Intraoperative complications in temporomandibular joint arthroscopy: A retrospective observational analysis of 899 arthroscopies

Management of arthroscopic perforation of the middle cranial fossa: a case report

Complications during temporomandibular joint arthroscopy have been described widely. However, while perforation of the neighbouring anatomical structures, such as the cranial fossa, is a possibility, perforation of the middle cranial fossa and its arthroscopic management have not been reported previously. This report describes a case of middle cranial fossa perforation diagnosed intraoperatively and its immediate arthroscopic management.

Sudden sensorineural hearing loss and vertigo following temporomandibular joint arthroscopy: a case report and literature review

Temporomandibular joint (TMJ) arthroscopy is a commonly performed procedure for the management of various TMJ disorders. While generally considered safe, it can occasionally lead to unexpected complications. This article presents a notable case of sudden sensorineural hearing loss and vertigo following TMJ arthroscopy, a rare but significant occurrence that warrants attention in clinical practice. By detailing this case, the aim is to highlight the clinical presentation, diagnostic challenges, and management strategies associated with these uncommon complications associated with TMJ arthroscopy.

Is the Complexity of Arthroscopic Temporomandibular Joint Surgery Associated With Short-Term Complication Rates?

BACKGROUND

Arthroscopy is regarded as a minimally invasive surgical procedure, with complication rates ranging from 1.7 to 4.4%. It remains unclear whether the complexity of the arthroscopic procedure is associated with the frequency of complications.

PURPOSE

The study purpose was to measure the association between the level of arthroscopic complexity and short-term postoperative complications.

STUDY DESIGN, SETTING, SAMPLE

The researchers implemented a prospective cohort study. Subjects presenting to Clinica Bupa Santiago, a tertiary care hospital in Chile between 2022 and 2023 who requires arthroscopy were enrolled. Inclusion criteria required subjects to have a history of joint disorder and a preoperative magnetic resonance imaging (MRI) to be scheduled for an arthroscopic surgery with a 6-month follow-up. Subjects lacking 6-month follow-up were excluded.

PREDICTOR VARIABLE

The predictor variable was the arthroscopy complexity level: level I (single puncture diagnostic sweep), level II (double puncture with instrumentation or shaver), and level III (discopexy or discectomy).

MAIN OUTCOME VARIABLE

The main outcome variable was intraoperative and postoperative complications, which were defined as any unwanted development resulting in lasting consequences, additional surgeries, or unresolved issues, and these were coded as either present or absent.

COVARIATES

The covariates included age, sex, duration of symptoms, prior conservative therapies, history of previous open joint surgery, and Wilkes stage.

ANALYSES

Data were analyzed using descriptive statistics with statistical significance set at P value <.05. χ2 or Fisher's exact test was used depending on the variable type.

RESULTS

A total of 165 subjects (285 joints) with a mean age of 28.9 years (SD 13.0) were included. Of these, 149 (90.3%) were female and 16 (9.7%) were male. Level I procedures were performed on 37 joints (13.0%) in 23 subjects (16.3%), level II on 53 joints (18.6%) in 27 subjects (16.3%), and level III on 195 joints (68.4%) in 116 subjects (69.9%). Complications occurred only in level III (7 procedures, 2.5%, P = .33), affecting 5 subjects (3.0%). Observed complications included transient frontal facial paresis, mouth floor edema, transient neuropathic pain, suture rejection, and emphysema.

CONCLUSION AND RELEVANCE

The postoperative complication rate after arthroscopy was 2.5%, with no statistically significant association with operative complexity. Although more complications were observed in advanced arthroscopies, this increase was not significant.

Validation of a training simulator for temporomandibular joint arthroscopy

OBJECTIVE

This study aims to evaluate a temporomandibular joint (TMJ) arthroscopy simulator using construct and face analyses.

METHODS

Thirty participants attending a TMJ training course were divided into novice and expert surgeons (more than 100 procedures) and performed two arthroscopic tasks (cavity access/cavity exploration) during which the surgical tool movements were tracked. Five objective metrics were used to measure surgeon ability and construct validity was assessed by comparing novel and expert performance. Face validity was assessed by subjective questionnaires rating simulator realism and utility (1-5 scale) and tissue consistency (1-4 scale).

RESULTS

Expert surgeons spent less total time (76.58 ± 47.40 vs. 27.60 ± 5.52; novices vs. experts) with higher average speed (7.40 ± 5.32 vs. 12.65 ± 5.37) and average acceleration (198.33 ± 2.42 vs. 325.93 ± 87.36). Movement smoothness revealed lower values in novice surgeons (3638.33 ± 1083.95 mm/s3; 2553.70 ± 768.01 mm/s3) than in expert surgeons (4655.63 ± 837.05 mm/s3; 4172.08 ± 1098.61 mm/s3). All these outcomes reached statistical significance (p ≤ 0.05) but in contrast total path of the instruments did not. Face validity scores averaged 4.75/5 for utility and over 4/5 for realism except for watertightness. Tissue consistency was regarded as lower than human tissue but without impact on the training experience. There were no statistically significant differences between the two groups.

CONCLUSIONS

Both the construct and face validity analyses confirmed the TMJ simulator can be regarded as a valuable, safe, economic adjunctive tool to train TMJ arthroscopy.

Outcomes of bilateral temporomandibular joint arthroscopy: an international multicentric prospective study including 524 joints

PURPOSE

This study aimed to evaluate the efficacy of bilateral TMJ arthroscopy in patients with different Wilkes stages, comparing the results obtained in different arthroscopic levels on a larger scale, unifying similar populations.

METHODS

A multicentric prospective clinical study was conducted in three TMJ departments performing temporomandibular joint surgery in Portugal and Brazil, with an enrolling window active from January 1, 2019, to December 1, 2022. The primary clinical outcome was TMJ pain evaluated through a visual analogue scale. The secondary clinical outcome was the maximum mouth opening (MMO). TMJ arthroscopy was performed with a 1.9-mm arthroscope, including a video system with a 2.8-mm outer protective cannula.

RESULTS

262 patients, representing a total of 524 operated joints were enrolled. The mean age was 35.3 years. A significant decrease postoperatively in VAS pain was observed for all Wilkes stages. The lowest value of VAS pain was observed in Wilkes II compared to Wilkes III and IV. In the secondary outcome, MMO was observed to have a significant improvement in all Wilkes stages.

CONCLUSION

In this multicentric study, bilateral TMJ arthroscopy was shown to be an effective procedure to reduce pain and increase maximum mouth opening in patients with different Wilkes stages, representing a valid minimally invasive solution.

Complications of temporomandibular joint arthroscopy. A critical appraisal of the literature

To search for the best available scientific evidence in relation to the reported overall and selective complication rates for arthroscopic surgery in patients presenting with internal derangement (ID) of the temporomandibular joint (TMJ). A comprehensive electronic search was conducted without data or language restrictions up to August 2023. Inclusion criteria were the following: study in humans, randomized or quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs), cohort studies and series of clinical cases. The proposed PICOS question was: "In clinical trials and retrospective clinical series of patients treated by arthroscopy, which were the overall and selective complication rates?" Exclusion criteria were animal studies, review papers, technical reports, and in vitro studies. The Cochrane Collaboration Tool was used to assess the risk of bias of the included studies in terms of their quality. The Strength of Recommendation Taxonomy (SORT) classification was used to determine the level of evidence of the selected studies. A total of 498 studies were identified. Of these, 16 studies fulfilled the inclusion criteria and were selected for qualitative assessment. Temporary 5th nerve deficit, ranging from 0.15% to 2.38%, was reported to occur in most larger series, comprising 7394 operated joints. Temporary 7th nerve paresis was reported to occur in 0.21%-0.7% in the largest series, comprising 6866 operated joints. Partial hearing loss was reported in 6 studies, ranging from 0.21% to 2.2% in 5845 operated joints. Edema of surrounding soft tissues, including parapharyngeal, soft palate and/or preauricular edema was reported in 8 studies, with complication rates ranging from 2% to 17.9% in 2274 operated joints. Laceration of the EAC was reported in 8 studies involving 2665 operated joints, with complication rates ranging from 0.3% to 6%. A total of 872 complicated events among 11,304 operated joints were reported, accounting for an overall complication rate of 7.71%. Complications from arthroscopic procedures have been inconsistently reported, but there are a small number of retrospective studies with well-reported complications rates. As overall complication rate accounts for less than 8% of the cases, arthroscopy seems to be a highly safe procedure for the treatment of internal derangement (ID) of the TMJ. Due to the absence of studies with high evidence, information for patients about complications should be based on clinical series of cases.

Comparison of the TMJ arthroscopy discopexy techniques: A systematic review and meta-analysis

This article aims to analyze which of the main arthroscopic discopexy techniques has the best results and if there are differences between the techniques for both pain and maxillary intercuspid opening. A systematic review and meta-analysis was performed according to the PRISMA statement. An electronic search was performed with no publication date restriction in PubMed, Ovid and Embase. The PICO criteria: (P) Patients: With temporomandibular internal disorders with discopexy indication. (I) Intervention: Temporomandibular joint arthroscopic discopexy. (C) Comparison: Arthroscopic discopexy among different techniques classified as non-rigid, semi-rigid and rigid. (O) Outcomes: Impact in clinical conditions such as pain and maximum mouth opening. The inclusion criteria were Patients with temporomandibular internal disorders with discopexy indication performed with different techniques classified as non-rigid, semi-rigid and rigid. The outcomes evaluated were pain and maximum mouth opening. Case series, cohort studies, quasi-experimental studies, and randomized clinical trials with at least 3 months of follow-up were included. The exclusion criteria considered were patients with related concomitant surgeries, patients with associated neoplastic disease or connective tissue disease. A total of 1515 joints where 1400 discopexies were performed including 849 females and 204 males. The most common diagnostic was Wilkes stage III in 257 joints. For pain and oral opening, the semi-rigid technique shows the best results median (MD) 4.84 (CI 2.52-7.16; p = 0.001, I2:100%), MD -2.78 (CI -4.34, -1.21; p = 0.001, I2:99%), respectively. The rigid technique has the greatest probability for complications MD 0.14 CI 95% (0.00, -0.28). Although the semi-rigid technique showed better results, there is no statistically significant difference. However, due to the heterogeneity of the studies, the results should be interpreted with caution.

Needle Therapy: A Minimally Invasive Therapeutic Concept as Part of Temporomandibular Single-Portal Arthroscopy

The transition from a single portal to a double portal can be complex, necessitating time and training to minimize complications that rely on the operator's skill. Needle therapy is a simple method for treating symptoms that has several benefits. Consequently, this innovative strategy aims to introduce an intermediate technique that enables surgeons to perform therapeutic procedures during single-port arthroscopy.

Effect of arthroscopic discopexy on condylar growth in adolescents with temporomandibular joint disc displacement without reduction: A retrospective self-controlled case series study

This study was a retrospective self-controlled study that aimed to evaluate the effect of arthroscopic discopexy on condylar height and mandibular position in adolescents with temporomandibular joint (TMJ) anterior disc displacement without reduction (ADDwoR). Patients between 10 and 20 years of age and diagnosed with bilateral TMJ ADDwoR by magnetic resonance image (MRI) were included in this study. All patients underwent a period of natural course before arthroscopic surgery and then a follow-up period postoperatively. Changes in condylar height and mandibular position were measured by MRI and X-ray radiographs. Data were analyzed by paired t-test, Pearson correlation analysis, and generalized estimating equations. This study comprised a total of 40 patients with a mean age of 14.80 years. Pearson correlation analysis showed correlations between condylar height and mandibular position changes. The condylar height change during the post-operative period was significantly higher than that during natural course period (3.57 mm, p < 0.001). The changes in mandibular position (including ANB angle, SNB angle, and Pog-Np) were significant different (all p < 0.05) between the two periods. This study found that arthroscopic discopexy can promote condylar growth and correct dentofacial deformity in adolescents with bilateral TMJ ADDwoR.

Temporomandibular Joint Minimally Invasive Procedures in the Pediatric Population: A Prospective Study

Over recent years, temporomandibular joint (TMJ) minimally invasive procedures, such as arthrocentesis and arthroscopy, have been appointed as an initial TMJ intra-articular treatment. Both procedures present safe and effective clinical results in managing temporomandibular disorders (TMD) by reducing pain and improving mouth opening. The use of these techniques in adults is validated in the literature. However, data on the safety and effectiveness of minimally invasive TMJ interventions in pediatric patients are scarce. This study aims to investigate the effectiveness of TMJ arthrocentesis and arthroscopy in the pediatric population. A prospective study was conducted at Instituto Português da Face (IPF) in Lisbon, Portugal, including patients treated for TMD from 1 June 2019 to 30 June 2023. In the present study, 26 patients (17 female and 9 male) were included, representing a total of 48 joints operated. A statistically significant reduction was observed in the primary outcome, TMJ pain, from 3.93 ± 2.80 preoperatively (mean ± SD) to 0.50 ± 1.53 (mean ± SD) postoperatively (p < 0.05). An improvement in the secondary outcome, maximum mouth opening, from 36.92 ± 8.79 preoperatively to 42.96 ± 5.07 postoperatively, was observed (p < 0.05). The overall success rate was 84.62%. This prospective study showed that TMJ arthrocentesis and arthroscopy appear to benefit pediatric patients with TMD, significantly lowering pain and improving MMO without relevant postoperative complications.

An exchange technique in temporomandibular joint (TMJ) arthroscopy to insert a larger operative cannula to facilitate advanced procedures

The paper describes a modification of the surgical technique for temporomandibular joint arthroscopy, using an exchange guide to replace the 2.2 mm cannula with one of 2.9 mm to better facilitate osteoplasty of the medial wall. The procedure is a simple and safe manoeuvre that reduces complications such as fluid extravasation into soft tissues, damage to the articular eminence, and bleeding into the superior joint space. Every oral and maxillofacial surgeon could benefit from this novel method, which reduces the chances of failure when exchanging the working cannulas, the potential morbidity of re-entry, and the duration of surgery.

Arthroscopic assisted release of lateral pterygoid versus scarification of retrodiscal tissue in management of internal derangement of temporomandibular joint-A randomized clinical trial

The purpose of this study was to compare the effectiveness of arthroscopic-assisted lateral pterygoid muscle release versus scarification of retrodiscal tissues in the treatment of temporomandibular joint internal derangement. A prospective, comparative, randomized clinical trial involved 16 patients with TMJ internal derangement. Arthroscopic assisted release of lateral pterygoid muscle was assigned to one group of patients (Group I). Group II patients received arthroscopic assisted scarification of retrodiscal tissues. Data collected through functional examination including visual analogue scale (VAS), maximum mouth opening, lateral excursion, and clicking sound immediately and after 3, 6, and 12 months. Pre- and post-operative MRI was used to assess disc position. The VAS scores decreased in both groups at the end of the follow-up period (0.45 vs 6.75, and 1.13 vs 6.50 in group I and II respectively; P<0.001). The maximum mouth opening improved to 32.9.50 ± 1.69 mm in group I, and 30.49 ± 0.93 in group II (P<0.001). Lateral excursion improved in both groups (P<0.001). Clicking sounds disappeared in all patients. Within the limitations of the study, it seems that arthroscopic assisted release of lateral pterygoid and scarification of retrodiscal tissues may be beneficial in management of anteriorly displaced discs that don't respond to conservative treatments.

External Jugular Thrombosis: A Previously Unreported Complication of Temporomandibular Joint Arthroscopy

Temporomandibular joint intra-articular disorders are commonly managed using arthroscopic-assisted procedures. Arthroscopic procedures are minimally invasive, generally successful, and report a low frequency of complications. Vascular complications are particularly uncommon. This case report summarizes the diagnosis and management of jugular vein thrombosis following temporomandibular joint arthroscopy.

Assessment of postoperative pain in patients undergoing temporomandibular joint arthroscopy with infiltration of dexamethasone disodium phosphate in different concentrations. A randomized controlled trial

The main aim of this work was to evaluate the effect of intra-articular, sub-synovial steroid injections (IASSSI) with different doses during temporomandibular joint (TMJ) arthroscopy. Using a single-blind, randomized clinical trial, the investigators enrolled a sample of subjects who underwent TMJ arthroscopy with vs. without IASSSI for treating TMJ disorder (TMD). The predictor variable was the treatment group classified as no treatment (A - without IASSSI) or active treatments (IASSSI (B) with 2 mg or (C) 4-mg dexamethasone). Study medications were randomly assigned. Only subjects were blinded to treatment assignment. The main outcome variables included the following: 1) pain assessed up to postoperative day 30 with the McGill Pain Questionnaire and visual analog scale (VAS); 2) maximum mouth opening (MMO); and 3) analgesic and anti-inflammatory drug consumption. Other variables were demographic (age, sex) or pathologic (disease manifestations and classifications). Descriptive and bivariate statistics were computed. Statistical significance was set at p ≤ 0.5, one-tailed test of hypothesis. The sample comprised 36 patients (n = 12 per study group). In the active group with 4 mg corticosteroids, pain reduction measured by VAS (odds ratio [OR] = 0.18; p = 0.013) and McGill scale scores (OR = 0.15; p = 0.048) was significantly higher than in the control group. The McGill scale scores significantly decreased in both IASSSI groups, compared to the control group, at the final follow-up (all p < 0.012), and IASSSI was significantly associated with reduced analgesic consumption at postoperative days 7 and 14 (p = 0.003). However, there was no significant difference regarding MMO among the three groups. Within the limitations of the study, it seems that intra-articular, sub-synovial steroid injections (IASSSI) with 4 mg dexamethasone should be preferred whenever appropriate when pain relief is the priority of the procedure. Brazilian Registry of Clinical Trials (ReBec)- 28yb2g.