A new pathologic classification for elbow stiffness based on our experience in 216 patients.

BACKGROUND: Elbow stiffness commonly causes functional impairment and upper-limb disability. This study aimed to develop a new pathologic classification to further understand and standardize elbow arthrolysis from a new perspective, as well as to determine clinical outcomes. METHODS: Extension-flexion dysfunction was classified into 4 types: EFI, tethers alone; EFII, tethers with blocks; EFIII, articular malformation; and EFIV, bony ankylosis. Forearm rotation dysfunction was classified into 3 types: FRI, contracture alone; FRII, radial head malunion or nonunion; and FRIII, proximal radioulnar bony ankylosis. A total of 216 patients with elbow stiffness were prospectively included and categorized preoperatively. All surgical procedures were performed by the same chief surgeon; different types underwent specific procedures. Patient data, elbow motion, and functional scores were analyzed. RESULTS: Mean range of motion (ROM) increased from 40° preoperatively to 118° at final follow-up; 88% of patients regained ROM of 100° or greater. The forearm rotation arc (FRA) with forearm rotation dysfunction increased from a preoperative mean of 76° to 128°; 82% of patients regained an FRA of 100° or greater. The mean Mayo Elbow Performance Index (MEPI) increased from 63 to 91 points; the proportion of patients with good or excellent results was 95%. EFI patients had the best ROM (129°) and MEPI (93 points) and EFIV patients achieved the most-changed ROM (116°), whereas EFIII patients had the worst ROM (104°) and MEPI (84 points) and the least-changed ROM (64°). The FRA was best in FRI patients (142°), followed by FRII patients (118°), and worst in FRIII patients (82°); in contrast, the changed FRA was greatest in FRIII patients (82°), followed by FRII patients (64°), and least in FRI patients (37°). CONCLUSION: This study suggests that the proposed pathologic classification provides a new perspective on the understanding and standardization of elbow arthrolysis, providing satisfactory clinical outcomes.

Incremental increase in percentage mouth opening after coronoidectomy in temporomandibular joint ankylosis.

The aim of this study was to evaluate the incremental improvement in mouth opening following coronoidectomy. Twenty-three patients with unilateral temporomandibular joint (TMJ) ankylosis (Sawhney types I-III) were assessed preoperatively; physical and radiological examinations were done (panoramic radiography and computed tomography). Data including demographic and clinical parameters were recorded. Patients with bilateral ankylosis, recurrent cases, and those with Sawhney type IV TMJ ankylosis were not included. The improvement in mouth opening was measured after ostectomy, after ipsilateral coronoidectomy, and after contralateral coronoidectomy. The improvements in mouth opening at each stage were analysed using the Student's t-test and Pearson's correlation coefficient. There was a marked improvement in maximal incisal opening (MIO) from 5.7 ± 4.2mm to 23.7 ± 5.9 mm after removal of the ankylotic bony mass. MIO was significantly increased after ipsilateral coronoidectomy (31.6 ± 7.4mm), and after contralateral coronoidectomy, a mean MIO of 39.4 ± 11.2mm was achieved. At more than 1 year of follow-up, all patients showed improved mouth opening. In conclusion, coronoidectomy plays an important role in improving mouth opening in the treatment of TMJ ankylosis.

Correlation between the disc status in MRI and the different types of traumatic temporomandibular joint ankylosis.

OBJECTIVES: We aimed to investigate the correlation between the disc status in MRI and the different types of traumatic temporomandibular joint (TMJ) ankylosis. METHODS: 51 consecutive patients (69 joints), diagnosed with traumatic TMJ ankylosis with a residual condyle (Types A2 and A3), were included in this study. All patients had pre-operative MRI, which was reviewed to determine the disc shape, length and position. The results were compared using the Mann-Whitney test. RESULTS: There were 37 joints of Type A2 ankylosis and 32 joints of Type A3. All joints of Type A2 and 27 joints of Type A3 (84.4%) definitely had a discernible disc, while 5 joints of Type A3 had no discernible discs. Among the discernible discs, the lateral disc of Type A2 and the whole disc of Type A3 had severe deformity, while the medial disc of Type A2 had mild deformity. The mean (standard deviation) disc length was 10.88 (1.19) mm in Type A2, but 7.50 (0.82) mm in Type A3. There was a significant difference between Types A2 and A3 (p < 0.05). As for the disc position, the intermediate position was found in all joints. CONCLUSIONS: There is a correlation between the disc status and the different types of traumatic TMJ ankylosis. Therefore, MRI examination is needed to help treatment planning and predict post-operative TMJ function.

Management of temporomandibular joint ankylosis type III: lateral arthroplasty as a treatment of choice.

Many surgical techniques for the management of temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this study was to report our experience using a lateral arthroplasty technique in the management of type III ankylosis. The records of 15 patients treated for TMJ ankylosis at our institution between 2007 and 2011 were reviewed. Pre- and postoperative information collected included age, gender, aetiology, ankylosis type/classification, existing facial asymmetry, maximum pre- and postoperative mouth opening, complications, and recurrence of ankylosis. The mean maximum inter-incisal opening in the preoperative period was 12.9 mm and in the postoperative period was 36.2mm. No major complication was observed in any patient. No recurrence was noted in any patient. Our working hypothesis was that for patients with ankylosis type III, the medially displaced condyle and disc can fulfil their role in mandibular function and growth after extirpation of the ankylozed mass. Although they are located in an awkward medial position, they should function exactly as they would after a properly treated, displaced condylar fracture.

Management of temporomandibular ankylosis--compromise or individualization--a literature review.

Temporomandibular joint ankylosis is defined as bony or fibrous adhesion of the anatomic joint components accompanied by a limitation in opening the mouth, causing difficulties with mastication, speaking and oral hygiene as well as inadvertently influencing mandibular growth. Surgical treatment procedures include arthroplasty of the joint cavity with or without a reconstruction and a coronoidectomy, an autogenous costochondral rib graft, distraction osteogenesis and intensive mouth-opening exercise, corrective orthognathic surgery or alloplastic joint prostheses. The authors of this study would like to provide the reader with an evidence-based review of the literature in order to determine the most efficient way to manage TMJ ankylosis and re-ankylosis. The authors have concluded that in order to achieve a satisfactory and durable effective treatment, an individualized approach is necessary in each case.

Traumatic temporomandibular joint ankylosis: our classification and treatment experience.

OBJECTIVE: This article studies the classification of traumatic temporomandibular joint (TMJ) ankylosis based on coronal computed tomographic (CT) scan and presents our treatment experience in the TMJ division of Shanghai Ninth People's Hospital. PATIENTS AND METHODS: From 2001 to 2009, 130 patients diagnosed with TMJ ankylosis were treated in the TMJ division. Among them, 84 patients with 124 joint injuries caused by trauma were treated first by our group of surgeons and were included in this study. All of them had CT scans, especially coronal reconstruction through the TMJ area before and after surgery. A new classification based on the coronal CT scan was proposed: type A1 is fibrous ankylosis without bony fusion of the joint; type A2 is ankylosis with bony fusion on the lateral side of the joint, while the residual condyle fragment is bigger than 0.5 of the condylar head in the medial side; type A3 is similar to A2 but the residual condylar fragment is smaller than 0.5 of the condylar head; type A4 is ankylosis with complete bony fusion of the joint. Our treatment protocol for type A1 ankylosis is fibrous tissue release or condylar head resection with costochondral graft (CCG) and temporalis myofascial flap (TMF). For type A2 and A3 ankylosis, the lateral bony fusion is resected, while the intact residual condylar fragment, displaced medially, is retained. We call it "lateral arthroplasty" (LAP). TMF or masseter muscle flap (MMF) is used as a barrier in the lateral gap between the TMJ fossa and the stump of the mandibular ramus. If the medial condylar fragment in type A3 ankylosis is too small to bear the load, it is resected with the bony mass. The joint is then reconstructed with CCG and TMF or MMF. For type A4 ankylosis, the bony fusion is completely removed and the joint is reconstructed with CCG and TMF or MMF. The result of the treatment was evaluated by CT scan and clinical follow-up. RESULTS: Among the 124 ankylotic joints, there were 14 type A1 ankylosis (11.3%); 43 type A2 ankylosis (34.7%); 46 type A3 ankylosis (37.1%); and 21 type A4 ankylosis (16.9%). Part of type A1, and all of type A2 and A3 ankylosis had the residual condylar head displaced medially, which accounted for 75% (93/124) of the TMJ ankylosis. Eighty-two joints (66.1%) had LAP treatment; 33 joints (26.6%) had CCG joint reconstruction; and 3 joints (2.4%) had TMJ fibrous tissue release. In our case, 1 joint (0.8%) had condylectomy and TMF; 3 joints (2.4%) with fibrous ankylosis had mouth opening treatment; and 2 joints had gap arthroplasty (1.6%). Forty-eight patients with 68 joints had long follow-ups from 10 months to 4 years. Among them, 4 of 17 joints reconstructed with CCG had reankylosis (23.5%), and 7 of 48 joints treated with LAP had reankylosis (14.6%). CONCLUSIONS: The new classification of TMJ ankylosis based on coronal CT scan is valuable in guiding clinical treatment. LAP with TMF is a good way to treat traumatic TMJ ankylosis when the medially displaced condylar head and disc are intact. CCG with TMF has a good result for type A4 ankylosis.

Versatility of full thickness skin-subcutaneous fat grafts as interpositional material in the management of temporomandibular joint ankylosis.

The authors present a review of seven patients (eight joints) with temporomandibular ankylosis treated between 2007 and 2008. The aim of this retrospective study was to present the experience of using full thickness skin-subcutaneous fat grafts, harvested from the patient's abdomen as interpositional material after gap arthroplasty. All patients presented with osseous ankylosis and were graded according to Topazian's classification. Postoperative follow up ranged from 12 to 24 months. Maximal inter-incisal opening (MIO) on presentation ranged from 0 to 8mm, which stabilized to 27-44mm at follow up. There was no evidence of re-ankylosis. This study found merit in the use of autogenous full thickness skin-subcutaneous fat graft as an interpositional material for up to 2 years following ankylosis release.

Use of temporalis fascia as an interpositional arthroplasty in temporomandibular joint ankylosis: analysis of 8 cases.

PURPOSE: Different interpositional materials have been used to prevent recurrence after gap arthroplasty in temporomandibular joint ankylosis. In this study, the versatility of the temporalis fascia as an interpositional arthroplasty was evaluated. MATERIALS AND METHODS: Eight cases of unilateral temporomandibular joint ankylosis were evaluated, with a follow-up of 11 months to 6 years. RESULTS: Patients had a preoperative maximal interincisal opening of 1 to 9 mm (mean, 2.75 mm). During the last follow-up observation after surgery, patients had a maximum interincisal opening of 32 to 40 mm (mean, 36.5 mm). Deviation to the affected side was observed in all cases. Paresthesia or anesthesia of the temporal branch of facial nerve was absent in all cases. Periodic panoramic radiographs showed that the intra-articular space was well maintained because of interposed tissue, without signs of relapse. There were no signs of reankylosis in any patient. CONCLUSION: The findings of this study show that the temporalis fascia is a good alternative for interpositional arthroplasty.

[Heterotopic ossifications in major burn injuries : An interdisciplinary challenge]. / Heterotope Ossifikationen bei Schwerbrandverletzten : Eine interdisziplinäre Herausforderung.

Heterotopic ossifications in peri-articular tissue can appear after severe head injury, spinal trauma or local joint trauma. Following extensive burns, heterotopic ossifications are a rare, but severe complication with an unknown pathogenesis. In a retrospective analysis of 672 patients who were treated in our burn center over the last 10 years we identified 5 cases (0.74%) of heterotopic ossification.

Management of temporomandibular joint ankylosis: 11 years' clinical experience.

OBJECTIVE: Many surgical techniques to manage temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this paper is to report one institution's experience using various management techniques and to evaluate the results of these surgical interventions. STUDY DESIGN: The records from our hospital of 42 patients treated for TMJ ankylosis between 1996 and 2007 were reviewed. Pre- and postoperative assessment included age, gender, etiology, ankylosis type/classification, existing facial asymmetry, maximal pre- and postoperative mouth opening, arthroplasty method (gap or interpositional arthroplasty), complications, and recurrence of ankylosis. RESULTS: The mean maximal incisal opening in the preoperative period was 7.51 +/- 6.48 mm and in the post operative period was 27.74 +/- 7.86 mm. All patients experienced significant reduction of pain during function and resumed eating a normal diet. There was no facial nerve paralysis. There was recurrence in 3 cases. CONCLUSION: Joint reconstruction with interpositional arthroplasty for the treatment of ankylosis proved to be effective regarding the prevention of recurrence and restoration of joint function and patient quality of life. Early postoperative exercises, appropriate physiotherapy, and close follow-up play an important role in the prevention of recurrence.

Intraoral approach for arthroplasty for correction of TMJ ankylosis.

This study evaluates the authors' technique using the intraoral approach for the management of temporomandibular joint (TMJ) ankylosis. The technique was used on 16 TMJs in 14 patients with a mean age of 28.5 years; their average postoperative mouth-opening was 33.7 mm. All the patients had Sawhney's type IV TMJ ankylosis except a child with type I. One patient had recurrent ankylosis and was managed using the same intraoral approach again. Average follow-up was 56 months. The protocol consists of interpositional arthroplasty via an intraoral approach and aggressive mouth-opening exercises. An intraoral incision is made over the buccal shelf and the soft tissue of the mandibular ramus reflected. Osteotomy is carried out at the coronoid process and adequate osteotomy is accomplished at the level of the condylar neck. Adequate gap osteotomy at the ankylosed condyle is performed and followed by placement of the interpositional material, such as rib cartilage, masseter, buccal fat pad and costochondral graft. The wound is then closed meticulously. The advantages of this intraoral approach are excellent cosmetic appearance with no facial scar, lower risk of injury to the facial nerve or auriculotemporal nerve and no salivary fistula formation.

Development of Korean Academy of Medical Sciences Guideline rating the physical impairment: lower extremities.

Lower Extremities Committee of Korean Academy of Medical Sciences Guideline for Impairment Rating develops new guidelines which are based on McBride method, American Medical Association Guides, Disability evaluation by The Korean Orthopaedic Association, The Korean Neurosurgery Society, and Korean Academy of Rehabilitation Medicine. The committee analyzed and discussed to create an ideal method practical in Korea. Our committee endeavors to develop new methods which are easy to use, but are suitable for professional use and also independent from the examinee's intentions. The lower extremities are evaluated on the basis of anatomic change, functional change, and diagnosis based evaluation. Nine methods are used to assess the lower extremities. Anatomic assessment includes leg length discrepancy, ankylosis, amputation, skin loss, peripheral nerve injury, and vascular disease. In functional assessment, range of motion and muscle strength are included. Diagnosis-based assessments are used to evaluate impairment caused by specific fractures, deformities, ligament instability, meniscectomies, post-traumatic arthritis, fusion of the foot, and lower extremity joint replacements.

Prediction of wrist prognosis in patients with early rheumatoid arthritis according to radiographic classification.

PURPOSE: We conducted a prospective study of patients with recent-onset rheumatoid arthritis to determine the importance of carpal height ratio (CHR) or ulnar translation ratio (UTR) in predicting radiographic progression of rheumatoid arthritis in the wrist, especially with regard to stable or progressive wrist arthritis. METHODS: We evaluated 106 wrists with early rheumatoid arthritis. Radiologic misalignment was assessed by measuring CHR and UTR. The modified Schulthess classification of rheumatoid wrist involvement was used to classify the subtypes of wrist joint destruction radiographically types I, II, III, and IV, defined as ankylosing, osteoarthritis, disintegrating, and normal, respectively. We evaluated the wrist joints as stable or progressive by measuring the values of CHR and UTR indices. We also examined whether the modified Schulthess classification of rheumatoid wrist involvement subtypes are associated with radiographic progression over 10 years using the baseline CHR and UTR indices. RESULTS: The mean CHR values of types I and III were 0.42 (95% confidence interval [CI], 0.40-0.43) and 0.37 (95% CI, 0.34-0.39), respectively. The mean UTR values of types I and III were 0.348 (95% CI, 0.336-0.360) and 0.351 (95% CI, 0.339-0.367), respectively. These values indicated that degradation was faster in types I and III than in other types. We then found type I and III wrists to have progressive arthritis, and type II and IV wrists stable arthritis. We also found that the baseline CHR index was a significant (p < .05) predictor of radiographic progression. CONCLUSIONS: Our results indicated that type I and III wrists had radiographic progression and ultimately underwent deformation. This analysis also showed that the baseline CHR index was even more useful in predicting radiographic progression after 10 years.

Histopathology of nonotosclerotic stapes fixations.

HYPOTHESIS: Different diseases without exact histopathologic classification can cause stapes ankylosis. BACKGROUND: Otosclerosis is a complex bone remodeling disorder of the otic capsule due to persisting measles virus infection and consecutive inflammatory reaction. In fact, clinical and demographic features of otosclerosis have reference to stapes ankylosis. In the clinical practice, otosclerosis and stapes ankylosis are incorrect synonyms. METHODS: Nonotosclerotic stapes footplates (n = 284) removed during stapedectomy were analyzed histologically. Otosclerosis was excluded during the histologic preselection (n = 437). Total RNA was extracted, and measles virus-specific reverse-transcriptase-polymerase chain reaction was performed. RESULTS: Nonotosclerotic stapes ankylosis was associated with total absence of measles virus RNA. Six main types of nonotosclerotic stapes fixations could be distinguished histologically: annular calcification (n = 152; 53.5%), globular fibrosis (n = 49; 17.25%), lymphocytic infiltration (n = 31; 10.9%), hemosiderosis (n = 22; 7.75%), granulomas (n = 17; 6%) and amyloidosis (n = 13; 4.6%). Fragmentation of nonotosclerotic stapes footplates was infrequent (7%) during stapes surgery. Only 1 floating footplate (0.35%) was reported. CONCLUSION: Two thirds of nonotosclerotic stapes footplates represented complete pathologic bone remodeling. Unlike otosclerosis, nonotosclerotic stapes fixations were characterized by basic histopathologic findings without organ specificity that can also be identified in case of different diseases. Prevalence of nonotosclerotic stapes ankylosis is approximately 30 to 40% among stapes fixation cases. The long-term prognosis and surgical considerations theoretically differ from those of otosclerosis.

Development of Korean Academy of Medical Sciences Guideline Rating the Physical Impairment: Lower Extremities

Lower Extremities Committee of Korean Academy of Medical Sciences Guideline for Impairment Rating develops new guidelines which are based on McBride method, American Medical Association Guides, Disability evaluation by The Korean Orthopaedic Association, The Korean Neurosurgery Society, and Korean Academy of Rehabilitation Medicine. The committee analyzed and discussed to create an ideal method practical in Korea. Our committee endeavors to develop new methods which are easy to use, but are suitable for professional use and also independent from the examinee's intentions. The lower extremities are evaluated on the basis of anatomic change, functional change, and diagnosis based evaluation. Nine methods are used to assess the lower extremities. Anatomic assessment includes leg length discrepancy, ankylosis, amputation, skin loss, peripheral nerve injury, and vascular disease. In functional assessment, range of motion and muscle strength are included. Diagnosis-based assessments are used to evaluate impairment caused by specific fractures, deformities, ligament instability, meniscectomies, post-traumatic arthritis, fusion of the foot, and lower extremity joint replacements.

Injerto de cartílago de crecimiento en la anquilosis temporomandibular / Growth cartilage graft in temporomandibular joint ankylosis

La anquilosis temporomandibular es una alteración crónica que produce una limitación progresiva de la apertura bucal y de los movimientos mandibulares que puede manifestarse en las dos primeras décadas de vida. El objetivo de este artículo es presentar un caso clínico de anquilosis temporomandibular bilateral tratado en forma quirúrgica con injerto de cartílago de crecimiento de cresta ilíaca y discutir los diversos tratamientos de esta patología, según la bibliografía internacional actual (AU)

Injerto de cartílago de crecimiento en la anquilosis temporomandibular / Growth cartilage graft in temporomandibular joint ankylosis

La anquilosis temporomandibular es una alteración crónica que produce una limitación progresiva de la apertura bucal y de los movimientos mandibulares que puede manifestarse en las dos primeras décadas de vida. El objetivo de este artículo es presentar un caso clínico de anquilosis temporomandibular bilateral tratado en forma quirúrgica con injerto de cartílago de crecimiento de cresta ilíaca y discutir los diversos tratamientos de esta patología, según la bibliografía internacional actual (AU)

[Posttraumatic temporomandibular joint ankylosis: clinical development and surgical management].

OBJECTIVE: To investigate the patterns of condylar fractures associated with temporomandibular joint ankylosis (TMJA) and treatment methods and results based on the different types of ankylosis. METHODS: Forty-two joints of ankylosis in 31 patients with were categorized to four groups according to Sawhney's classification and undergone surgical treatment as follows: a joint release and disc reposition for Type I ankylosis, a dissection of bony block and disc reposition for Type II; a dissection of full-joint and employment of the temporal myofascial flap as interposition for Type III; a radically dissection of full joint followed by ramus distraction osteogenesis and genioplasty for Type IV. All of patients were followed up for 9 to 54 months with an average of 30 months. The range of mouth opening and temporomandibular joint (TMJ) function were assessed. Condylar fractures were retrospectively investigated on the patterns and the course of ankylosis development. Macroscopical visualization on the osseously ankylosed sites and disc displacement were analyzed in comparison with the radiological findings. RESULTS: Condylar sagittal and comminuted fractures were most susceptible to TMJA. Early fibrous ankylosis occurred usually at the 4th or 5th month post-traumatically with an average month opening of 18.3 mm. The articular discs were found displaced in all cases and early bony bridge formed at a limited area where there was no disc as cushion. During fellow-up, considerable improvement in mandibular movement was attained with a stable joint function and mouth opening range of over 30 mm except for two cases in which ankylosis relapsed. CONCLUSIONS: Condylar sagittal and comminuted fractures are most likely to cause ankylosis. Early surgical intervention could reduce the disc and avoid the later ankylosis.

The interpositional dermis-fat graft in the management of temporomandibular joint ankylosis.

The aim of this retrospective clinical study is to present the clinical experience of using dermis-fat interpositional grafts in the surgical management of temporomandibular joint (TMJ) ankylosis in adult patients. Eleven adult patients who presented with ankylosis of the TMJ were identified and included in the study. All patients underwent a TMJ gap arthroplasty which involved the removal of a segment of bone and fibrous tissue between the glenoid fossa and neck of the mandibular condyle. The resultant gap was filled with an autogenous dermis-fat graft procured from the patient's groin. All patients were followed up for a minimum of 2 years. Five of the 11 patients were found to have osseous ankylosis while 6 patients had fibro-osseous ankylosis. Two patients had bilateral TMJ ankylosis that were also treated with costochondral grafts which were overlaid with dermis-fat graft. The average interincisal opening was 15.6 mm on presentation which improved to an average of 35.7 mm following surgery. Patients were followed up from 2 to 6 years post-operatively (mean 41.5 months) with only 1 re-ankylosis identified out of the 13 joints treated. This study found that the use of the autogenous dermis-fat interpositional graft is an effective procedure for the prevention of re-ankylosis up to 6 years following the surgical release of TMJ ankylosis.

Imaging of temporomandibular joint ankylosis. A new radiographic classification.

OBJECTIVES: To compare the pre-operative clinical and radiographic findings of temporomandibular joint (TMJ) ankylosis with those found at operation and propose new classification. METHODS: Thirty-three patients were treated for TMJ ankylosis. There were 18 unilateral and 12 bilateral cases. All patients underwent pre-operative clinical and radiographic examination, (consisting of a panoramic radiograph, axial and coronal CT. The surgical findings were compared with the imaging features. RESULTS: Post-contrast coronal CT was the best imaging modality for planning surgery as it displayed the anatomical relationship between the ankylosed segment and the surrounding vital structures, particularly where the sphenoid and temporal bones were involved. CONCLUSIONS: Surgical planning should be based on coronal and axial CT. A new classification of TMJ ankylosis based on the CT findings is proposed.