Interposition arthroplasty in post-traumatic temporomandibular joint ankylosis: A retrospective study

Temporomandibular joint ankylosis which is most frequently caused by trauma, presents with restriction in mouth opening in early stages and if children are the victim and not treated early, it presents with growth retardation of the involved mandibular side. Various methods are available for surgical correction. We have reviewed our experience with the efficacy of different interpositional materials in post-traumatic cases in our set up with special reference to temporal fascia over last three years. Twenty seven patients with history of trauma, mostly fall from height, have been studied. They were evaluated clinically and by computed tomography (CT) scan, orthopantogram and x- ray lateral oblique view. The most common age group was 10-15 years with mean 12.5 years and male to female ratio 1:2. Preoperative mouth opening (inter incisor distance) was 1-2 mm in 17 cases and 2-4 mm in 10 cases. We have used temporalis fascia in nine, costochondral graft in seven, silastic sheets in five and T-plates in six cases. Post-operatively, adequate mouth opening of 30-50 mm was observed in six months follow-up and more than 50 mm at one year follow up in 21 cases out of which nine cases have interpositional material as temporalis fascia alone. The postoperative period was uneventful in all cases and none required re-operation for recurrences. We conclude that interpositional arthroplasty, especially with pedicled temporal fascia, is the best method to prevent recurrences and establish good mouth opening and full range of jaw movements.     

Surgery of temporomandibular joint under local anaesthesia

Temporomandibular joint ankylosis is a debilitating disorder arising from an inability to open the mouth. This leads to poor nutrition, poor dental hygiene, and stunted growth. Anaesthesia, especially general anaesthesia, is very difficult to administer. There is a lack of direct visualization of the vocal cords, tongue fall following relaxation, and an already narrowed passage due to a small mandible, which makes even the blind nasal intubation difficult. There are various techniques described in literature to overcome these challenges, failing which, one needs to do tracheostomy. All the risks of difficult intubation and general anaesthesia can be avoided if the surgery is done under local anaesthesia. A simple but effective method of successful local anaesthesia is described, which allows successful temporomandibular joint reconstruction.     

Calcium pyrophosphate dihydrate deposition disease (pseudogout) after total knee arthroplasty

The authors report a case of calcium pyrophosphate dihydrate deposition disease (pseudogout) presenting in the early period after primary total knee arthroplasty. The patient's symptoms resolved with conservative management including colchicine and indomethacin. The presentation of pseudogout resembles septic arthritis and should be included in the differential diagnosis to prevent unnecessary surgery in these patients.     

Bradycardia and asystole during temporomandibular joint reconstruction

Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other trigeminal nerve branches can occur. We report the presentation and management of bradycardia and asystole from stimulation of the mandibular branch of the trigeminal nerve during temporomandibular joint reconstruction.     

Replacement of the patello-femoral joint with the total condylar knee arthroplasty

Summary We have studied 241 total condylar knee arthroplasties with replacement of the articular surface of the patella in 206 patients. The average age was 65 years.The technique of replacement of the patellofemoral joint emphasises realignment of the quadriceps mechanism, minimal excision of the patella to preserve subchondral bone, preservation of soft tissue attachments including the infrapatellar fat pad, and closure of the quadriceps without tension.The results of replacement have been good to excellent in 95 per cent of patients followed for two years or more. There were no subluxations, dislocations or fractures. Loosening was noted in one case associated with anterior knee pain. Discomfort was also noted with eccentric placement of the prosthesis where bone was left uncovered.We consider that routine replacement of the patello-femoral joint is advisable with total condylar knee arthroplasty.

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Résumé Etude de 241 arthroplasties totales du genou avec remplacement de la surface articulaire rotulienne, pratiquées sur 206 malades dont l'âge moyen était de 65 ans.En ce qui concerne la technique du remplacement rotulien, il faut insister sur le réalignement du tendon quadricipital, sur une résection limitée de la rotule afin de conserver l'os sous-chondral, sur la préservation des parties molles péri-rotuliennes y compris le ligament adipeux et sur la suture sans tension du quadriceps.Les résultats du remplacement rotulien ont été excellents ou bons chez 95% des opérés, suivis deux ans ou plus. Il n'y a eu ni subluxations, ni luxations, ni fractures. Un seul cas de descellement a été observé, s'accompagnant de douleurs à la face antérieure du genou. Une gêne a également été notée lorsque la prothèse a été placée en position excentrique, là où l'os était resté découvert.On peut donc recommander l'utilisation systématique de la prothèse rotulienne au cours de l'arthroplastie du genou par prothèse «total condylar».

     

肘关节叉状成形术重建肘关节功能的疗效分析

[目的]探讨肘关节叉状成形术治疗肘关节疾病的手术技术及临床疗效。[方法]自1973~2002年106例肘关节疾病患者进行肘关节叉状成形术,获得随访53例56肘,男16肘,女40肘,其中类风湿关节炎39肘,结核9肘,骨关节炎4肘,色素沉着绒毛结节性滑膜炎4肘,平均病程(11.36±5.30)年(6~30年),手术时平均年龄(39.43±11.01)岁(18~62岁)。手术指征为严重疼痛、关节僵硬或畸形。手术采用肘后正中纵切口或S形切口。游离显露尺神经,并加以保护,切除后关节囊、滑膜及病变组织。先于桡骨颈部切除桡骨小头,再切除部分鹰嘴突和冠状突,扩大鹰嘴突的滑车轨迹。凿除肱骨滑车和肱骨小头,保留肱骨内外上髁,肱骨下端呈叉状。用2枚细骨圆针交叉穿过尺骨鹰嘴,再进入肱骨下端行内固定,并使两者之间保留1~1.5cm的空隙。术后平均住院14d,随访平均(12.63±6.47)年(4~34年)。以HSS肘关节评分标准进行临床疗效评价。[结果]随访时肘关节屈曲畸形全部消失,关节屈伸活动度由术前(13.66±5.30)°增加到术后(91.07±12.01)°(P<0.05)。HSS评分:术前(25.71±11.30)分,术后(84.00±7.97)分,差别有显著性(P<0.05),其中优15肘(26.9%)、良24肘(42.8%)、可13肘(23.2%)、差4肘(7.1%),优良率69.7%。35肘无疼痛,21肘轻度疼痛。各病种间差别无显著性(P>0.05)。[结论]肘关节叉状成形术是治疗肘关节疾病的有效方法。     

Development of outcome research for total joint arthroplasty

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are now the most common major orthopedic procedures in the world. Outcome research for patients undergoing total joint arthroplasty is now the accepted method of choice for evaluating the results of surgery. This study design incorporates the use of patient-derived data collected from patient self-administered questionnaires that will capture data on the patient's experience of pain, functional disability, and general health status. These questionnaires do not replace traditional measures of clinical endpoints, such as mortality and complication rates, but will be additions to data collection. The patient-derived data allow orthopedic surgeons to assess the impact of total joint arthroplasty on the health status of their patients. The need to collect these data is increasingly necessary with the growing demands on orthopedic surgeons to demonstrate the efficacy of total joint arthroplasty to maintain funding from both public and private funding sources. This article introduces the development of outcome research for patients undergoing total joint arthroplasty. Received for publication on May 19, 1999; accepted on Aug. 6, 1999     

Immediate changes in temporomandibular joint opening and pain following vibration therapy: a feasibility pilot study

Objective

The purpose of this pilot study was to determine the scientific and process feasibility in an effort to direct future larger trials.

Methods:

Scientific Feasibility: Twelve subjects were randomly allocated to an intervention and a control group. The intervention protocol consisted of intraoral vibration therapy on the muscles of mastication bilaterally for a period of 1 minute per muscle. Process Feasibility: Several feasibility outcomes were examined including recruitment and retention rates and consent.

Results:

Scientific Feasibility: Large effect sizes were generated for both mouth opening and VAS in favour of the intervention group. Process Feasibility: a recruitment ratio of 2.3 respondents to 1 participant was determined, along with a retention to loss ratio of 13:1 and a consent to loss ratio of 12:0.

Conclusion:

Scientific Feasibility: The scientific results should be interpreted with caution due to the small sample sizes employed. The study seems to support the scientific feasibility of a future larger single treatment trial. Process Feasibility: Recruitment and retention rates and ratios seem to support future studies. Utilizing the feasibility results of the current study to direct a future larger multiple treatment trial consistent with other comparable TMD studies however is limited.     

全膝关节表面置换治疗严重膝关节畸形

目的探讨人工全膝关节表面置换术(TKA)治疗严重膝关节畸形临床疗效。方法应用全膝关节表面置换治疗严重膝关节畸形36例(48膝)。使用HSS评分标准评估分析术前、术后膝关节功能及术后疼痛、膝关节活动度的改善情况。43膝采用后稳定型人工全膝关节假体,5膝采用CCK型人工全膝关节假体。结果术后早期均无感染等并发症发生。术后X线片示假体位置良好,下肢力线良好。患者均获得随访,时间6～18个月。HSS评分术前为(41±5.3)分,术后6个月为(87.7±6.5)分。手术优良率为83.3%。患者疼痛、功能方面及活动度均有明显改善。结论全膝关节置换术对严重膝关节畸形的治疗效果满意。但应严格掌握手术适应证。     

Restoration of the joint line in total knee arthroplasty

The purpose of the study was to assess the effect of the joint line position in a posterior cruciate ligament–retaining, mobile-bearing total knee arthroplasty (TKA). Seventy-six consecutive TKAs performed by 1 surgeon were prospectively assessed for a minimum of 2.5 years. Posterior cruciate ligament–retaining, mobile-bearing TKA was performed in all cases. The joint line was elevated 1 mm on average (range, −11 to +10). There was no correlation between joint line position and range of motion, knee function scores, knee pain scores, or patellar height. The joint line position in a posterior cruciate–retaining, mobile-bearing (LCS AP Glide; DePuy, Leeds, United Kingdom) TKA did not affect the early clinical results.     

Knee joint synovial cyst following total knee arthroplasty with bone allograft

Allograft has been shown to be highly successful for managing large osseous defects in total knee arthroplasty. We report a 68-year-old woman in whom a bone allograft had been used during total knee arthroplasty owing to a massive segmental medial tibia plateau defect 4 years earlier. Eighteen months after surgery, a 10 × 10 cm knee synovial cyst was detected by computed tomography scanning on the anteromedial side of the tibial plateau, and an en-bloc surgical excision was performed. At 36-month follow-up, a 16 × 12 cm cyst was found. Excision was again performed with removal of the allograft and application of an autologous iliac graft. After allograft removal, clinically and radiologically satisfactory results were achieved at the final follow-up.     

Predictors of intensive care unit admission after total joint arthroplasty

Total joint arthroplasty (TJA) is a relatively safe orthopedic procedure. However, complications do occur, and some may necessitate admission to the intensive care unit (ICU). Our purpose was to determine risk factors associated with admittance to ICU after TJA. We evaluated 22,343 primary and revision total hip and knee arthroplasties from 1999 to 2008. One hundred thirty patients were admitted to the ICU. Cases were matched 1:2 for date of surgery, surgeon, and type of surgery. The causes for admission to ICU were recorded. Independent risk factors for ICU admission were smoking, cemented arthroplasty, general anesthesia, allogenic transfusion, higher C-reactive protein, lower hemoglobin level, higher body mass index, and older age. Proper identification and management of these "at-risk" patients may decrease the incidence of ICU admittance after TJA.     

Clinical outcomes of primary total joint arthroplasty among nonagenarian patients

A retrospective cohort study and a comparative literature review were undertaken to determine outcomes and survival/mortality rates among nonagenarian patients who underwent total joint arthroplasty (TJA). Thirty-nine patients who underwent TJA (14 hips, 25 knees) aged 90+ years were identified from a database of 9817 primary TJA cases performed at one hospital between 1998 and 2010. Findings were compared to synthesized data from relevant published literature review (LR). The mean age was 91.3 (±1.4) years, 79.5% were rated by the American Society of Anesthetists as 3+. Medical complication rate was 25.6% vs 36.2% for LR cases (P = .219). Perioperative death rate was 2.6% vs 2.1% among LR cases (P = 1.000). At 3.8-year follow-up, mortality rate was 59% (LR, 58.2%; 5.1 years), with a mean age of 95.2 (±3.5) years at death (LR, 96.3 ± 3.4). Excellent clinical outcomes were achieved. Primary TJA remains a viable and effective procedure in nonagenarian patients.     

Trapeziectomy or revision into a cemented polyethylene cup in failed trapeziometacarpal total joint arthroplasty

Objectives: Total joint replacement as treatment of osteoarthritis of the trapeziometacarpal joint may lead to excellent short-term results, but also with a high risk of failure of the trapezium component. The aim of this study was to compare revision using trapeziectomy with a revision into a cemented trapezium cup. Methods: Thirty-four patients with a mean follow-up time of 47 months were included in a case control study with 17 hands revised with a cemented cup and 21 trapeziectomy. Results: At follow-up, no significant difference was found in self-reported outcome, with pain at rest or activity and in grip strength comparing patients revised using trapeziectomy with patients revised with insertion of a new cup. There was, however, a high risk of re-revision in patients treated with insertion of a new cup and at the follow-up 4/17 cups had been re-revised and 5/17 cups had radiological signs of implant loosening. Conclusion: IT was found that trapeziectomy should be the standard salvage procedure after a failed trapezium implant and revision of cup loosening with a cemented cup has an unacceptable failure rate.     

Surgeon energy expenditure during total joint arthroplasty

Although there is extensive literature related to total hip arthroplasty (THA) and total knee arthroplasty (TKA), most of this research has been devoted to analyzing patient outcomes and complications. There are no published articles to date investigating the energy expenditure of the surgeon during these procedures. Using a SenseWear Pro(2) Armband, energy expenditure measured as energy expended during 22 primary THAs or TKAs by a single surgeon was recorded. Total hip arthroplasty required a greater expenditure of energy than TKA (P < .05). No significant trend was detected when comparing patient body mass index to the number of calories used by the surgeon. The physiologic demands placed upon the surgeon for various procedures should be recognized and is an additional factor to consider when determining procedure reimbursement.     

Advances in closure technology and technique for total joint arthroplasty: Stitches in time

Wound closure is an important, often under emphasized, step in total joint arthroplasty. Meticulous, evidence based, surgical technique is critical for optimizing postoperative function and preventing wound complications. Robust, anatomic closure of the joint capsule in total hip arthroplasty via the posterior approach is essential. Closure of the arthrotomy in total knee arthroplasty in flexion may improve postoperative range of motion, and the use of barbed suture improves efficiency and may lead to cost savings. Skin closure with running subcuticular monofilament suture with topical skin adhesives improves peri-incisional blood flow and decreases postoperative wound drainage.     

Pseudogout in the Early Postoperative Period After Total Knee Arthroplasty

Postoperative pseudogout after total knee arthroplasty is rare. If pseudogout attacks are misdiagnosed as periprosthetic sepsis, patients may undergo unnecessary surgical procedures. We report a case of pseudogout in the early postoperative period. The attack ensued shortly after a nonsteroidal antiinflammatory drug was discontinued. The diagnosis was confirmed by aspiration, and the patient improved after readministration of the nonsteroidal antiinflammatory drug. Although rare, pseudogout should be considered in the differential when approaching a suspected infection after total knee arthroplasty.     

A review of anaesthetic technique in 15 paediatric patients with temporomandibular joint ankylosis

Temporomandibular joint ankylosis presents a serious problem for airway management. This relatively rare problem becomes even more difficult to manage in children because of their smaller mouth opening with near total trismus, and the need for general anaesthesia before making any attempts to secure the airway. A technique for securing the airway that combines local blocks for nerves of larynx and topical anaesthesia of upper airways for placement of these blocks, and minimal general anaesthesia for these manoeuvres, is described. For general anaesthesia, a combination of halothane and ether by spontaneous ventilation, using bilateral nasopharyngeal airways, was used. Because of the severe trismus, a tongue depressor or tip of a laryngoscope was used with a fibreoptic light source in the buccal sulcus to visualize the tracheal tube in the pharynx. Nasal forceps, with a smaller tip and narrower blade than Magill forceps was used to guide the tracheal tube towards the air bubbles coming out of larynx. No attempt was made to visualize the larynx, but its position was guessed from the direction of these air bubbles. We review the anaesthetic technique in 15 such cases of severe trismus managed successfully between 1986 and 1999.     

Quantifying cardiovascular risks in patients with metabolic syndrome undergoing total joint arthroplasty

The coexistence of diabetes, hypertension, obesity, and dyslipidemia is defined as metabolic syndrome. Studies show substantial cardiovascular risks among these patients. The risk of patients with metabolic syndrome undergoing total joint arthroplasty (TJA) is unknown. Patients with and without metabolic syndrome undergoing TJA during a 3-year period were analyzed for postoperative complications. Metabolic syndrome was defined by having 3 of the following 4 criteria: obesity (body mass index ≥30 kg/m(2)), dyslipidemia, hypertension, and diabetes. Patients with metabolic syndrome had a significantly higher risk of cardiovascular complications compared with controls (P = .017). The risk of an adverse event increased by 29% and 32%, respectively, when there were 3 or 4 syndrome components. Patients with metabolic syndrome undergoing TJA have increased risk for cardiovascular complications. Our results show that metabolic syndrome may have a clustering effect and pose increased risk when individual risks factors are combined.