approach which was consistent with the department’s protocol. The mean operation time was 31.0 (SD: 8.9) min. Postoperative radiographs consisted of submentovertex and occipitomental views. No CT scans were performed. Of the 210 patients with zygomatic complex fractures 33 patients were treated with reduction without fixation. The remaining 177 patients underwent reduction and fixation using 225 plates (22 1.5 mm Martin-plates and 203 2.0 mm Martinplates) and 943 screws. The distribution and localisation of the plates is demonstrated in Fig. 3 and Fig. 4. The mean operation time for all zygomatic complex fractures was 65.9 (SD: 3.7) min. In 141 patients only one plate was placed. One hundred and thirty seven plates were placed on the lateral orbital rim. The plate was positioned on the zygomatico-alveolar crest in 2 patients. The surgeons felt that the zygomatic complex was most displaced at the zygomatico-alveolar crest in these patients as this approach gives better control of the reduction at this location. The infraorbital margin was used for fixation in 2 other patients. In both patients it was clear preoperatively that an orbital floor reconstruction was necessary. Two plates were required in 29 patients. In 26 patients the first plate was placed on the lateral orbital rim and in 3 patients on the zygomatico-alveolar crest. The second plate was fixed on the zygomatico-alveolar crest in 15 patients and on the infraorbital margin in 14 patients.
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
T. Forouzanfar et al. / Journal of Cranio-Maxillo-Facial Surgery xxx (2013) 1e7
Fig. 1. Treatment protocol (s.r: stable reposition; i.r: instable reposition; s.f: stable fixation; i.f: instable fixation).
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120
Patients
100 80 60 40 20 0 Fall
Violence Vehicle Sport accident accident
Other
Missing
Fig. 2. Mechanism of the injury.
Table 1 Clinical signs and symptoms.
Oedema Pain Hematomas/ecchymosis Malar depression Palpable bone deformity e intraoral Palpable bone deformity e extraoral Paraesthesia Mouth opening limitation Diplopia Enophthalmos
N (%)
Missing files (%)
64 62 85 88 37 72 111 32 20 10
38 173 23 108 136 115 69 88 68 78
(27.1) (26.3) (36.0) (37.3) (15.7) (30.5) (47.0) (13.6) (8.5) (4.2)
160
(16.1) (73.3) (9.7) (45.8) (57.6) (48.7) (29.2) (37.3) (28.8) (33.1)
Patients
140 120 100 80 60 40 20 0 0
1
2
3
4
5
Fig. 3. Used osteosynthesis plates.
Patients
3.3. Complications and retreatment As demonstrated in Table 2 the main complication consisted of a suboptimal reduction of the fracture (15 patients), of whom 12 patients needed no retreatment. The second most noted complication was wound infection (9 patients). In all patients the infection developed within 2e3 weeks of surgery. In 8 patients the infection was intraoral at the zygomatico-alveolar crest, whereas in one patient the infection was in the region of the lateral orbital rim. In the latter patient the osteosynthesis material was removed 5 weeks after surgery. All other patients were treated successfully with amoxicillin-clavulanate 625 mg, three times daily for one week. In total 7 patients needed secondary treatment. Two patients were retreated during their hospital stay. The first was treated for a solitary zygomatic complex fracture. After open reduction with fixation clinical analysis demonstrated a displaced zygomatic complex which required further treatment. The second patient presented with a displaced zygomatic arch fracture. Following closed reduction the radiographic analysis demonstrated a suboptimally performed reduction. The patient underwent successful surgical retreatment. Four patients underwent surgical retreatment after discharge. One of these patients had been treated for a fracture of the zygoma by closed reduction. This patient presented with clinical signs of a displaced zygomatic complex one week after discharge and further treatment was required. Retrospective review of the postoperative radiographs taken prior to discharge showed no malposition or indication for further surgery. The remaining 3 patients were retreated surgically between 2 and 4 weeks after discharge. These patients needed secondary correction of the orbital floor following a fracture of the zygomatic complex. The orbital floor was not initially treated during the reduction of the zygomatic bone, as these patients initially did not show clinical signs that could justify a primary orbital reconstruction (according to our department’s protocol, Fig. 1). The pre- and postoperative radiographs were simple plain views (submentovertex and occipitomental radiographs) which showed no displacement. The seventh patient underwent correction of an orbital floor reconstruction one month after the initial treatment. The inserted PDS-sheet had dislodged anteriorly. The fracture was part of a zygomatic complex fracture. Despite the primary reconstruction and retreatment the patient developed late enophthalmos and diplopia. A further successful reconstruction with a Medpor implant was necessary.
200
4. Discussion
150
There is considerable information available on the epidemiology and mechanism of injury for zygomatic bone fractures, however, there is a lack of information regarding treatment protocols and there is still no consensus on the treatment of these fractures. This retrospective analysis was performed to investigate our department’s protocol. In doing so we hope to contribute to the development of a consensus on the treatment of zygomatic complex fractures.
100 50 0 Lateral orbital rim
ZM buttress
Infraorbital rim
Para-nasal
Zygomatic arch
Fig. 4. Location of the osteosynthesis plates. Table 2 Postoperative complications.
Three patients needed fixation at all three buttresses. A 1.5 mm plate was placed paranasally in 3 patients in addition to the 3 buttresses. One patient was treated with 5 osteosynthesis plates: 3 on the buttresses, 1 paranasally and 1 on the zygomatic arch. Orbital floor reconstruction was performed in 13 patients using PDS-sheets (8 patients) and Medpor-implants (5 patients).
N (%) Wound infection Suboptimal reduction e no retreatment Suboptimal reduction e retreatment Secondary orbital reconstruction e retreatment Facial nerve damage e transient
9 12 3 4 1
(3.8) (5.1) (1.3) (1.7) (0.4)
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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In the last 10 years 236 patients with a fracture of the zygomatic complex were admitted to our department for surgical treatment. The main cause of injury was vehicle accidents, followed by violence and falls. These results are consistent with the literature as traffic accidents are frequently seen as the most frequent cause of maxillofacial trauma in many countries (Calderoni et al., 2011; Naveen Shankar et al., 2011; van den Bergh et al., 2011b). In recent years interpersonal violence has increased and it has surpassed traffic accident as the main causative event (van den Bergh et al., 2011b). Others point out an etiological transition tendency towards a rise in aggression over traffic accidents (Gomes et al., 2006; Hwang et al., 2009; Lee, 2009; Lee and Antoun, 2009; van Beek and Merkx, 1999). Twenty-six patients were diagnosed with a solitary fracture of the zygomatic arch. All of these patients were treated using the Gillies approach. In seven patients the reduction was not satisfactory on clinical analysis or following review of the postoperative radiographs. Thirty-three of 210 patients with zygomatic complex fractures were treated with reduction without fixation. The remaining patients were treated with reduction and fixation. As plate osteosynthesis has become state of the art in the treatment of facial fractures, all remaining fractures (N ¼ 177) were fixed with plates (Alkan et al., 2007; de Matos et al., 2010; Ellis et al., 1985). A total of 225 plates were used. Recent studies have stated that standard postoperative radiographical analysis of maxillofacial fractures is not necessary. Radiographs are taken routinely after treatment of maxillofacial trauma for several reasons, including surgical treatment evaluation, detection of defects after surgery before the patient is discharged, identification of the osteosynthesis material for future removal, for teaching and medicolegal reasons (Durham et al., 2006; Jain and Alexander, 2009; van den Bergh et al., 2011a). 413 preoperative and 361 postoperative radiographs were analysed in the treatment of 236 patients. This issue has to be investigated further and will not be discussed further as it is out of the scope of this study. In the author’s opinion performing routine postoperative radiographs is of questionable value considering that 361 postoperative radiographs were performed and only 1 patient was retreated on the basis of this evidence. Several authors (Jarrahy et al., 2011; Kaufman et al., 2008) propose a CT scan as the gold standard in diagnosing and planning zygomatic complex fractures. Our department’s protocol uses conventional radiographs to diagnose fractures although a CT scan is performed when required for treatment planning. Conventional radiographs have the advantage of being more cost effective and expose the patient to less irradiation. Figs. 5 and 6 demonstrate a zygomatic complex fracture with minimal displacement on conventional radiographs (submentovertex and occipitomental views). In this case a CT scan would not be necessary. Figs. 7 and 8 show conventional postoperative images after reduction with a hook. A CT scan may be advantageous for treatment planning in cases with comminuted orbital floor fractures, as demonstrated in Fig. 9. Fig. 10 demonstrates a postoperative coronal CT-image of a comminuted orbital floor fracture which was reconstructed with a Medpor-titanium implant. Irrespective of the increased cost and irradiation we have to admit that the decision to perform a scan is much easier nowadays following the introduction of the conebeam CT. Markowitz and Manson showed that the frontozygomatical area is not a good reference point for fracture reduction and that a second or perhaps even a third area of evaluation can be beneficial (Markowitz and Manson, 1989). Habal demonstrated good reduction by their sequential surgical approach using the zygomaticomaxillary buttress as first approach, followed by the infraorbital
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Fig. 5. Preoperative submentovertex radiograph of a zygomatic complex fracture on the right side.
Fig. 6. Preoperative occipitomental radiograph of a zygomatic arch fracture on the right side.
rim and frontozygomatical area in the third place (Habal, 2010; Ridgway et al., 2009). Ellis advised the zygomaticomaxillary approach as the first choice, followed by the infraorbital rim and lateral orbital rim (Ellis and Kittidumkerng, 1996). In contrast, in our department the lateral orbital rim approach is the first choice, followed by the zygomaticomaxillary buttress and the infraorbital
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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Fig. 9. Preoperative CT-image of a comminuted orbital floor fracture on the left side.
Fig. 7. Postoperative submentovertex radiograph of a zygomatic complex fracture on the right side. Fixation was not necessary.
Fig. 10. Postoperative CT-image of a reconstructed orbital floor on the left side. A Medpor-titanium implant was used for the reconstruction.
Fig. 8. Postoperative occipitomental radiograph of a zygomatic arch fracture on the right side.
rim as the latter approach is associated with higher complication rates (Bahr et al., 1992; Ridgway et al., 2009). During surgery the reduction is assessed by palpating the infraorbital rim and the zygomaticomaxillary buttress. If the fracture is adequately reduced, fixation is performed using a plate at the frontozygomatical suture. The development of the department’s approach was clarified by interviewing the senior surgeons. In the past fixation was performed by wiring and the best location for fixation with wires proved to be the frontozygomatical region. Following the introduction of osteosynthesis the department decided to use the same
approach, therefore the same approach is still used in the present protocol. This study did not demonstrate any differences in the incidence of infection between different fixation sites, this is in line with the literature. Recently Knepil and Loukota (Knepil and Loukota, 2010) described the type of contamination during surgery. Most fractures of the zygomatic complex may be classified as clean or cleancontaminated, depending on whether the surgical approach is transcutaneous or transoral. Clean operations in healthy patients have a low risk of infection, and therefore antibiotic prophylaxis is not indicated. Avoiding a transoral approach converts a cleancontaminated operation into a clean operation, which makes the use of prophylactic antibiotics unnecessary. Published data regarding the effectiveness of prophylactic antibiotics in the surgical treatment of maxillofacial fractures and especially zygomatic bone fractures is scarce, and the level of evidence is low (Zhang et al., 2010). The authors of the present study only used prophylactic antibiotics according to the department’s protocol. This protocol states that patients only receive prophylactic
Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004
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antibiotics if either the zygomatico-alveolar crest or the infraorbital margin is used for fixation. As we did not investigate the patients’ opinion on the formation of scar tissue at the lateral orbital rim, we are not able to draw firm conclusions about this important subject. Although our results are in line with the literature, the extraoral approach is questionable if the same results can be achieved using an intraoral approach. 5. Conclusion This study gives an overview of 236 patients who underwent surgical treatment for a zygomatic complex fracture according to the “Amsterdam” protocol. Twenty-eight patients presented with complications, including wound infection (9 patients) and transient paralysis of the facial nerve (1 patient). Seven patients (2.8%) needed surgical retreatment, four of whom needed secondary orbital floor reconstruction for enophthalmos and diplopia. This report demonstrates important data that may improve the treatment of the zygomatic complex fractures and contribute towards reaching a consensus opinion on the management of this type of fracture. Funding No grants were used. References Alkan A, Celebi N, Ozden B, Bas B, Inal S: Biomechanical comparison of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104: 752e756, 2007 Bahr W, Bagambisa FB, Schlegel G, Schilli W: Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: a retrospective study. Plast Reconstr Surg 90: 585e591, 1992 Bogusiak K, Arkuszewski P: Characteristics and epidemiology of zygomaticomaxillary complex fractures. J Craniofac Surg 21: 1018e1023, 2010 Calderoni DR, Guidi Mde C, Kharmandayan P, Nunes PH: Seven-year institutional experience in the surgical treatment of orbito-zygomatic fractures. J Craniomaxillofac Surg 39: 593e599, 2011 de Matos FP, Arnez MF, Sverzut CE, Trivellato AE: A retrospective study of mandibular fracture in a 40-month period. Int J Oral Maxillofac Surg 39: 10e15, 2010 Durham JA, Paterson AW, Pierse D, Adams JR, Clark M, Hierons R, et al: Postoperative radiographs after open reduction and internal fixation of the mandible: are they useful? Br J Oral Maxillofac Surg 44: 279e282, 2006 Ellis 3rd E, el-Attar A, Moos KF: An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 43: 417e428, 1985 Ellis 3rd E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 54: 386e400,1996, discussion 400e401 Gomes PP, Passeri LA, Barbosa JR: A 5-year retrospective study of zygomaticoorbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J Oral Maxillofac Surg 64: 63e67, 2006
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Please cite this article in press as: Forouzanfar T, et al., A 10-year analysis of the “Amsterdam” protocol in the treatment of zygomatic complex fractures, Journal of Cranio-Maxillo-Facial Surgery (2013), http://dx.doi.org/10.1016/j.jcms.2012.12.004