Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm.
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2015-11
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Abstract
Background
Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised.Materials and methods
A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article's reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis.Result
Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware management. Finally, our review revealed that there were no reported differences in outcomes between groups.Conclusions
Management of CMF hardware infections should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for management of CMF hardware infections based on this critical review of the literature is presented and discussed.Type
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Cahill, Thomas J, Rikesh Gandhi, Alexander C Allori, Jeffrey R Marcus, David Powers, Detlev Erdmann, Scott T Hollenbeck, Howard Levinson, et al. (2015). Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm. Annals of plastic surgery, 75(5). pp. 572–578. 10.1097/sap.0000000000000194 Retrieved from https://hdl.handle.net/10161/25662.
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Scholars@Duke
Alexander C Allori
Pediatric plastic and craniofacial surgeon, taking care of children with cleft lip/palate and other facial differences.
Dedicated to the improvement of multidisciplinary team-based care, especially by way of standardized, prospective outcomes measurement ("If you don't measure it, you can't improve it.")
Passionate about using causal inference methods to improve observational studies.
Jeffrey Robert Marcus
My research parallels our specialized clinical programs at Duke. I am involved in clinical research looking comprehensively at outcomes of cleft care to develop standards for evaluating a team’s overall success. Based on a recent grant from the Centers for Disease Control (CDC), we are also participating with several centers to look specifically at academic, psychosocial, and surgical outcomes for all children with clefts born in North Carolina. We are committed to the technique of nasoalveolar molding for children with clefts and are engaged in analyzing its benefits. In rhinoplasty, we have developed a model for nasal respiratory physiology, and we are looking at the effects of specific surgical procedures on nasal airflow and resistance. Our Craniofacial imaging lab has developed sophisticated software to analyze cranial shape, and we use these techniques to define abnormal conditions and their treatment relative to normal. Lastly, our craniomaxillofacial trauma team continues to look at factors associated with facial trauma in North Carolina in order to implement techniques and processes to deliver optimal care and results.
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