British Journal of Oral and Maxillofacial Surgery 44 (2006) 480–481

Endoscopically assisted reduction and fixation of condylar

neck/base fractures—The learning curve
R.A. Loukota ∗
Department of Oral and Maxillofacial Surgery, Leeds Teaching Hospitals NHS Trust, Leeds Dental Institute, Clarendon Way, Leeds LS2 9LU, UK

Accepted 13 November 2005

Available online 19 January 2006

Abstract

Following the introduction of a new technique for fixation of fractures of the condylar neck and base in our department, the operative times
were compared with those for the traditional and frequently used method of open reduction and internal fixation. A distinct learning curve
was seen.
© 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Endoscopic assisted fixation; Condylar neck fractures; The operative times learning curve

Introduction sis Research Group (SORG) prospective randomised trial,3

Endoscopically assisted reduction and fixation of fractures of
the condylar neck is a recognised method of treatment but is
not commonly used in the UK.1,2 Our surgical learning curve
is shown and quantified.
Method
Over a six-week-period we did five consecutive endoscopi-
cally assisted reductions and internal fixations of fractures of
the condylar neck and base.3 In each case the operative times
were recorded. These were then compared with the previ-
ous five fractures of the condylar neck or base treated by the
standard (within our department) transparotid approach.
The fractures treated (both groups) met our standard cri-
teria for open reduction and internal fixation (ORIF) of
condylar fractures: the patients had symptoms and the frac-
tures had vertical overlap of more than 5 mm or angulation
of the fragments more than or equal to 30◦ (these crite-
ria exceed the requirements of the Strasbourg Osteosynthe-
∗
Tel.: +44 113 343 6219; fax: +44 113 343 6264.
E-mail address: rloukota@doctors.org.uk.
which required 2 mm overlap and 10–45◦ angulation).
The patients were informed that the endoscopically
assisted approach was a new technique in the department
and were informed of the risks and benefits, as well as the
possibility of conversion to an open operation if the endo-
scopically assisted method was unsuccessful. Patients were
also given the option of treatment by the traditional open
reduction and internal fixation. All patients consented to the
endoscopically assisted procedure, but one patient requested
that we abandon the operation if this method failed, as she
wanted to avoid an open operation.
The operations in both groups were done by a single sur-
geon. Three operations in the endoscopically assisted group
were done using transbuccal instruments (Fig. 1) and two
using intraoral right angled instruments.
Results
The duration of the operations are shown in Fig. 2. These
show that at first times were 2.5 times greater than for the
standard technique, but by the end of the study period they
were approaching the times of the standard method. These
show the learning curve for the surgical technique.

0266-4356/$ – see front matter © 2005 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2005.11.019
 R.A. Loukota / British Journal of Oral and Maxillofacial Surgery 44 (2006) 480–481
Fig. 1. Screenshot of endoscopically assisted transbuccal drilling.
Fig. 2. Graphic representation of learning curve.
Discussion
There has been discussion about the efficacy of open reduc-
tion and internal fixation of fractures of the condylar neck
and base, and the recent SORG multicentre prospective ran-
domised trial showed both subjective and objective benefits
of endoscopic operations over treatment by ORIF.3
Following the introduction of any new technique it is
well recognised that the operator will experience a “learning
curve”. This also applies to the other members of the theatre
team. The length and gradient of this curve is important in
481
the assessment of the potential benefits of a new procedure
and whether they are outweighed by the increased operating
time.
Endoscopically assisted reduction and fixation of condy-
lar fractures has the benefit to the patient of either no external
scarring (if a completely transoral approach is used), or min-
imal scarring (if a combined transbuccal/transoral approach
to instrumentation is used). Furthermore the risk of damaging
the facial nerve is reduced.
The gradient of the learning curve will obviously be mul-
tifactorial, the experience of the surgeon in both general
treatment of condylar fractures and use of endoscopes being
major factors. Likewise the experience of the theatre team,
with regard to the use and setting up of endoscopes and right-
angled or transbuccal instrumentation is relevant, as well as
poor functionality of specific instruments.4 We attempted to
minimise the team factors by carrying out all the procedures
on routine lists in our own dedicated theatre. This resulted
in the same or similar team assisting for each procedure, a
team that was experienced with the equipment. This would
not have been the case if the patients had been treated in the
general acute theatres in our hospital.
Our results show that although the initial endoscopically
assisted operations took considerably longer time than our
usual transparotid approach, in a short time scale the operat-
ing time for endoscopically assisted procedures dropped to
a similar level of a transparotid approach. It should be noted
that procedures were carried out by the surgeon nominated
within our unit as having a special interest in condylar frac-
tures and so relatively experienced in the procedure. It should
not be inferred that all surgeons will have the same learning
curve and others may approach their usual ORIF times faster
or more slowly.
References
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