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JOURNAL OF MAXILLOFACIAL TRAUMA
Rivista di Traumatologia Maxillofacciale
Official Journal of the International Society of Maxillofacial Trauma
Journal of Maxillofacial Trauma 2014 August;3(2):23-30
Plate and screw fixation of facial fractures: risk factors for hardware removal
Murray M. 1, Tandon R. 2, Elo J. 1, Herford A. 1
1 Oral and Maxillofacial Surgery, Loma Linda University, Loma Linda, CA, USA;
2 University of Texas Southwestern/Parkland, Memorial Hospital, Dallas, TX, USA
AIM: The need for hardware removal secondary to open reduction internal fixation of facial fractures is not uncommon, but carries with it certain costs and potential complications. This study seeks to identify common variables among patients who have undergone hardware removal following treatment for maxillofacial traumatic injuries, and suggests alternative means of therapy for those patients and fractures.
METHODS: A retrospective chart review study spanning the five-year period from January 1, 2006 to December 31, 2010 was performed. Patients who underwent hardware removal surgery either in the clinic or the operating room during that five-year period were included in the study. Descriptive and quantitative data included the following: age, sex, fracture location, approach to the facial skeleton, presence of teeth in the line of fracture, use of concomitant maxillomandibular fixation post-operatively, and reasons for plate/screw removal. During the five-year period, there were 1,748 patients treated for facial fractures. Of those, 1,471 required open reduction and internal fixation. 220 patients underwent hardware removal during this 5-year time period. 145 of these 220 patients had had hardware placed from a prior non-trauma related surgery (orthognathic surgery), and were thereby excluded from the study. 75 patients had hardware removed that was originally placed to treat a facial fracture.
RESULTS: Of all the patients treated at our three institutions during the 5-year period, 3% of patients required plate removal. Infection was the most common cause for removal. 19 of 75 patients (25%) required additional hardware placement after removal. The average time from hardware placement to removal was 22 months. 56 patients previously had an intraoral approach for fracture fixation; while 18 had an extraoral approach. One patient had both intra- and extraoral approaches. 27 patients had teeth in the line of fracture that later required removal, and 19 patients were placed into maxillomandibular fixation postoperatively for at least 2 weeks. The mandibular angle (fracture) was the most common location where hardware removal was required. The highest site for hardware failure by percentage was the naso-orbito-ethmoid (NOE) region.
CONCLUSION: Most hardware requiring removal after treatment for maxillofacial trauma occurs in the mandible secondary to infection, and most plates were removed within 1 year of placement. Proper perioperative measures should be taken to prevent infection. Proper fixation and immobilization is required for all fractures, but especially those of the mandibular angle and body, where muscle pull has the strongest influence. Though hardware removal was required in approximately 3% of the patients in our three institutions, very few cases resulted in a malunion or non-union requiring further fixation. This demonstrates that even though the patient required a secondary surgery to remove their hardware, the initial treatment was still effective in healing their facial fracture.