【doc】羟基磷灰石人工骨植入修复缺损及改善复视和眼球运动功能
羟基磷灰石人工骨植入修复缺损及改善复
视和眼球运动功能
~[~l~f)~.~~7a-~e6~/2003-10-25/~
3574ChineseJournalofClinicalRehabilitation,October252003Vol.7No.26 ~BasicResearch.
Reconstructionofthedefectoforbitalblowoutfracturesbyhy- droxyapatitebonesubstituteandrehabilitationofambiopiaand theophthalmickinesicfunction**
BinYang,Shao-HaiChang,Yu-QingLan,Man-YunXiao,Qing-QiHong BinYang~,Shao-HaiChang~,Yu-Qingtan%Man-YunXiao~,Qing-Qi Hang',~DepartmentofPlasticSurgery,2OrthodonticDepartment,3Depatment ofOphthalmology,SunYat-SenMemorialHospital,SunYat-SenUniversity, Guangzhou510120,GuangdongProvince,China
BinYang-~-,Male,HanNationality,Bornin1963,inMeizhouCity,Guang- dangProvince,China,Associateprofessor,Vice-chiefphysician,Doctorof ShanghaiSecondMedicalUniversityin1997.Researchdirection:plasticand reconstructivesurgery,ybdoctor@gzsums,edu.cn
Telephone:+86-20-87334335Fax:+86-20-87334335
Supportedby:ChinesePost-doctoralScientificFund,No.522205021* Received:2002-12-18Accepted:2003-06-04(26/GH)
YangB,ChangSH,LanYQ,XiaoMY,HangOO.Reconstrudionofthedefedoforbital blowoutfraduresbyhydroxyapatitebonesubstituteandrehabilitationofambiopiaand theophthalmicIdnesic[undion.ZhongguoL/nchuangKan,g;&2003;7{26):3574-6 AIM:Throughmeasuringthechangesoforbitalvolumepre-uad
poet-operati~ely,toinvestigatethereconstruetivesurgicalproceduresof enophthAimosandorbitalskeletaldefectsbyimplantinghydroxyapatitebone substituteinpatientswithorbitalblowoutfractureandevaluatetheeffecton
rehabilitationofeyemovement
METHODS:Allthe11patientswithorbitalblow-outfracturecamefromthe inpatientsinCenterofCranio-MaxillofacialSurgery,Sun-YatSenUniversity h-am1997to2000with6malesand5females,aged18-42year&Thefeatures oforbiteddeformities,thechangesoforbitalvolumeandthemechanismsof enophthAimosin11patientswithorbitalblowoutfractureswereanalyzedby meansofthree-dimensioualcomputer-assisteddiagnosticanddesignsys- temThereconstructiveoperationswereemployedonthese11patientswith orbitalblowoutfracturestocorrectdeformitiesandrestoreorbitalvolumeby implantingautogenousbonegraftsorhydroxyapalJtebonesubsti- tutes.Hydrexyapatitebonesubstitutewasimplantedtoreconstructtheorbital bonydefectandimprovetheeyemovement
RESULTS:Preoperativelythedeviationoforbitalvolumesbetweennormaland traumaticsidewas(9.24-2.8)em3,whichshowedasi~ifieantdifference betweentwosides(t=9.740,P<0.05).Pest-operativelythedeviationwas (0.544-0.18)cm3,therewasnotasignificantdifferencebetweenthem(P> 0.05).Therewerenotseriouscomplicationssuchasinfectionofbonegraft, exposureofhydroxyapatiteimplantinallpatients.Ofthese11patients,10pa- tientsgotsatisfactoryappearanceofeyelidsandorbit,ofwhichthediplopiaand enophthAimoswerecorrected,witheyemovementfunctionrestoringnormally. Onepatientremaineddlplopiaaftersurgicalcorrection.
CONCLUSION:Implantingautogenousbonegraftsandhydroxyapatitebone substitutestorestoreorbitalvolumeandreleasingentrappedextmocuLarmus- cleswereprovedtobeeffectiveforimprovingeyemovementfunctionandana- biopiaafterfracture.
INTRODUCTION
Thetoni.clinicalmanifestationsoforbitalblowoutfracturesinclude enophthalmos,dip]opia,disturbanceofophthalmickinesicfunction andinjuryinfraorbitalnerveandnnsolacrlmalduct.Afterclinicalre- search,Converseeta/pointedoutthatenophthalmos,diplopia,dis-
~ceofophthalmickinesicfunctionweremainlycausedbyher- niafionorentrapmentoforbitalcontentsandextraocularmusclesinto paran~alsinusesafterorbitblowoutfracture;andthetreatmentsin- cludedreleasingentrapments,restoringextraocularmusclesbalance, andimplantinghighpolymermaterials,suchasteflon,intoorbital cavitytocorrectorbitaldeformities.Incurrentclinic,thematerials mostlyusedtocorrectorbitaldeformitiesincludeantogenonsbone graftsandbioactivebonesubstitutes.Inthisstudy,thecomputer-alded three-dimensionaldiagnosisanddesignsystemforcraniofacialsurgery (3DCMFCADS)[1.2]wereusedtodiagnoseorbitalblow-outfracnavs quantitativelyandqualitatively,tostudythemech--i~mofenoph- thalmos,diplopia,deformitiesoforbitanddisturbanceofopthalmi~ kinesicfunction,andtoevaluatetheeffectofimplantinghydroxyap- atitebonesubstituteintoorbitcavitytocorrectdeformitiesand diplopiaandrestoreophthalmickinesicfunction.
MATERIALSANDMETHODS
Subj~ts
Allthe11inpatientswithorbitalblow-outfracturecamef~mthe CenterofCranio-M-~inofaeialSurgery,Sun-YatSenUniversityf~m 1997to2000.Allofthemwerepure.nih~dorbitalblow-outfrao~ tures,with6malesandtheother5females,ran~.ginagef~om18to 42years,withameanof31years,Thecausesofthefractureincluded trafficaccidentsofvehicleandshipandathletictraOthercran- iofacialtrsticdeformitieswereexcluded.
Ma/tads
D/.g,,oa/co~y~/+
Inthese11patients,CTimagingmaterialsofposttmumalicdefectsof orbitalboneswereallobtainedbystandardmethed[~"3].ThentheCT im,~eswereinputintothe3DCMFCADSthroughscannervideo-digital signedtransferring.Theimageswereprocessedbyimageprocessing
softwareunderwindowsstandardmode,andthree-dimensionelmea- surementofthe..gle,distance,areaandvolumeoftheCTsectional im~esandthree-dimensionalimageswere~-~dyzedwithmeasurement progran~Alongthebonyorbitalrim,theareaoforbitwasdescribed.And theareavaluewasobtainedthroughpixels.mm,,tlon.Themeanvalueof orbitalareaofthetwoadjacentCThtyerswasmultipliedbytheheightto obtaintheorbitalvolume(OV)betweenthetwohtyers,thenallthevol- tuneswereaddeduptoobtainthewholeorbitalvolum~Allthematerials wereinputtothe3DCMFCADScreatedbytheanthozI]'2],andthemethod setupbytheauthorwasusedtomeasureOVofthenorm,dabnormal sideorbitalcavityandapex-globedistance(AGD).
Accordin8toOVandapexglobedistanced(AGD)measuredthrough 3DCMFCADS,thevolumeofautogenousbonegraftorbonesubstitute tobeimplantedintotheorbitalcavityandthedistanceoftheeyeballto bereplacedanteriorlyweredecided.Andawaxmodelwasusedasa plateofautogenousbonegraftorbonesubstituteduringoperationwas prefabricated.
Operat/veprocedures
Incisionswerechosenaccordingtothepositionoforbitalfracture.The adherenceoffibrosistissueswasreleasedandtheorbitalcontents herniatingintoparanm~dsinuseswererettL~ed.Thenautogenousbone graftsofbonesubstitutewereimplantedintoorbitalcavitytocorrect thedeformitiesofmedialorbitalwallandflooroforbit,torestoreor- b/~dvolume,andtheeyeballwasreplacedanteriorlytorestoreits protrusiondegree,thenenophthalmoswascorrected.
Typicalcase:Male,41yearsold,thetraumaintherightorbitwas causedbyshippingaccident.Enoph&Almosanddildopiawerepre- sent.Thethree-dlmensionalCTimageshowedthattherewasnodam- ageofostconoflateralorbit(FigureI),buttheCTsliceimageshowed thatthereweremedialorbitalwed](]p.minapapyrsceaoftheethmoid)
ISSN1671-5926CN21-1470/Rwww.zglck[corn~~,~.~2y_~j~A,Z_~~/~}~][~ blow-outfracture,herniationofextmocularmuscleintoethmoidalsi- nus,subeideneesoforbitalfloorfractureandenophthahnos(Figure2) Beingmeasuredby3DCMFCADS,orbitalvolumeofthenomadside was28.52cm3,buttheabnormalsideenlargedto37.9cm3,witha difference9.4cm3.AndtheAGDofthenormalsidewas22.5mm~but theabnormalsideshortenedto17.8mm~withadifference4.7 ram.Accordingtothesizeoforbitalwalldefectandthechangeof shapeandvolume,twoplatesofhydroxyapatitobonesubstitutewere shaped.Inu'acanthusandlowereyelidincisionswdreusedtoreturn orbitalcontentsandreplaceeyebal]antoriody,thenthetwoplates wereimplantedtoeachofmedialorbitalwallandorbitalfloor(Figure 3),soenophthalmesanddiplopiawerecorrected(Figure4). Figure1Three-dimensional
imageoforbitpreoperatively
Figure2CTsectionalimage
preoperatively(enophthalmosand
fiacmreofmedialorbitalwall)
Figure3CoronalCTimageFigure4AxialCTimage(eyeball
postoperatively(bonesubstituteshasbeenreposited)havebeenimplantedtomedialwall
andflooroforbit)
Statisticalanalysis:Toanalyzethechangeofthevolumeand distancevalues,normal-abnormalself-pairedttestwasusedin statisticprocessingAtthesametime,OVandAGDTMwereanalyzed bycorrelativeregression.
RESULTS
CTroarer/rigresu/ts
Allthe11patientsunderwentCT~ntamlnationinsimilarcondition preoperativelyandpostoperatively.TheCTimagesobtainedwereinput
into3DCMFCADS.ThechangesofOV(cm3)andAGD(mm)werefrom pre-topost-operatiouwere9.3~2.8,0.54~0.18(P<0.01,t= 9.740),and5.1~0.7,0.15~0.03(P<0.05,t=2.253),respeo- tively.Andthechnng~werestatisticallyanalyzedtoshowasit,nificant correlation,whichcanbepresentedasthefollowingequatiomY=- 11.1342+0.7628X,correlativecoefficientr=0.9113.Thecornea, iris,lens,vitreousbodyandretinaofthese11patientswereeTamined withslitlampandophthalmoscope.Noabnormalitywasfound. F_ffectsofhydroxyapatiteimplantingoperationonophthalmic functions
Theoperatingproceduresofthese1Icasesweredesignedaccordln~to theresultsofqualitativeobservationandmeasurementanalysisof three-dimensionalimagespreoperativelyandwaxmedehofbone substituteswereshapedinadvance.Accordin~tothepositionoforbital wallfracture,incisionsofintracanthus,lowereyelidandconjunctival sacwereusedtoreconstructthedefects,orbitalcontentsreturned, eyeballsreplacedanteriorlyandbonesubstitutesimplantedtoorbital cavities.In10ofthepatients,enophihalmos,dysfunctionofeye movementfunctionanddiplopiawerecorrected,withgoodappear- ancesofeyelidandorbitalare&However,inoneoutofthe11pa- tients,theeyeballs'movementwasnotharmoniousbetweentwosides postoperatively,thediplopiaremainRuncorrected.
3575
DISCUSSION
Mechanismofdeformitiesoforbitalwallblow-outfractureand dys.fM~nofeyemoyostnt.function
Orbitalwallblow-outfracturesmostlyhappenatorbitalfloor(85%) andmedialorbitalwall(49%)[41.Ifnoproperreconstructivesurgical treatmentisreceivedearlyinpureorbitblowingoutfracture,therewill oftenbesomedeformitiesandfunctionaldimnbancooforbitand
eyeball,includlnsenophthalnms,diplopia,decreaseofvisionacuity, dysfunctionofeyemovementfunction,numbofinfiraorbitalareaandso on.Enophthalmesanddiplopiaarecommon,andtheyarethemA;, reasonsforpatientstoseeadoctor,andalsothemA;,indicationsfor surgicaltreatment[51.Earlyin1889,l~n~hadpaintedoutthatthe causeofenophthalmosafterinjurywasthediscrepancybetweenthe bonyOVandvolumeoforbitalcontent~Thisvolumediscrepancywas thoughttobecausedbythefollowingcauses:(~)Increasedbonyorbital volumefollowingtra(~)Fatnecrosiswithdecreasedsoft-tiesue volume;(~)l./mlringoftheglobeposteriorlybyentrappedtissue;(~) Displacementoforbitalcontentsoutofthebonyorbit.Enophthalmos anddiplopiawerebothseeninallthese11patients.ThroughCT continualsc~nnin~~imagesofbonedefectsoforbitalfloorandmedial orbitalwallandposteriordisplacementofeyebal]wereob- served.ExaminationsduringoperationsapprovedtheCTimagesof bonedefectoforbitalwall,andtheconcomitantherniationoffatand extraocularmusclesintoethmoidalsinusormarillarysinus,entrap- mentoradherenceoffiberlimitedthecontractilemovementofex- traocularmusclesandtheircoordinatedfunction.Observationsduring operationalsoapprovedthatthecausesofdiplopiawasthatdisplace- mentofeyeball,enophthalmos,entrapmentorfibrousadherence causedbyhemiatiouofextmocularmusclesintoma~ilarysinusor/ andethmoidalsinusthroughorbitalwalldefectsaftertr~;which resultodineyeballslookin~thinffsondifferenthorizontalplanesand themovementofextra~ularmusclesbeinglimited,whichweresim- ilartopreviousstudies.Becauseenophthalmosandentrapmentofex- traocularmusclescausedthetwopupils/ndifferenthorlzuntalora~,d planesandthetwoeyeballsmovedharmoniously.Thenthedeviationof theaxesofthetwoeyeballsappeared,Le.diplopiaappeared. Inthisstudy,three-dimensionalimagingwasusedtomeasurethe
orbitalvolumechan~eoforbitblow-outfractures.Andthech,mt,ewan st,~ti~ticallyanalyzedtorevealasitmificantcorrelationbetweenOV andAGD,andwhichwasali.carregressioncorrelationbetween them.Every10cm3theOVenlarged,a5mmshortenessofAGDfol- lowed.Thisindexpresentedthedegreeofenophthalmes.Itpresented thatthelargertheOVenlarged,theworsethedegreeofenophthalmos anddiplopi&ThatcoincidedwiththeresearchresultsofBiteeta/. ReconstructiveeHects
Thehydroxyapatitobonesubstituteimplantingintoorbitalcavitycau correctandrestoredeformitiesoforbitalwall,diplopiaandopbthAlmlc kinesicfunction.Basedonthemechanismoforbitalblow-outfractures whichpresentedabove,them,,i,treatmentprincipleoflatemmmatic orbitalandeyedofonnitiesincludedimplantingautogenousbonegrafts oralloplasticmaterialstorepairbonedefects,torestoreOV,tocor- rectdiplopiaandtoreplaceeyeball[6-8].Kawamoto'smethod[5]was usedintheseconsecutivepatients.Weelevatedperioatoumandez- pesuredmedialorbitalwallandorbitalfloorcompletely,returnedthe herniatingorbitalcontents,releasedtheentrapmentandfibrosislim- itationofextraocctdarmuscles,repositodtheeyeballanteriorlyto restoredthepmtrnsiondegreeofeyebalLInthis11patients,autoge- nouscostalbonegraftsandhydroxyapatitowereusedtorepairthe defectsofmedialorbitalwallandorbitalfloor.Theimplantsshouldbe putcarefullybehindtheequatorialaxisofeyeballIfnot,theeyeball wouldmoveupward,nolongerprotrudedanteriorly.Inordertoprevent theedemaoftissuesandtheabsorptionofimplants,theoverrestora-
3576
lionofprotrusiondegreeofeyeballwasnecessary.Iftheorbitalwall defectsofpureorbits]blow-outfractureweresmall~theimplants wouldattachtothebonywallstably,nospecialfixationwasneed-
ed.Thetreatmentprinciplefordiplopiaaaddisturbanceofopbthalmlc kinesicfunctioncausedbyorbitalblow-outfracturedependedonthe tlmingoftranmaIllearlytra,,ma;CTeTaminationshouldbedone.If anyherniationorentrapmentofextraocularmuscleswerefound,the reconstructiveoperationshouldbedoneassoonaspossible,soasto releasetheentrapmentofextraocularmuscles,implantautogenous bonegraftsorbonesubstitutetoobliteratedefectsofboneandreduce OV,keeptheanatomicplaceofeyeballandrestoreophthalmickinesic function.Inlatetraumatheextraocularmusclesentrappedatthesiteof fracturewouldbefibroticandextraocularmuscleparalyticdiplopia hadhappenedduetomotorneuropathy.Eventheextrocularmuscles entrappedhadbeenreturned,theirfimctionwouldnotberestored cempletely.Atthistime,surgicaltreatmentofextraocul~muscles couldbetakentoimprovethesymptomofdiplopi&Withtheabove methods,in10oftheescases,satidyingappearanceandfunctionwere obtained.Afterashorttermfollow-uppostoperativelyfor6to12 months,seriouscomplicationssuchasnerosisofautogenousbone, exposureofbonesubstitutes,anddisturbanceofophthalmickinesic functionandlacrimalappa.rabmfunctionhaven'tbeenobserved.]~ onedthe11patients,thediplopiaremaln~uncerrectly,itwasprob- ablycausedbythefibrosisofinferiorrectusmuscleafterextrapped intosinusandunrestorationofitscontractingfunctionwhichcaused theuncoordinativemovementoftheeyeballs.
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