Managing Temporomandibular Joint Ankylosis Concurrent With Extrahepatic Portal Vein Obstruction: A Report of a Rare Case and Literature Review Investigating the Hypercoagulability Link

This report describes the understudied co-occurrence of temporomandibular joint ankylosis (TMJA) and extrahepatic portal vein obstruction (EHPVO), exploring a shared pathway involving hypercoagulability. TMJA is an acquired pathology where joint surfaces fuse, causing restricted mouth opening and facial asymmetry. Globally, TMJA is prevalent among 1.5 to 5 patients/million, with a higher incidence in developing countries. While trauma and infections often cause TMJA, the pathogenesis remains unclear in many cases. Recent literature notes a link between TMJA and EHPVO, a noncirrhotic vascular disorder causing portal hypertension and upper gastrointestinal bleeding in children. Prothrombotic disorders such as protein C and S deficiency may contribute to EHPVO, mirroring TMJA's association with hypercoagulability. This report focuses on an 11-year-old female diagnosed with TMJA, accompanied by a history of ear infection and concurrent EHPVO. We further presented clinical observations, surgical interventions, and outcomes alongside a literature review to understand the probable connection between EHPVO and TMJA.

Management of temporo-mandibular joint ankylosis using different surgical approaches

Comparison of gap arthroplasty (GAP), interpositional arthroplasty (IAP) and distraction osteogenesis (DO) simultaneous with interpositional arthroplasty (DO+IAP) in management of TMJ ankylosis is of interest to dentists. The study comprised 36 individuals with TMJ ankylosis, 16 of whom were female and 20 of whom were male. Both prior to and following surgery, the maximum inter-incisal opening (MIO) and facial pattern were noted. The postoperative MIO was 33.23 ± 1.23mm, 35.24 ± 1.11mm and 38.24 ± 1.34mm in GAP, IAP and DO+IAP respectively. Data is statistically significant with high MIO observed in DO+ IAP technique and low MIO in GAP technique (p < 0.005). In addition to lengthening the mandible, concurrently processed interpositional arthroplasty alongside DO for TMJ ankylosis corrects gross asymmetry of the face, occlusal mal-alignment, midline change, and creates room for previously un-erupted teeth to emerge.

Conversion of First Metatarsal-Phalangeal Joint Arthrodesis to Arthroplasty: A Case Report

Introduction

Arthrodesis remains the gold standard for most first metatarsal-phalangeal joint (1MTPJ) pathologic conditions due to its high patient satisfaction, low complication rates, and consistent data. 1MTPJ arthroplasty remains a pursued procedure given the advantages described above, but the literature remains complicated and controversial as a primary surgical treatment. To the authors' knowledge, there is no prior report describing utilization of arthroplasty as an approach to managing clinical failure of a successful fusion in the setting of a technically successful procedure without a post-operative complication.

Case Report

We present a case report of a 70-year-old female patient who underwent a successful 1MTPJ arthrodesis for hallux valgus and hallux rigidus and extensive tarsometatarsal arthrodesis for midfoot arthritis. Although the patient had radiographic evidence of successful fusion and had no surgical complications, she presented with dissatisfaction and pain due to functional limitations imposed by the procedure sequelae. The patient was diagnosed with right foot hallux interphalangeus with painful retained hardware. Conservative management failed to improve dissatisfaction or symptoms, and the patient opted for surgical takedown of her fusion with conversion to metatarsal-phalangeal joint arthroplasty, removal of hardware, and second toe proximal phalanx exostectomy. A stepwise surgical technique is described for the procedure, which was successful in addressing the patient's perceived clinical failure.

Conclusion

Our case report describes a rare example of a patient who did not tolerate successful arthrodesis of the 1MTPJ, which was successfully revised to recreate the joint using a decellularized dermal allograft. The procedure resulted in fantastic patient satisfaction and long-term outcomes. This case report highlights a potential salvage option for patients who do not tolerate a 1MTPJ arthrodesis.

Interpositional Arthroplasty With Quadriceps Tendon in Patellofemoral Joint Osteoarthritis: An Alternative Way

We present a case report of a 45-year-old Malay female prison officer with a diagnosis of lateral patellofemoral joint (PFJ) osteoarthritis (OA) in her right knee for whom conservative treatment failed. She was periodically followed up for the unresolving anterior right knee pain, and the patient was offered interpositional PFJ arthroplasty with the quadriceps tendon. A novel technique of interpositional PFJ arthroplasty using lateral inner section ipsilateral quadriceps tendon was applied. The approach and surgical technique were described in this case report. The aim of this study is to describe why this technique was chosen, step by step with images on how interpositional PFJ arthroplasty is done and its satisfactory outcome following a three-month follow up.

Combined Gap and Interpositional Arthroplasty Utilizing Three-Dimensional Printed Model in a Dog with Temporomandibular Joint Ankylosis and Pseudoankylosis

Objective: To report the surgical treatment of a canine with both ankylosis and pseudoankylosis of temporomandibular joint (TMJ). Methods: The patient presented for inability to open his mouth. Facial asymmetry with normal dental occlusion was appreciated and computed tomography (CT) was performed. CT was used to diagnose ankylsosis and pseudoankylosis of left TMJ secondary to chronic maxillofacial trauma. A gap arthroplasty followed by interpositional arthroplasty using temporalis muscle fascia was performed to remove the site of fusion and prevent re-ankylosis between remaining cut boney surfaces. A three-dimensional (3D) printed skull for surgical planning and intraoperative spatial localization was employed. Results: Following preoperative and intraoperative evaluation of the 3D printed skull, the surgery was performed successfully without major complications. The patient's TMJ range of motion was markedly improved and remains improved as noted by inter-incisal distance measurements, ability to pant, and ease of chewing. Conclusion: A combined Gap and interpositional arthroplasty was assisted with the use of a 3D printed skull and immediately resulted in improved TMJ range of motion and patient quality of life. Three-month postoperative CT revealed stable ostectomies with no complications, with the exception of left-sided disuse masticatory muscle atrophy. Long-term follow-up is warranted. Clinical Significance: Three-dimensional printed skull models may be utilized preoperatively and intraoperatively to determine individual variants and landmarks, especially in cases where anatomical structures are difficult to recognize. Gap arthroplasty with interpositional myofascial transposition is an option for a patient with both anklyosis and pseudoankylosis of the TMJ.

Interpositional Arthroplasty in the Treatment of Hallux Rigidus: A Systematic Review

Hallux rigidus is the most common arthritic condition of the foot. Interpositional arthroplasty (IPA) is indicated for advanced-stage hallux rigidus and attempts to maintain joint motion through insertion of a biologic spacer into the joint. However, the data evaluating the effectiveness of IPA are limited. The purpose of this study was to systematically review the outcomes of IPA in the treatment of hallux rigidus. MEDLINE, EMBASE, and Cochrane Library databases were systematically reviewed based on the preferred reporting items for systematic reviews and meta-analyses guidelines. Outcomes collected and analyzed included: American Orthopaedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (HMI) score, visual analogue scale score, short-form 36 score, range of motion (ROM), radiographic parameters, and postoperative complications. The level and quality of clinical evidence were recorded and assessed. Sixteen studies with a total of 428 patients met inclusion/exclusion criteria. The mean AOFAS-HMI score improved from 51.6 ± 10.1 (range 35.0-64.2) preoperatively to 86.0 ± 7.7 (range 71.6-95.4) postoperatively (p ≤ .001) at weighted mean follow-up of 58.0 ± 34.5 (range 16.5-135.6) months. The preoperative weighted mean total ROM was 39.3° ± 9.6° (range 24.2-49.9) and the postoperative weighted mean total ROM was 61.5° ± 4.8° (range 54.0-66.5) (p ≤ .001). The complication rate was 21.5% with metatarsalgia as the most commonly reported complication. One study was level 3 and 15 studies were level 4 clinical evidence. This systematic review demonstrates improvement in functional and ROM outcomes following IPA procedure at mid-term follow-up. The procedure however has a moderate complication rate. In addition, there is a low level and quality of evidence in the current literature with inconsistent reporting of data.

Conversion of First Metatarsophalangeal Joint Arthrodesis to Interpositional Arthroplasty With Acellular Dermal Matrix for First Ray Ulceration: A Case Report

The purpose of this study is to report the outcome of the conversion of a first metatarsophalangeal (MTP) joint arthrodesis to an interpositional arthroplasty with an acellular dermal matrix for a chronic nonhealing first ray wound. To our knowledge, this is the first case report converting a first ray arthrodesis to an interpositional arthroplasty to heal a chronic ulceration. A 78-year-old female developed a chronic neuropathic ulceration under the first metatarsal head and hallux after a first MTP joint arthrodesis. The patient failed local wound care and underwent gastrocnemius recession, hallux interphalangeal joint fusion, and an interpositional arthroplasty with the use of an acellular dermal matrix. Bone tunnels were placed proximal to the metatarsal neck, where absorbable sutures affixed to the dermal matrix were passed from plantar to dorsal, and the graft was secured to the reamed metatarsal head and associated capsule. Postoperative radiographs revealed improved alignment of the first MTP joint. Complete reepithelialization of the plantar ulceration occurred within 2 weeks postoperatively. At the 16-month follow-up, the patient was ambulating without restriction and continued to be free of first ray ulceration and infection. This case study details the use of an acellular dermal matrix in an interpositional arthroplasty to offload a chronic nonhealing ulceration secondary to elevated first ray pressure associated with first MTP joint arthrodesis. The goal of this treatment is to reduce pain, heal the ulceration, and prevent its recurrence.

Interpositional Arthroplasty With Extensor Digitorum Brevis Tendon in Freiberg Disease

BACKGROUND

No consensus has been reached in the treatment of Frieberg disease. Our aim was to evaluate medium- to long-term results of patients with advanced Freiberg disease managed with extensor digitorum brevis tendon interpositional arthroplasty.

METHODS

There were 24 patients (19 females, 5 males) managed with interpositional arthroplasty for advanced Freiberg disease between 2003 and 2015. The mean follow-up was 133.8 (range, 60-198) months. According to Smillie classification, there were 4 grade 3, 13 grade 4, and 7 grade 5 patients. Patients were evaluated preoperatively and at the final follow-up with the American Orthopaedic Foot & Ankle Society (AOFAS) score and metatarsophalangeal joint range of motion and postoperatively with visual analog scale (VAS) and subjective satisfaction evaluation. Joint space was evaluated on x-rays.

RESULTS

Mean AOFAS score increased (53.9 to 80.3, P = .001). Eight patients had excellent, 14 had good, and 2 had fair scores. A significant increase was found in dorsiflexion (38.1° [24°-52°] vs 55.3° [34°-65°]; P = .001) and plantarflexion (19.0° [10°-28°] vs 28.6° [19°-39°]; P = .001). Narrowing of the joint space was not seen in any patient, but expansion was determined in all patients (0.39 [0.35-0.47] vs 0.44 [0.41-0.47] cm; P = .002). Of the patients, 9 were very satisfied, 12 were satisfied, 2 were moderately satisfied, and 1 was dissatisfied. The mean postoperative VAS pain score was 1.7 ± 0.9 (0-4).

CONCLUSION

After a minimum 5-year follow-up, most patients with Freiberg disease managed with interpositional arthroplasty using the extensor digitorum brevis tendon had excellent to good functional results with a widening of the joint space.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Low-cost procedure for deformity correction in rheumatoid hands

BACKGROUND

Surgical correction of ulnar drift of metacarpo-phalangeal joint (MPJ) due to Rheumatoid arthritis (RA) is conventionally done by silicon joint arthroplasty which is expensive and may be associated with many complications. We report the outcome of low-cost autologous interpositional arthroplasty.

MATERIAL AND METHODS

Five patients (8 hands, 32 arthroplasties) underwent correction of ulnar drift of MPJ by dorsal capsule interpositional arthroplasty. Results were assessed according to the degree of recovery of movement at the MPJ and correction of ulnar drift. Functional improvement was graded as excellent, good and fair. Pain alleviation was assessed by visual analogue score (VAS) score.

RESULTS

Excellent results were seen in 3 patients (5 hands, 20 arthroplasties), good in 1 patient (2 hands, 8 arthroplasties) and fair in 1 patient (1 hand, 4 arthroplasties). VAS score for pain decreased from mean preoperative 8.2/10 to 1/10. On average follow up of 1.4 years there was good hand function, no recurrence of deformities and patients were pain free.

CONCLUSION

Interpositional arthroplasty for MPJ using dorsal capsule for correction of post RA ulnar drift is a low-cost option which improves the hand function and cosmesis. Additionally, it avoids all the complications related with the use of silicon joints.

Functional Outcomes of Local Pedicle Graft Interpositional Arthroplasty in Adults With Severe Freiberg's Disease

BACKGROUND

Conservative treatment or debridement is generally sufficient for Freiberg's disease grades I and II but operative intervention for the late stages of the disease process (III-V) is more challenging. Debridement alone is not sufficient and various forms of arthroplasty have been put forward. We have evaluated the outcomes of patients treated with an interpositional arthroplasty technique using a pedicle graft of periosteum and fat made into a "Rollmop" spacer for severe Freiberg's disease. No results have previously been reported for this technique.

METHODS

Twenty-five consecutive cases (23 patients) were performed from February 2009 to September 2016 (20 females, 5 males). Mean age at surgery was 52.6 years (range 19-70.5 years) with 92% affecting the second metatarsal. Twenty-three were primary cases and 2 were revision cases. Five cases were stage III, 12 were stage IV, and 8 were stage V. All patients underwent interpositional arthroplasty using a periosteum and fat pedicle graft from the affected metatarsal shaft as described by Myerson. Patients were evaluated using Manchester-Oxford Foot Questionnaire (MOXFQ) and American Orthopaedic Foot & Ankle Society Questionnaire (AOFAS). Mean follow-up was 3.5 years (0.6-7.6 years). Paired 2-tailed Student t tests were used to assess clinical significance.

RESULTS

Surgery allowed 8 patients to return to normal footwear, 10 patients returned to fashion footwear/heels, and 5 returned to sports. Nineteen cases (17 patients) were assessed with patient-reported outcome measures and all showed a clinically and statistically significant improvement in their scores. Mean pre- and postoperative VAS pain scores were 6.2 (range 4-9) and 1.8 (range 0-6) ( P < .05). Mean perioperative AOFAS scores were 45.6 (range 15-73) and 82.7 (range 57-100) ( P < .05). Mean perioperative MOXFQ scores were 60.0 (range 23-89) and 18.1 (range 0-80) ( P < .05).

CONCLUSION

This novel interpositional arthroplasty technique using a "rollmop" of periosteum and fat for severe Freiberg's disease produced significant improvements in pain, functional outcome, and patient satisfaction without donor site morbidity. Furthermore, it allowed patients to return to desired footwear and sporting activities. The functional outcome and joint range of motion was superior after a K-wire was no longer placed across the joint, and we believe it is essential to avoid this to permit early range-of-motion exercises.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Long-Term Follow-up of Capsular Interposition Arthroplasty for Hallux Rigidus

BACKGROUND

Capsular interposition arthroplasty is a joint- and motion-sparing procedure that has been shown as an effective alternative to fusion. This study aimed to evaluate patient function and satisfaction after long-term follow-up.

METHODS

Sixty-four patients were treated with capsular interposition arthroplasty for hallux rigidus by the senior author performed between February 1998 and July 2011. Twenty-two patients could not be reached for follow-up and were thus excluded from the analysis. Therefore, 42 remaining patients were evaluated using the visual analog scale (VAS), Foot Function Index (FFI), Short Form 12 (SF-12), and patient satisfaction scores. The mean follow-up was 11.3 (range, 4-16) years.

RESULTS

The mean VAS for pain was 7.9 preoperatively and 1.8 postoperatively ( P = .003). The mean preoperative SF-12 physical score was 42.0 vs 64.2 postoperatively ( P = .02). The mean preoperative SF-12 mental score was 50.7, while the postoperative SF-12 mental score was 54.6 ( P = .01). The total FFI score also significantly improved, with a preoperative value of 98.3 and a postoperative mean score of 49.6 ( P = .001). The mean patient satisfaction score was 7.4 of 10. Overall, 39 of 42 patients (92.9%) stated they would have the surgery again. Four of the 42 patients (9.5%) required conversion to hallux metatarsophalangeal fusion at a mean of 6.1 years after the index procedure secondary to pain, but no other complications were reported.

CONCLUSION

Capsular interposition arthroplasty was a safe and effective treatment for severe hallux rigidus. These longer term results demonstrate a high level of patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Treatment of Stiff Elbow in Young Patients with Interpositional Arthroplasty for Mobility: Case Series

INTRODUCTION

The elbow is a complex joint involving many articulations and complex biomechanics come into play. Elbow motion is crucial to upper limb movement that loss of 50% of elbow function equals to loss of 80% of upper extremity global function. Restoring movement and stability is challenging to the surgeon while treating a stiff elbow. Unlike other arthroplasties of hip and knee, total elbow arthroplasty (TEA) may not be a primary treatment. Interpositional arthroplasty (IPA) can be considered a viable option in posttraumatic arthritis of elbow in young patients.

CASE REPORT

We report two cases of interpositional arthroplasties done in young patients secondary to posttraumatic event. The first case is 22-year-old female with a history of stiff elbow following a posttraumatic event 3 years back and the second case is 24-year-old male laborer with stiff elbow following trauma more the 10 years back for which he took native treatment. In both the cases through posterior approach to the elbow, we did osteolysis and prepared fascia lata grafts are interpositioned over the recreated articular surfaces. Both the patients in the follow-up have a good range of motion, stability and are satisfied.

CONCLUSION

IPA is a good treatment option in young patients with posttraumatic arthritis. Elbow instability, fascia rupture, thigh pain, and hernia are the problems of IPA. IPA to TEA transition is possible.

Glenohumeral kinematics after soft tissue interposition graft and glenoid reaming: A cadaveric study

BACKGROUND

The management of young patients with glenohumeral arthritis is controversial. Resurfacing of the glenoid with biologic interposition and reaming of the glenoid have been suggested as potential treatment options. The goal of this study was to determine the change in glenohumeral contact pressures in interposition arthroplasty, as well as glenoid reaming in an arthritis model. We hypothesized that interposition with meniscal allograft will lead to the best normalization of contact pressure throughout the glenohumeral range of motion.

MATERIALS AND METHODS

Eight fresh-frozen cadaveric shoulders were tested in static positions of humeral abduction with a compressive load. Glenohumeral contact area, contact pressure, and peak force were determined sequentially for (1) intact glenoid (2) glenoid with cartilage removed (arthritis model) (3) placement of lateral meniscus allograft (4) placement of Achilles allograft (5) arthritis model with reamed glenoid.

RESULTS

The arthritis model demonstrated statistically higher peak pressures than intact glenoid and glenoid with interpositional allograft. Meniscal and Achilles allograft lowered mean contact pressure and increased contact area to a level equal to or more favorable than the control state. In contrast, the reamed glenoid did not show any statistical difference from the arthritis model for any of the recorded measures.

CONCLUSION

Glenohumeral contact pressure is significantly improved with interposition of allograft at time zero compared to an arthritic state. Our findings suggest that concentric reaming did not differ from the arthritic model when compared to normal. These findings favor the use of allograft for interposition as a potential treatment option in patients with glenoid wear.

Interpositional arthroplasty with palmaris longus tendon graft for osteonecrosis of the second metatarsal head: a case report

Osteonecrosis of the second metatarsal head is often attributed to Freiberg's disease. We describe the case of a 27-year-old Taiwanese male soldier with persistent painful disability of the right forefoot of 9 months' duration, but no history of trauma. A series of radiographs suggested the diagnosis of late-stage Freiberg's disease. The lesion was treated with interpositional arthroplasty using a palmaris longus tendon graft, in a modification of the traditional interpositional arthroplastic technique for treating Freiberg's disease. After 2 years of follow-up examinations, the patient was satisfied with the clinical outcome, despite having a limited range of motion of the right second metatarsophalangeal joint relative to the adjacent toes. The patient returned to his army group with functional activity that was better than he had experienced before surgery. We believe this modified interpositional arthroplastic treatment strategy will provide more symptom relief and satisfactory functionality for the treatment of late-stage Freiberg's disease.