British Journal of Oral and Maxillofacial Surgery (2004) 42, 331—334

An audit of the effectiveness of postoperativeradiographs–—do they make a difference?

N. Bali, V. Lopes*

Department of Oral and Maxillofacial Surgery, University Hospital Birmingham, Birmingham, UK

Accepted 9 March 2004

Available online 6 May 2004

KEYWORDSPostoperative;Radiograph;Injury

Summary We examined the impact of postoperative radiographs after repair of fa-cial fractures on immediate postoperative management. This was completed in twoparts: first we did a retrospective study from January to July 2001, and secondly aprospective observational study for the remainder of 2001. All patients who had ageneral anaesthetic for the treatment of a facial fracture were included. The inter-vention was postoperative radiographs before discharge. The outcome measure waswhether the patient had to return to theatre within a month.A total of 257 patients were included of whom 3 (1.2%) returned to theatre for

correction of the initial procedure. In each case this was based on the postoperativeclinical findings. No patient was returned to theatre solely on the evidence of animmediate postoperative radiograph.In line with official guidelines, we suggest that postoperative radiographs must not

be used routinely, but only when they are required clinically. This minimises the riskto patients, and may lead to speedier discharge and appreciable savings.© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.

Introduction

It is common practice to take postoperative radio-graphs after repair of a facial fracture. The reasonseems to be that if a problem is apparent on theradiograph then appropriate action could be takenbefore the patient is discharged home. It was ourimpression that postoperative radiographs rarely ifever, influenced the decision to return the patientto theatre for correction of the earlier repair.The guidelines of the National Radiographic

Protection Board1 and the Royal College ofRadiologists2 state that a specific indication must

*Corresponding author. Tel.: +44-7811-400389.E-mail address: vicmaxfax@aol.com (V. Lopes).

exist for taking a radiograph, which will result ina change in management. As it was felt that thismaxim was not being adhered to, we started witha retrospective audit followed by a prospective ob-servational study to examine the impact of routineimmediate postoperative radiographs on the man-agement of patients with maxillofacial injuries.

Method

For the retrospective study we collected data fromJanuary to July 2001, and all patients were as-sumed to have had postoperative radiographs, aswas routine in our unit. For the subsequent fivemonths (August—December 2001) we did a prospec-

1 0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.2 doi:10.1016/j.bjoms.2004.03.003

332 N. Bali, V. Lopes

tive audit. It was not possible to examine all radio-graphs collected retrospectively. All patients wereincluded who had a general anaesthetic for thetreatment of a facial fracture. Complex craniofa-cial trauma was excluded. The intervention wasa postoperative radiograph before discharge. Theoutcome measure was whether the patient had tobe returned to theatre within a month after theinitial operation. This gave adequate time for anyearly complications thatmight be picked up by post-operative radiography to be assessed and treated.

Results

We treated 257 patients with 278 fractures. A totalof 140 fractures (50%) were treated in the retro-spective period and 138 in the prospective period(50%). Of these, 246 (88%) were managed by openreduction, and the remaining 32 (12%) by closedreduction. A breakdown of the types of fracturetreated is shown in Table 1.Three patients (1.2%) had to be returned to

theatre for correction of the initial procedure.Of these, two were fractured mandibles, and theother was a fractured zygoma:

Table 1 Maxillofacial fractures treated under gen-eral anaesthesia at University Hospital Birminghamduring 2001.

Number of fractures

MandibleDirect 159Indirect 8

ZygomaORIF 42Elevation 15

Zygomatic archORIF 0Elevation 9

NasalORIF 2Manipulation 9

MaxillaLe Fort 1 1Le Fort 2 4

DentoalveolarORIF 4Orbital floor 25

Total 278

ORIF: open reduction and internal fixation.

• The first was a fractured mandible that wastreated in the retrospective period of the studyinitially by direct plating, and was returned totheatre for repeat operation.

• The second was a fractured zygoma treated in theprospective period, which was initially treated byclosed elevation but returned to theatre for openreduction and internal fixation.

• The third was a fractured mandible also treatedprospectively, which was initially treated by di-rect plating and was returned to theatre for re-peat operation.

In the case of both fractured mandibles, occlusaldiscrepancy led directly to the need for furtheroperation. In the case of the fractured zygoma itwas also a clinical decision. No patient returnedto theatre based on the evidence of an immedi-ate postoperative radiograph alone. During the pe-riod of prospective data collection it was notedthat on seven occasions (5%) a postoperative ra-diograph that showed an unfavourable reductionwas disregarded in favour of an adequate clinicaloutcome.

Discussion

Maxillofacial units routinely request immediatepostoperative radiographs, and it is our impres-sion that this is overprescription, the reasons forwhich may be custom and practice over manyyears, defensive medicine, to reassure the pa-tient, or maybe the surgeons to confirm that theyare competent. Custom and practice cannot bean indication to guide this practice. The manage-ment of facial fractures has changed dramaticallyin recent years from one of closed reduction andfixation to mainly open reduction and fixation.During closed reduction it can be difficult to de-tect clinically whether the fracture has been ade-quately reduced and so postoperative radiographsare of obvious benefit. However, during open re-duction the fracture can be seen and adequatereduction and fixation may be assessed periopera-tively, which removes the need for a postoperativeradiograph.The proposed advantages of postoperative radio-

graphs before discharge are: detection of fracturesthat require immediate repeat operation; to have abaseline record; to have a medicolegal record; forteaching and for personal audit.The main disadvantages are: exposure of the pa-

tient to irradiation; increased cost; and delayed dis-charge.

An audit of the effectiveness of postoperative radiographs 333

Every exposure to irradiation carries a healthrisk. The National Radiological Protection Boardguidelines on diagnostic medical exposures3 statethat ‘‘investigations utilising ionising radiations of-fer potential benefits . . . however, such radiation isassociated with an increased risk in the long termof malignant disease . . . there is also a putativebut low risk of serious hereditary disease . . . . Theprobability of occurrence of these adverse effectsis directly proportional to the level of exposure,without any dose threshold. It is necessary to con-sider the potential harm . . . arising from even thelowest levels of absorbed radiation dose and toavoid those exposures which have no merits.’’This confirms the principle that the dose must

be justified to minimise any risks of irradiation. Astudy by the Royal College of Radiologists suggestedthat unnecessary radiation from diagnostic radiol-ogy causes 100—250 deaths from cancer every yearworldwide.4 Whilst the risk from dental radiogra-phy is low, three studies have indicated a possibleassociation between the use of dental radiographyand tumours of the brain and parotid glands.5—7

However, a more recent study has found no clearevidence associating dental radiography with braintumours.8

With regard to the costs, an orthopantomogramand posteroanterior view of the mandible costs £80in our unit, and the cost of two occipitomental viewsis £90. Abandoning the routine prescribing of imme-diate postoperative radiographs after repair of fa-cial fractures would save more than £21,000 a year.If drugs for patients to take home are prescribedin advance, discharge can immediately follow re-view instead of being delayed until after review ofthe radiographs. In our unit this delay is likely to be4—6h.We found that immediate postoperative radio-

graphs detected no fractures that required imme-diate reoperation, and decisions to reoperate werebased purely on clinical findings. Baseline recordsmay be of use in selected cases, but in light of therisk and cost there must be a clear clinical indi-cation. The same argument applies to radiographstaken for teaching, research, and personal audit,and there may even be a case for obtaining thepatient’s consent if the radiographs are in additionto the normal clinical requirements.Postoperative radiographs are unnecessary for

medicolegal purposes. It has been stated by theRoyal College of Radiologists that ‘‘if, as a resultof careful clinical examination you decide that aradiograph is not necessary for the future manage-ment of the patient, your decision is unlikely tobe challenged on medico-legal grounds . . . ’’.2 Thisworking party also went further to claim that it may

even be unethical to obtain radiographs for possi-ble future medicolegal proceedings. We discussedit further with both the Medical Defence Unionand the Medical Protection Society, who backedup this view. Both Unions advised that good clini-cal notes are adequate evidence should litigationstart.We found only one other comparable study (from

1988) in which Ogden et al. reported a retrospectiveaudit.9 They assessed 183 simple fractured zygomastreated by a Gillies approach, of which only onerequired a repeat operation. They suggested thatclinical judgement alone is sufficient for postopera-tive evaluation and challenged the accepted proto-col of requesting postoperative radiographs. Theirwork contrasts sharply with trends in North Amer-ica towards intraoperative radiographs to confirmreduction of the fracture.10,11 It has even been sug-gested by Stanley10 that intraoperative computedtomographymay reduce the need to expose all frac-ture sites and may reduce theatre costs in the longterm. This is not our practice, and is not generallyaccepted in the management of facial fractures inthe UK.

Acknowledgements

We thank the maxillofacial consultants at Uni-versity Hospital, Birmingham, particularly Mr. B.Speculand and Mr. M.J.C. Wake, for their help andsupport.

References

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334 N. Bali, V. Lopes

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