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Delayed onset porous polyethylene implant-related inflammation after orbital blowout fracture repair: four case reports
© Aryasit et al. 2016
Received: 19 March 2015
Accepted: 21 June 2016
Published: 7 July 2016
Porous polyethylene implants are commonly used in orbital blowout fracture repair because of purported biocompatibility, durability, and low frequency of complications. Delayed inflammation related to porous polyethylene sheet implants is very rare and no case series of this condition have been reported.
This is a retrospective review of clinical presentations, radiographic findings, histopathological findings, treatments, and outcomes of patients who developed delayed complications in orbital blowout fracture repair using porous polyethylene sheets. Four male patients were included with a mean age of 49 years (range 35–69 years). Blowout fracture repair was complicated with implant-related inflammation 10 months, 2 years, 3 years, and 8 years after surgery. Chronic and subacute orbital inflammatory signs were noted in two patients and acute fulminant orbital inflammation was found in two patients. Three patients developed peri-implant abscesses and one patient had a soft tissue mass around the implant. All patients underwent implant removal and two of these patients with paranasal sinusitis had sinus surgery. Histopathological findings revealed chronic inflammatory changes with fibrosis, and one patient had foreign body granuloma with culture positive Staphylococcus aureus.
Delayed complications with porous polyethylene sheets used in orbital blowout fracture repair may occur many years following the initial surgery in immunocompetent patients. Low-grade or fulminant inflammation could complicate blowout fracture repair related with the implant.
Delayed complications related to alloplastic implant materials in orbital blowout fracture repairs are infrequent and generally appear as isolated case reports. Warrier et al. reported inflammation and infection that developed 1.5–20 years after silicone implants for orbital fracture repair . Custer et al. described six cases of late infection/inflammation in supramid implants ranging from 8 to 16 years after implantation . Long-term durability and safety of porous polyethylene implants for orbital fracture reconstruction have been reported [3, 4]; however, there have been very few reported late complications. In a retrospective review of 30 patients, Ng et al. reported a patient who developed delayed onset recurrent implant infection leading to implant removal . Samimi et al. reviewed 21 explanted periorbital biomaterials due to nonresolving infection or exposure and reported one immunosuppressed patient who had granulomatosis with polyangiitis with an infected porous polyethylene sheet after 3 years . The former case developed several bouts of inflammation from 6 months after fracture surgery, and finally had the implant removed 36 months after the original surgery . In addition, the latter case involved an immunocompromised patient .
In this case series, we describe the clinicopathological features of inflammation after orbital blowout fracture repair using porous polyethylene sheets, which is rarely encountered after a long postoperative duration in immunocompetent patients .
Medical records of four consecutive patients who developed delayed complications related with porous polyethylene sheets after orbital blowout fracture repair at Samsung Medical Center between 2007 and 2010 were retrospectively reviewed. Delayed onset inflammation was regarded if an implant-related inflammation occurred 6 months later than the fracture repair. The clinical presentations, radiographic findings, histopathological findings, and treatment and outcome data were collected. The Samsung Medical Center Institutional Review Board approved the retrospective review of the patients’ data, and the study adhered to the tenets of the Declaration of Helsinki.
Clinical presentations, radiographic findings, histopathological findings, treatments, and outcomes
Patient number/Duration of onset of complication/Location of implant
Histopathological findings/Results of culture
F/Ub time (mosc)
Eye pain, diplopia with 2 mm hyperglobus, hypoesthesia for 14 days
Peri-implant soft tissue mass, clear sinus in CTe
Fibrosis with chronic inflammation and calcification/negative culture
Implant removal, mass debulking
Postoperative persistent hypoesthesia of the cheek, 0.5 mm of the hyperglobus
Persistent eyelid swelling for 5 months
Peri-implant low-signal intensity with surrounding tissue enhancement in T1-enhanced MRf, clear sinus
Foreign body granuloma/positive CoNSd culture
Implant removal, abscess drainage
Infection resolved without complications
Eye pain, skin redness, conjunctival injection, eyelid swelling, hyperdeviation with diplopia for 2 days
D-shaped low density mass with enhanced rim, mucosal thickening of ethmoid and maxillary sinuses in CT
Chronic sinusitis with eosinophils, features compatible with inflammation in the nasal mucosa/negative culture
Implant removal, abscess drainage, sinus drainage by ENTg surgeons
3 mm of enophthalmos
Eye pain, skin redness, conjunctival injection, eyelid swelling, proptosis for 1 day
D-shaped soft tissue-density mass with enhanced rim, mucosal thickening of ethmoid and maxillary sinuses in CT
Chronic inflammation in the nasal mucosal tissue/negative culture
Implant removal, abscess drainage, sinus drainage by ENT surgeons
Infection resolved without complications
Histopathological findings of the orbital mass revealed fibrosis and chronic inflammation (Fig. 1). Patient 2 showed foreign body granuloma with giant cell infiltration adjacent to the fragmented implant spicules (Fig. 2). Coagulase negative Staphylococcus aureus was cultured from the explant. All patients had clinical resolution after explantation and systemic broad spectrum antibiotic treatment (Figs. 1b, 2b).
Delayed inflammation related to orbital implantation for orbital fracture repair is very rare. Approximately 350 cases underwent orbital fracture repair using porous polyethylene sheets during the same period from 2007 to 2010 at Samsung Medical Center. Furthermore, there were no other cases out of 1000 patients throughout the entire surgical log of orbital fracture repair at the same institution since 1994. This complication is very rare but should be reported for clinicians who care for orbital fracture patients.
Patient 2 showed chronic inflammatory signs with abscess formation without sinusitis. The explanted porous polyethylene sheet was brittle and histopathological examination showed foreign body granuloma adjacent to the implant spicules. Microbial infection and long-term tissue inflammation could result in implant degradation. In an experimental study to examine the responses of implanted porous polyethylene after direct inoculation of Staphylococcus aureus into rats, electron microscopy showed bacteria and active inflammatory infiltrates on the degraded implant surface . In another animal study, giant cells were detected at the interface between the implants and surrounding granulation tissue, indicating a chronic foreign body reaction . In specific circumstances, porous polyethylene in the fracture site can precipitate chronic inflammation and foreign body reactions.
Three of the patients in this series were culture negative for microorganisms. We could not determine whether the reasons involved prior use of antibiotics or sterile inflammation.
Absorbable alloplastic materials are manufactured and used for orbital wall fracture. They were originally designed to sustain the prolapsed orbital tissue as long as the implant support was needed, and not to serve as a foreign body in the fracture site [14–20]. Long-term follow-up and accumulation of clinical experiences can help identify the proper implant for orbital wall fracture repair.
Porous polyethylene implants are commonly used in orbital blowout fracture repair because of purported biocompatibility, durability, and low frequency of complications. However, delayed onset of porous polyethylene implant infection or inflammation may complicate orbital fracture repair. Porous polyethylene sheets may provide an incompetent barrier to sinus infection, and can remain as a foreign body in the fracture site, resulting in an implant-related inflammation.
CT, computed tomography; ENT, ear, nose and throat; MR, magnetic resonance
Availability of data and materials
All the data supporting the findings is contained within the manuscript.
OA analyzed and interpreted the clinical data and wrote the manuscript. DN also assisted in writing and revising the original manuscript and its English revision. AG made substantial contributions to the experimental design and acquisition of clinical data. KIW and KYD conceived the study, participated in its design and coordination, and revised the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patients for publication of this case report and any accompanying images.
Ethics approval and consent to participate
The Samsung Medical Center Institutional Review Board approved the retrospective review of the patients’ data.
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