Ultra-High Molecular Weight Polyethylene (marPOR) is a Suitable Material for the Reconstruction of Orbital Floor Fracture Defects in Human Cadavers

Although advances in biotechnology continue to introduce new materials for reconstruction of orbital floor defects, there is still inconclusive data about which material is best fit for orbital floor reconstruction [7]. However, current studies report PDS and Polyglactin 910/PDS composites, two materials which are widely used for orbital floor reconstruction, to be associated with increased infection rates and reduced ocular motility after surgery [7, 17, 18]. Due to their low stability, PDS and Polyglactin/PDS composites should be used only for defects smaller than 1–2 cm2 [10]. Titanium mesh offers higher strength and stability, but may cause tenderness, weather sensations, cicatricial eye movement disorders and beam hardening in x-ray examinations [12, 13, 19]. UHMWPE is an innovative biomaterial, which seemingly combines the advantages of PDS and titanium mesh, making it a suitable material for the reconstruction of orbital floor fractures. The present study is the first to investigate, if the use of UHMWPE leads to sufficient reconstruction of orbital volumes compared to a conventional Polyglactin 910/PDS composite patch (Ethisorb, Ethicon, Johnson & Johnson, New Brunswick, NJ, USA). For this purpose, UHMWPE (marPOR, KLS Martin Group, Tuttlingen, Germany) with two different strengths, 0.85 mm and 1.5 mm, was used. All materials led to statistically significant restoration of intact orbital volumes (orbital volumes before the fracture), but orbits that were reconstructed using marPOR with a strength of 0.85 mm exhibited the most accurate restoration with an absolute volume difference of − 0.05 mL from the mean volume of intact orbits. Using marPOR with a strength of 1.5 mm led to slight overcompensation. Mean orbital volumes tended to be smaller than intact orbital volumes with an absolute mean volume difference of − 0.34 mL, probably due to the simple size of the material. Even though Ethisorb is the thinnest material with a strength of 0.5 mm, orbits that were reconstructed using Ethisorb turned out to be 0.21 mL smaller on average compared to mean intact orbital volumes. Despite its thickness of 0.85 mm, marPOR offers a high ductility. The properties of UHMWPE are highly dependent on its microstructure rather than molecular mass, resulting in a very stable, but light-weight material with a molecular weight of 3.5–7.5 million g/mole [20, 21]. Furthermore, it provides a very high modulus of elasticity with 0.5–0.8 GPa. With its three-dimensional, highly porous compound structure, marPOR provides best conditions for neovascularization, osseointegration and therefore a good long-term stability [21]. Due to the porous structure, potential retrobulbar hemorrhage should not lead to any increase in retrobulbar pressure. The results and properties implicate that UHMWPE (marPOR) is not only very stable, preventing any soft tissue from prolapsing through the fracture, but also gently adapts to the bony contour of the orbit, which in turn leads to the most accurate volume restoration. In this context, it provides good manual ductility during the surgery. On the other hand, the stability of high-weight titanium mesh comes at the price of worse flexibility, demanding pre-contoured patient-specific titanium mesh for adequate orbital reconstruction, which is costly and time intensive, respectively [22]. In contrast to titanium mesh, UHMWPE is also radiolucent, does not affect any x-ray examinations and should not lead to tenderness or weather sensations [23]. Moreover, UHMWPE’s significance for achieving outstanding performances in total joint arthroplasties is unquestionably proven not only by its high wear-resistance, biocompatibility, durability, ductility and toughness, but also by the low infection rates below 1% of patients. [21, 24]. This may be a huge advantage over PDS as well as Polyglactin 910/PDS composites with reported infection rates up to 4% [7, 8]. However, further studies must clarify if this is also applicable in the context of orbital floor reconstruction. Because Polyglactin 910 and PDS are biodegradable materials, long-term stability, remnant defects and patient outcome significantly rely on the plates’ resorption rate. The risk of remnant defects have been increased as the plates had incomplete resorption, affecting one third of patients in a study of Tabrizi et al. [25]. This should not be seen in orbits reconstructed with marPOR as it is an inert, non-biodegradable material. We conclude that marPOR is an appropriate alternative material to be used for the reconstruction of orbital floor defects. However, clinical studies must be conducted in order to prove the effectiveness and safeness of marPOR in the context of orbital floor reconstruction. As it is already an approved CE medical product, marPOR could be used for orbital floor reconstruction today, minimizing any obstacles for further clinical evaluation.

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