Craniomaxillofacial trauma
Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis

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Purpose

To date, no clear evidence-based guidelines exist pertaining to the ideal timing to perform surgical treatment of orbital fractures. The purpose of this study was to determine if early treatment of orbital fractures resulted in better patient outcomes.

Materials and Methods

We designed and implemented a systematic review and meta-analysis to test the null hypothesis of no difference in outcomes between different time intervals between orbital injury and surgical intervention. PubMed, Embase, the Cochrane Library, the Elsevier text mining tool database, and clinicaltrials.gov trial registry were queried. The quality of evidence was based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The predictor variable was the timing of operative repair (early vs late). The outcome variable was complete recovery. Other variables of interest were diplopia, enophthalmos, and preoperative motility restriction. Meta-analyses were performed when definitions of active and control interventions and patient outcomes were deemed similar. In addition, χ2 tests were performed to determine differences in clinical outcomes between early and late operative repair.

Results

Of the 1,160 articles reviewed, 20 met the inclusion criteria. Surgery performed less than 2 weeks after injury was significantly associated with greater odds of complete recovery of symptoms (odds ratio [OR], 6.9 [95% confidence interval (CI), 1.35-35.06]), as well as a lower incidence of postoperative diplopia (OR, 0.3 [95% CI, 0.1-0.9]) and enophthalmos (OR, 0.2 [95% CI, 0.1-0.9]). Repair performed less than 30 days after injury was associated complete resolution of preoperative motility restriction (OR, 24.6 [95% CI, 1.30-462.34]) as well as diplopia.

Conclusions

Differences in the timing of surgery and definition of patient outcomes, as well as variations in methods of evaluating postoperative outcomes, potentiate the risk of bias and warrant downgrading of the quality of evidence in a study. The timing of repair varied among 2, 4, and 8 weeks after injury. However, a short time to surgical intervention was significantly associated with resolution of vertical dystopia, postoperative enophthalmos, and motility restriction.

Section snippets

Study Design and Sample

To address the research question, we developed a protocol for a systematic literature review.13 We integrated evidence from primary studies and published systematic reviews.14, 15, 16 The study population was composed of all articles published until October 2018. For inclusion in the study sample, we defined the target population as children or adults with orbital fractures due to facial trauma, in addition to articles that defined interventions as having a shorter or longer timing (as defined

Results

Overall, 1,160 articles were reviewed, of which 20 met the inclusion criteria (Fig 1). These studies included a total of 614 patients undergoing operative orbital floor reconstruction, of whom 22 were enrolled in an RCT. These studies included 1 narrative review, 2 systematic reviews, 1 RCT, and 16 nonrandomized cohort studies7,30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51 comparing interventions, thus providing a post hoc analysis of the association

Discussion

The purpose of this study was to determine whether the available evidence pertaining to the timing of operative management in patients with orbital fractures portrayed differences in clinical outcomes and complication rates. We hypothesized that a shorter time to surgery would be associated with more favorable prognoses. Moreover, we aimed to compare patient outcomes, including preoperative and postoperative complications, between a shorter interval to intervention and a longer interval to

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    Conflict of Interest Disclosures: Dr Dorafshar receives royalties from Elsevier and KLS Martin and indirect research support from De Puy Synthes. All other authors do not have any relevant financial relationship(s) with a commercial interest.

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