外伤后眶骨畸形伴眦角移位后期整复的近期疗效

SECONDARY RECONSTRUCTION OF POSTTRAUMATIC ORBITAL DEFORMITIES WITH CANTHUS DISLOCATION

目的探讨外伤后眶骨畸形伴眦角移位的二期修复方法。方法1998年6月-2007年7月,收治外伤后陈旧性眶骨骨折畸形伴内、外眦韧带断裂移位37例。男22例,女15例;年龄13～46岁,平均21岁。车祸伤29例,拳击伤6例,木棍击伤2例。伤后至该次手术时间3个月～8年。眶颧骨折11例,鼻眶筛骨折15例,合并眶颧、鼻眶筛骨折8例,额骨骨折3例。第1次接受整复手术31例,第2次手术6例。手术采用头皮冠状切口、下睑睫毛缘切口及口内龈颊沟切口入路,根据骨折畸形错位程度分别将骨折截断复位或对凸起处凿除磨平、凹陷处充填固定,重建正常眶缘结构;自体骨或Medpor眶内容充填薄片修复眶下壁,矫正眼球内陷畸形;充分松解内眦韧带与邻近组织的瘢痕粘连,根据眶内侧壁骨折有无移位情况,选择钢丝直接固定或骨折片复位后行内眦韧带固定术。结果36例术后切口Ⅰ期愈合,1例因合并上颌窦炎引起重建眶下缘的肋骨感染致手术失败。其中24例获随访,随访时间3～6个月,未见植入物移位、排斥脱出及感染等并发症。12例眼球内陷患者有2例矫正不足。18例内眦韧带断离眦角移位的患者有3例矫正不足。其余患者外观明显改善,术后6个月对3例自体骨和Medpor移植患者行CT检查,显示固定良好。结论外伤后眶骨骨折伴眦角移位的畸形后期修复应重视骨折复位与填充,同时兼顾眦角移位修复和眼球内陷矫正,全面考虑,综合治疗才能取得理想效果。

Objective To explore the secondary surgical reconstruction for orbital bone deformities accompanied with canthus dislocation after trauma. Methods From June 1998 to July 2007, 37 patients with secondary orbital bone fracture deformity accompanied with medial or lateral canthal ligament dislocation posttraumatically were treated, among whom there were 22 males and 15 females, aged 13-46 years old （21 on average）. There were 29 cases of traffic accident, 6 of boxing injury and 2 of beating injury by sticks. The latest reconstruction was performed on these 37 cases during 3 months to 8 years after injuries. There were 11 cases of orbital maxillary zygoma （OMZ） fracture, 15 of naso-orbito-ethmoid （NOE） fracture, 8 of OMZ and NOE fracture and 3 of frontal fracture. There were 31 patients who were reconstructed for the first time and 6 for the second time. Typical bicoronal and subcilliary incisions and intro-oral approach were employed to expose all the fractured sites. According to the fractured position and the degree of deformity and dislocation, the orbito-zygomatic fracture was repositioned after osteotomy and rigid fixation, or the heaved fragments were trimmed with a burr and the depressed fragments were filled with autogenous bone such as ilium, cranial outer table or Medpor in order to reconstruct orbital wall framework; the orbital walls were repaired to correct the enophthalmos with autogeneous bone or Medpor after the herniated orbital contents were released. The medial canthal ligament was anchored superior-posteriorly to the lacrimal fossa with transnasal wires fixation or fixed with titanium miniplates and nails. Results The 36 patients＇ incisions obtained healing by first intention after the operation, and 1 case failed because of wound infection from maxillary sinusitis. There were 24 patients who were cured successfully with facial appearance and function improved significantly. During the follow-up for 3-6 months, no complication was found such as dislocation of the implant, rejection and infection. Two patients still showed slight enophthalmos while 3 patients with canthus dislocation regained improved appearances but not satisfactory. At 6 months after operation, the CT scan conducted in 3 patients with autogenous bone and Medpor grafting showed all fractures were fixed rigidly. Conclusion Surgical reduction combined with bone grafting is a satisfactory method for the correction of secondary orbital bone deformity, and the repair of canthus dislocation and correction of enopbthalmos should be considered at the same time. An ideal result could be achieved only through all-round consideration and comprehensive treatment.