Effectiveness of intraoperative radiography in zygomatic fracture management: a systematic review and meta-analysis

Zygomaticomaxillary complex (ZMC) fractures are among the most common midfacial injuries, but achieving accurate reduction is challenging due to the complex anatomy and limited intraoperative visualisation. Traditional intraoperative assessment is subjective and often leads to residual asymmetry, prompting the use of computed tomography (CT), cone-beam CT (CBCT) and C-arm fluoroscopy to improve surgical accuracy and outcomes. This systematic review and meta-analysis followed PRISMA guidelines. PubMed, Google Scholar, Semantic Scholar, and the Cochrane Library were searched until June 2025. Studies using intraoperative CT, CBCT, or C-arm for ZMC fracture management were included. Risk of bias was assessed with the Joanna Briggs Institute checklist, and evidence quality with GRADE. A random-effects meta-analysis was used to estimate the pooled prevalence of intraoperative revision. Fourteen studies involving 652 patients were included. Intraoperative imaging was primarily used to assess reduction and fixation of ZMC fractures. The pooled prevalence of intraoperative revision was 22% (95% CI: 17% to 27%) with low to moderate heterogeneity (I² = 32.6%). Subgroup analysis showed revision rates of 25% for CT, 20% for CBCT, and 19% for C-arm. No significant difference was found between orbital floor exploration and non-exploration groups (p = 0.15). Evidence quality was rated moderate-to-low for CT, and low for CBCT and C-arm with GRADE analysis. Intraoperative imaging provides effective real-time assessment of ZMC fracture reduction and fixation. Residual mal-reduction requiring immediate revision was detected in approximately 22% of cases, supporting the routine use of intraoperative imaging to potentially reduce secondary corrective procedures.