Objective
Complex orbital reconstruction is challenging because it is difficult to achieve adequate visualization intraoperatively and reconstruct the unique anatomy. Post-traumatic enophthalmos is the most common and challenging complication of orbital fracture. Although the current studies mainly support early orbital reconstruction which led to superior clinical outcomes, late orbital reconstruction is sometimes inevitable due to an untreated orbital defect or insufficient primary reconstruction. This study aimed to analyze the reconstructive outcomes of late complex orbital reconstruction under intraoperative navigation assistance.

Material and Methods
A retrospective study was conducted on consecutive 17 unoperated patients from 2015 to 2019 presenting with unilateral delayed primary or secondary complex orbital fractures at the Chang Gung Memorial Hospital, Linkou Branch. All patients underwent orbital reconstruction via intraoperative navigation more than 30 days after injury. The preoperative presentation and postoperative complications were described. CT-measurement outcomes were analyzed. Pearson Correlation analysis was performed to determine the relationship between enophthalmos and changes in orbital volume.

Results
All extensive orbital fractures were successfully reconstructed. Enophthalmos and hypoglobus were improved in all patients postoperatively. Average enophthalmos and hypoglobus among the 17 patients, evaluated by a 6-month postoperative follow-up CT scan, were significantly improved from 2.3mm to 0.2mm, 2.5mm to 1.5mm, respectively. There was a high correlation between the difference of the injured and uninjured orbital volume and the degree of enophthalmos (r= 0.72, p= 0.001), and for every 1 cm3 of orbital volume change, clinical enophthalmos was changed by 0.761 mm (Y = 0.761X, R2 = 0.89, p= 0.001). There were no major complications during the follow-up, and all patients were satisfied with their final appearance.

Conclusion
Based on the results, our surgical approach under the assistance of an intraoperative navigation system can be a safe, accurate, and effective method for the management of delayed primary and secondary complex orbital fractures. The approach optimizes clinical outcomes and particularly improves post-traumatic enophthalmos significantly in delayed primary and secondary orbital reconstruction.

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