Comparison of Arthrocentesis and Arthrocopy

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


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


Equipment Dyocam TM 750 PAL video camera system

(Dyonics)

arthroscopy


Equipment DRK scope-21 arthroscope and arthroscopic cannula

with an irrigation port

arthroscopy


Equipment A: DRK scope-21

arthroscope B: outer cannula; D

1.8mm C: sharp-edged trocar D: blunt trocar

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


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


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


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


Technique Distension of upper joint space with local anesthesia

arthroscopy


Technique Distraction of mandible

arthroscopy


Technique Posterolateral puncture with rotatory movements of sharp trocar and cannula

arthroscopy


Technique Arthroscope slides down the cannula and connected

to the irrigation extension tube

arthroscopy


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


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


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


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


Correction of distorted image Optical characteristic

of the arthroscope Distorted shape of

arthroscopic image Taken into account

with mathematical equation

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

Comparison of Arthrocentesis and Arthrocopy

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