Comparison of Two-Point Versus Three-Point Fixation in Treatment of Zygomaticomaxillary Complex Fractures: An Updated Meta-Analysis

Abstract

Purpose: Zygomaticomaxillary complex (ZMC) fractures are a prevalent form of craniofacial trauma. However, no universally accepted fixation method has been established to prevent postreduction displacement in ZMC fractures.

Methods: Computerized and additional manual searches of the Medline, Embase, Chinese National Knowledge Infrastructure, and Cochrane Central database for potential studies, published from inception to May 2024, were performed. The inclusion criteria were as follows: randomized controlled trials comparing two-point and three-point fixation for managing ZMC fractures; studies with at least 5 weeks of follow-up; sufficient data published to estimate relative risk or standardized mean difference (SMD) with a corresponding 95% CI. The following exclusion criteria were applied: nonrandomized prospective studies, retrospective studies, case series, case reports, animal and in vitro studies; letters to the editor; review articles; case reports, and studies without discrete outcomes data. The predictor variable was type of fixation. The primary outcome variables assessed in this study encompassed fracture instability, malar asymmetry grade, malar height, and vertical dystopia. These parameters were employed as quantitative measures of displacement. The secondary outcome was postoperative complications, including enophthalmos. Systematic review with meta-analyses, 2 reviewers independently extracted the relevant data, with disagreements resolved by consensus. Statistical analyses were performed using Stata, version 18.0 (StataCorp LLC, College Station, TX, USA).

Results: After reviewing 205 publications, the final sample was composed of 8 studies, with 189 participants in the two-point group and 187 in the three-point group. Patients were followed up for at least 5 weeks in all the studies. Fracture instability was greater with 2-point fixation than with 3-point fixation (relative risk 2.63 [95% CI: 1.95-3.56] P < .001). Less vertical dystopia at 3 and 6 weeks were seen with 3-point fixation than with 2-point fixation (SMD 0.59, [95% CI 0.31-0.87] P < .001) (SMD 6.30, [95% CI 3.02-9.58] P < .001). Enophthalmos, malar asymmetry grade II (3 months), operation duration, malar height, and vertical dystopia (mm) 1 week did not differ between the groups.

Conclusions: Three-point fixation may provide more stability and less vertical dystopia than two-point fixation. This finding should help surgeons in making evidence-based decisions when selecting an optimal fixation pattern.