Abstract
The traditional arthroscopy technique includes the creation of three ports in order to enable visualization, operation, and arthrocentesis. The aim of this study was to assess an advanced temporomandibular joint (TMJ) arthroscopy technique that requires only a single cannula, through which a one-piece instrument containing a visualization canal, irrigation canal, and a working canal is inserted, as an alternative to the traditional double-puncture technique. This retrospective study assessed eight patients (13 TMJs) with pain and/or limited range of movement that was refractory to conservative therapy, who were treated between June 2015 and December 2015. The temporomandibular joint disorder (TMD) was diagnosed by physical examination and mouth opening measurements. The duration of surgery was recorded and compared to that documented for traditional arthroscopies performed by the same surgeon. Operative single-cannula arthroscopy (OSCA) was performed using a holmium YAG (Ho:YAG) 230 μm fibre laser for ablation. The OSCA technique proved effective in improving mouth opening in all patients (mean increase 9.12 ± 1.96 mm) and in reducing pain (mean visual analogue scale decrease of 3.25 ± 1.28). The operation time was approximately half that of the traditional technique. The OSCA technique is as efficient as the traditional technique, is simple to learn, and is simpler to execute.
Temporomandibular joint (TMJ) arthroscopy is a therapeutic technique for TMJ disorders (TMDs) involving internal derangement. This technique was introduced in the late 1980s by McCain and others, and effectively reduces pain and increases inter-incisal opening. The traditional technique includes the insertion of three ports in order to enable visualization, operation, and arthrocentesis (outflow), rendering it a complex and cumbersome technique, with a steep learning curve. A case series is presented here in which the operative single-cannula arthroscopy (OSCA) technique was employed. This technique requires a single cannula, which is used for the insertion of a one-piece instrument containing a visualizing canal, an irrigation canal, and a working canal. The approach simplifies arthroscopy surgery by precluding the need for the insertion of a second trocar to introduce the working tip into the field of surgery. Thus, the proposed technique is a single-hand operation, with no need for the coordination of two pieces inside the joint space. The technique ensures visually guided surgery with a working tip adjacent to the arthroscope.
Materials and methods
This retrospective study was approved by the necessary ethics committee. The study was performed between June 2015 and December 2015 in a medical centre in Galilee, Israel.
Each patient’s TMD was diagnosed by physical examination, mouth opening measurements, objective pain on a 10-point visual analogue scale (VAS; 0 = no pain, 10 = severe pain), and a joint load test performed using two wooden spatulas placed between the posterior teeth, where contralateral pain suggested some extent of joint inflammation. Mouth opening and the VAS were measured 2 weeks before the procedure and 3 months following the procedure. Panoramic X-ray imaging (ProMAX 3D classic; Planmeca, Helsinki, Finland), computed tomography (Ingenuity 128; Philips, Israel), and/or magnetic resonance imaging (Tesla 1.5; General Electric, Israel) was also performed. Systemic involvement, such as fibromyalgia or rheumatoid arthritis, was ruled out according to the history obtained and relevant laboratory tests.
All patients suffering from a TMD were first treated conservatively, which included the use of a stabilization (flat plane) appliance, physical therapy, and medications for a period of 3 months. Patients who were refractory to conservative treatment were referred for diagnostic arthroscopy. Eight patients diagnosed with adhesions, fibrillations, and/or synovitis on diagnostic arthroscopy underwent OSCA in the same procedure. Patients were evaluated 24 h, 7 days, 14 days, 1 month, 2 months, and 3 months after surgery.
Surgical technique: operative single-cannula arthroscopy
While the patients were under general anaesthesia with nasoendotracheal intubation, landmarks for arthroscopic surgery were drawn on the cantho-tragal line, 10 mm medially and 5 mm caudally. First, 2 ml bupivacaine (Marcaine) were injected into the joint space using a 22-gauge needle, in order to expand the structures. Next, a sharp trocar with a 1.6-mm (or 2-mm) cannula was introduced into the superior joint space using a standard superior posterolateral technique. Once inside the joint, the sharp trocar was removed and a blunt obturator was inserted to separate the soft tissues within the TMJ. The arthroscope (an interdisciplinary semi-rigid 0.9-mm diameter endoscope, PD-DS-1083; PolyDiagnost, Hallbergmoos, Germany) was then inserted through the middle handle of the three female Luer lock connections, for irrigation and instrumentation ( Fig. 1 ). A ‘one-track arthrocentesis’ was then performed by irrigating (saline) through the irrigation canal and rinsing through the working canal. Next, an 18-gauge needle was inserted 5 mm medially and 5 mm caudally from the puncture point of the working cannula to form an outflow tract to enable execution of a standard arthrocentesis under diagnostic visualization. Finally, the OSCA was performed by introducing a holmium YAG (Ho:YAG) 230 μm fibre laser through the working canal ( Figs. 2–4 ). This visually guided surgery included lavage and removal of the fibrillated or degenerated fibrocartilage and redundant synovial tissue, posterior cauterization or sclerosis of the retrodiscal tissue, laser discoplasty, and disc mobilizations. It is important to emphasize the possible use of the other hand or mechanical instruments with a diameter of around 1 mm or less. After completion of the surgery, sodium hyaluronate (12 mg/ml, 0.8 ml) was injected. The operation time was measured from the moment the cantho-tragal line was drawn to the moment a Steri-Strip (3M, St. Paul, MN, USA) was placed over the operation site.
Statistical analysis
Comparisons of preoperative and postoperative VAS scores and mouth opening measurements were performed using the paired Student t -test. The operation time of the traditional double-puncture technique was compared to the operation time of the single-cannula technique using the unpaired Student t -test. Two-tailed P -values of 0.05 or less were considered statistically significant. Data are expressed as the mean ± standard deviation (SD).
Results
Eight patients, three males and five females, with a mean age of 44.1 ± 10.1 years (range 30–63 years), underwent OSCA. Three patients presented with unilateral TMD and five with bilateral TMD (total 13 joints). Eight TMJs were classified as Wilkes stage IV and five as Wilkes stage III ( Table 1 ).
| Patient number | Sex | Age (years) | Affected TMJ | Wilkes stage | Joint load test | VAS | Maximum mouth opening (mm) | ||
|---|---|---|---|---|---|---|---|---|---|
| Preoperative | Postoperative | Preoperative | Postoperative | ||||||
| 1 | F | 30 | Unilateral | III | Positive | 6 | 4 | 27 | 35 |
| 2 | F | 40 | Unilateral | III | Positive | 7 | 3 | 31 | 40 |
| 3 | M | 52 | Bilateral | IV | Positive | 8 | 5 | 28 | 35 |
| 4 | F | 63 | Bilateral | IV | Positive | 8 | 3 | 29 | 37 |
| 5 | F | 44 | Bilateral | III | Positive | 9 | 5 | 25 | 32 |
| 6 | M | 47 | Unilateral | III | Positive | 7 | 4 | 23 | 34 |
| 7 | M | 36 | Bilateral | IV | Positive | 6 | 5 | 28 | 39 |
| 8 | F | 41 | Bilateral | IV | Positive | 8 | 4 | 21 | 33 |
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