Date post: | 28-Nov-2014 |
Category: |
Documents |
Upload: | pilyoungg1994 |
View: | 139 times |
Download: | 2 times |
The comparison of arthrocentesis and
arthroscopy
Definition
The procedure of aspirating fluid from a joint space by needle, and following this with injection of a therapeutic substance
TMJ arthrocentesis Lavage of upper joint space and hydraulic
pressure Manipuation to release adhesion Improvement of jaw motion Therapeutic injection of a steroid
arthrocentesis
Mechanism
Unclear, but postulated as possible reasons Release of negative pressure on the disc Release of adhesion Reduction in surface friction
arthrocentesis
Advantage
Simplicity and minimal risk In the office or clinic Under local anesthesia or IV sedation Facilitation of muscular relaxation to
patient with myofascial pain dysfunction
arthrocentesis
Indication and contraindication
Indication Patient with unresponsive or resistant to non-surgical
approaches Closed lock : ADD w/o reduction Hypomobility : restricted condylar translation in
superior joint space Patient who have undergone previous invasive
procedure
Contraindication Limitation of motion as the only complaint and
working diagnosis of bony or fibrous ankylosis Extracapsular causes
arthrocentesis
Procedure
Skin landmark Line : from lateral canthus to the midpoint of tragus Point 1 : 10mm anterior and 2mm inferior to the alar-tragus
line Point 2 : 20mm anterior and 10mm inferior to the line
10mm
2mm
10mm
10mm
arthrocentesis
Procedure
Local anesthesia Lidocaine 2% with
epinephrine 1:100,000 is injected in a manner to achieve an auriculotemporal nerve block
infiltrated in the two marked area
arthrocentesis
Procedure
Localization The patient is instructed to
open maximally and deviate to the opposite side as best as possible
This opens the fossa target and allows the surgeon to aim toward the posterior aspect of condyle
arthrocentesis
Procedure
Needle insertion 22-gauge needle advanced into the superior joint
space from the point of the posterior mark following the path and angulation previously determined with the condyle distracted
arthrocentesis
Procedure
needle placement into the superior joint space
output is established with a positive return of irrigant
arthrocentesis
Procedure
Lavage of articular space Extension tubing
attached and through and through irrigation established while collecting outflow
Steroid suspension being administered (a cloudy return is seen in the extension tubing)
arthrocentesis
Post Op care
Ice pack for first 8 hrs Hot pack for 1 week Soft diet Medication : NSAID for 2 weeks Physiotherapy : MMO 20times / day
for 2 wks
arthrocentesis
Concept
Terminology Arthros : joint Scopein : to view Simply means to look directly into the joints
Basic indication Diagnosis and treatment
arthroscopy
Diagnostic arthroscopy
Indication Internal derangement Osteoarthritis Arthritides Pseudotumors Post-traumatic complaints
arthroscopy
Diagnostic arthroscopy
Contraindication Absolute
Bony ankylosis Advanced resorption of glenoid fossa Infection in the joint area Malignant tumors
Relative Increased risk for hemorrhage Increased risk for infection Fibrous ankylosis
arthroscopy
Diagnostic arthroscopy
Equipment Dyocam TM 750 PAL video camera system
(Dyonics)
arthroscopy
Diagnostic arthroscopy
Equipment DRK scope-21 arthroscope and arthroscopic cannula
with an irrigation port
arthroscopy
Diagnostic arthroscopy
Equipment A: DRK scope-21
arthroscope B: outer cannula; D
1.8mm C: sharp-edged trocar D: blunt trocar
arthroscopy
Diagnostic arthroscopy
Anesthesia Blocking the auriculotemporal nerve Infiltrating the subcutaneous tissue lateral
to the joint 3~4 ml of lidocaine/epinephrine, 10mg/ml Can be combined with IV sedation Short acting BZD, MDZ G/A preferred in case of markedly impaired
TMJ mobility or advanced case
arthroscopy
Diagnostic arthroscopy
Puncture Supine position Upper compartment
distension A: inferolateral
good access for posterior part limeted anterior approach risk of puncturing of lower part
B: anterolateral C: endaural
arthroscopy
Arthroscopic examinationarthroscopy
Arthroscopic examinationarthroscopy
Arthroscopic examinationarthroscopy
Diagnostic arthroscopy
Complication Vascular injury
Withdrawal of all the instrument Compartment condyle position Open bleeding control
Ligation or cauterization
Extravasation Avoid excessive pressure
Scuffing Broken instruments
arthroscopy
Diagnostic arthroscopy
Complication Otologic complications
Perforation of tympanic membrane Dislocation of malleus
Intracranial damage Through the glenoid fossa Pre Op CT evaluation
Infection Preophylactic antibiotics
Nerve injury
arthroscopy
Arthroscopic surgery
Equipment In addition to the instruments
for diagnostic arthroscopy, the following instruments can be used
Forceps, knives, and scissors Mini-shavers Surgical lasers
arthroscopy
Arthroscopic surgery
Technique Distension of upper joint space with local anesthesia
arthroscopy
Arthroscopic surgery
Technique Distraction of mandible
arthroscopy
Arthroscopic surgery
Technique Posterolateral puncture with rotatory movements of sharp trocar and cannula
arthroscopy
Arthroscopic surgery
Technique Arthroscope slides down the cannula and connected
to the irrigation extension tube
arthroscopy
Arthroscopic surgery
Procedure Lavage
Slowly injecting a total of 100ml of isotonic saline soln. Constant check of the outflow Patient may move the jaw during the irrigation Decompress the upper compartment of TMJ
arthroscopy
Arthroscopic surgery
Procedure Lysis
There may be fibrotic bands Can be effective in some
patient with marked fibrosis
Lateral capsule release Laser technique Holmiun-Yag laser
arthroscopy
Arthroscopic surgery
Procedure Debridement and abrasion
Osteoarthritis and arthritides Irregularity of the fibrocartilage and disk Interfere with the smooth functioning of TMJ Shaver : require considerable surgical skill Holmiun:YAG laser : better alternative
Restriction Hypermobility and recurrent luxation Producing scar tissue in posterior disk attachment Limiting forward translation
arthroscopy
Arthroscopic surgery
Intraarticular pharmacotherapy Corticosteroid and hyaluronan Alleviation of pain Improvement of mandibular function Hyaluronan : good effect on clicking joints Extravasation of therapeutic material
Atrophy of subcutaneous tissue Cause severe pain
arthroscopy
Navigation arthroscopy
Workstation with a CT scanner or MRI device Graphic virtual structure should be matched with
the imaging data Optoelectronic tracking technology
2 infrared source camera units At least 4 small reflection spheres
arthroscopy
Navigation arthroscopy
Correction of distorted image Optical characteristic
of the arthroscope Distorted shape of
arthroscopic image Taken into account
with mathematical equation
arthroscopy
Navigation arthroscopy
Preoperatively acquired CT Simulation for Op site
Puncture site for endoscope Working channel
Provide safe corridor by virtual rectangles superimposed on the real-world space
Error range from 0.0mm to 2.5mm
arthroscopy
Navigation arthroscopyarthroscopy