Delayed onset porous polyethylene implant-related inflammation after orbital blowout fracture repair: four case reports
Aryasit et al. BMC Ophthalmology
Delayed onset porous polyethylene implant-related inflammation after orbital blowout fracture repair: four case reports
Orapan Aryasit 3
Danny S. Ng 2
Alice S. C. Goh 1
Kyung In Woo 0
Yoon-Duck Kim 0
0 Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , South Korea
1 International Specialist Eye Center (ISEC) , Kuala Lumpur , Malaysia
2 Department of Ophthalmology and Visual Sciences, Faculty of Medicine, The Chinese University of Hong Kong , Kowloon , Hong Kong
3 Department of Ophthalmology, Faculty of Medicine, Prince of Songkla University , Hat Yai, Songkhla , Thailand
Background: 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. Case Presentation: 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. Conclusions: 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 inflammation; Orbital fracture; Porous polyethylene
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 [
Longterm durability and safety of porous polyethylene implants
for orbital fracture reconstruction have been reported
]; 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 [
former case developed several bouts of inflammation
from 6 months after fracture surgery, and finally had
the implant removed 36 months after the original
]. 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.
All patients were male with mean age of 49 years
(range 35–69 years) (Table 1). None had a significant
past medical history or current disease. Orbital blowout
fracture occurred after automobile traffic accidents
(two patients), sports injury (one patient), and an
accidental fall (one patient). All patients had uneventful
blowout fracture repair using porous polyethylene
sheets (Medpor®, Porex Surgical, Newnan, GA, USA) of
1 mm thickness for correction of enophthalmos and
diplopia, using a transconjunctival approach for the
inferior wall and a transcaruncular approach for the medial
wall fracture. All implants were soaked in gentamicin
solution before implantation. Methylprednisolone (250 mg)
was infused intravenously at the end of the surgery, and
postoperative systemic antibiotics were administered.
None of the patients showed sinusitis at the time of
blowout fracture repair.
The onset of symptoms varied among the patients.
Patients 1 and 2 presented with subacute and chronic
eyelid swelling and pain, respectively (Figs. 1a, 2a).
Acute fulminant orbital inflammation was seen in
patients 3 and 4, who had eye pain, conjunctival injection,
and eyelid swelling with concurrent sinusitis. Patient 4
had an upper respiratory infection 2 weeks prior to the
presentation of orbital inflammation. None of them had
any anterior and posterior segment abnormalities or
optic nerve dysfunction. The implants for the patients
were well placed in the computed tomography (CT)
scan except for one patient. The implant in the patient
3 was misplaced in the posterior orbit showing a gap
between bony edge and the implant. All four patients
underwent surgical exploration and implant removal
under coverage of systemic antibiotics. The fibrotic
tissue around the implant was resected partially and left
behind for avoidance of vital orbital tissue damage. All
the explanted implants were submitted for Gram
staining and microbial culture.
Histopathological findings of the orbital mass revealed
fibrosis and chronic inflammation (Fig. 1). Patient 2
aYrs years, bF/U follow-up, cmos months, dCoNS coagulase negative Staphylococcus aureus, eCT computed tomography, fMR magnetic resonance imaging, gENT ear,
nose and throat
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
A lack or reduction of fibrovascularization into the
implant for orbital fracture repair might play a role in
implant infection. Porous polyethylene is susceptible to
infection in the early postoperative period before sufficient
fibrovascular ingrowth occurs in 3 months [
patient series showed delayed onset of porous
polyethylene sheet-related infection or inflammation after
10 months and up to 8 years, which lagged beyond the
duration for fibrovascularization. Mauriello et al.
studied 10 patients who developed infections after
alloplastic implants with silicone and gelatin film for orbital
floor fracture repair, and noted that the predisposing
factors were dental surgery, upper respiratory infection,
implant extrusion into the maxillary sinus, medial
implant migration resulting in dacryocystitis, rhinoplasty,
and snorting cocaine [
]. Custer et al. reported small
fistulous tracts between the supramid implant capsule
and the maxillary sinus that led to infection [
]. In our
case series, we speculate that the implanted porous
polyethylene sheet and integrated surrounding fibrous
tissue adjacent to the paranasal sinuses could still be an
incompetent barrier to sinus infection, even after a long
postoperative period. In patient 3, the edge of the
implant did not cover the whole defect of the medial wall
fracture, and which might serve as a precipitating cause
of infection (Fig. 3).
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
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 [
followup 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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