【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

【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. REFERENCES 1YangB,HuangHZ,ZhangDS.Theestablishmentofthethree-dimensionalcomput- er-assisteddiagnosisanddesigningsystemforcraniomaxillofacialsurgery,gouq/a~ HemianWalkeZazhi2000;10(4):288-91 2YangB,ZhangDS,HuangHZ,etal.Theclinicalapplicationsofthe three-dimensinnalcomputer-assisteddiagnosisanddesigningsystemforcraniomax- illofacialsurgery.ZhongguoZbengxingWaikeZazhi2001;17(2):80-3 3YangB,HuangHZ,ZhangDS.Acomparativestudybetweenthree-dimensionalCT imagemeasurementandanthropometryofcraniofacialstructures.KouqiangHemian WaikeZazhi2000;10(2):99-102 q3r~lll~fff~J/~.7~J/~.26~2003-10-25/~ ChineseJournalofClinicalRehabilitation,October252003Vol.7No.26 4ZhangDS.ZhangDishengplasticandreconstructivesurgery.Shanghai:Shanghai ScientificandTechnologicalPublishingHouse2002:317-26 5AmrithS,SanSM,LiraTC,LeeTK.Ophthalmixinvolvememincraniofacialtrau- ma.JCraniomaxillofacSurg2000;28(2):140-76KinnunenI,AitasaloK,PollonenM,VarpulaM.Reconstructionoforbitalfloor fracturesusingbioactiveglass.JCraniomaxillofacSurg2000;28:229-347YangJF,ChenZC,QiuLP,etal.EvaluationoncytotoxicityofHAcoatedartificial bone.XiandaiKangfu2001;5(11B):67 8ZhangWT.Themechanismofthehealingoflongbonedefect.ZhongguoL/nchuang KantgTCu2002;6(2):186-7 t~Y~',~,I~I~,M~,,',~I~',,l'~~.~t M,,~JM-~91"~,2.*~.It~,3I~,/'-~-,Af/"~$510120 Y~,~,1963~,/"~Af~*A,~-~,1997~~~g~1- ~'~:~,lJ~,lJ.~~,~,&~,~,'~#1"~1-~~~Eo lll'~-~~,]~.,~'-"~.~R(522205021)* []~j:~tt~~l~/~,~.~.~It~E)k-r'l~a~A~l~ ~-~J~:11~E~l~'~[fi:~(~I~q~Ill~:~]][l~'~i~qu,L,/E~[~J~:i-~'o~J6 ~,~5~,~lS-42~.X~11~t~l~E~l['~'~[f~J~f~'],--" ti[iJ~:;~]~'E~i~l--~l[~ll~J~i~)t2(9.3+2.S)c~m~,~J;i-~;~..l~J~ J~:t~:t~:i~l~.~(t=9.740,P<0.01);;~El~i~l--~l[~ll~J ~tY~(o.544.0.is)~m+,~~:~.~lt~(P>o.05)o~ ~;~1~1~1~.!~,~i~[It~,~o*~qu1~;~:~l~]l~l~.l~,I~ ~l~/~'~[~lllt~lll~l~t~'~o ~.Q'~'~':R318~l~/~:A~I~I'~':1671-5926(2003)26-3574-03 ~,~,'~t~,~@~,,,"~J~.~),3-~i~,~J$~ ~;~:~[]fll~]~J.~]~[J1.cp~l~li'~,2003,7(26):3574-6 ,com/2003nd/03-26zy.htm (EditedbyLiCH) ~'J-,LT.~'~FI~110041;2LT..~-~..x,.~.~:~=J-,.LT.~'~FI~ 110o16;~~F~g~AE~E~E~,~'~F~11OO31) ::~J~J-~'z~'~~];~:t~:~];,~'l~,~f~l~l~122~J(201fl]~)I~I1~ ~,~t~,~-~~JI~~,~T~t?o ~J'~.:1998/2001.~.,~J~122'~](201I~.),~-~96I~.,~" 115~,~f~5~12~o~l~.,~,)~l~l~l~/:~'~r~l~.;[~c~z~ JL~i~~-[~b'.~~:~:~3~~/F~$)~.Jl~x'~I~r~I~,~~1t~(1996~)o ~:~7~~~,~JDlii~~ ~T~,~l:q~,~~o~7~'~~ ~/t~fl~x:~j660~750p,m,2~/d,15min/~o~J~lt[~.~, ~o~l~g."~~~l1.0;~~0.6 g~~tT.*J~:2003-08-20(26/GW) P2~o ~i~::~]~2~5~,122~](201[1~.)i~J~fY~: J~:~_J~;~52I~,~(45I~,:~[~7I~;dt~J~;~131 ~(8I~,:~6I~,~.;~41~o201lt[~dt~5-7~125I~,~ ~(96I~,:~29I~;8~10~55I~,~(33I~,:~17 6Wo ~J~I~t~i~J~1~,~J~1~~ltAli~/~i~illr,:~~.Jl~:t~Et~:~j~,L.~-y~.-~,~,~JL ~J~~~;~,~~,~;~,