Fused hip conversion to total hip arthroplasty with the direct anterior approach: surgical technique on a regular surgical table under fluoroscopic guidance

PURPOSE

Conversion of a fused hip to a total hip arthroplasty (THA) is technically challenging due to the loss of anatomical references. Here, a reproducible technique using the direct anterior approach (DAA) with a regular surgical table under fluoroscopic guidance is described, which has several advantages over traditional such as lateral or posterior approaches.

METHODS

There were reported 11 cases of ankylosis hip that were converted to THA using the same surgical technique protocol. Clinical and radiographic outcomes were recorded at 3.2 years of follow-up. A detailed preoperative evaluation was performed, including a pelvis radiological evaluation and magnetic resonance image (MRI) to assess the integrity of the periarticular soft tissue and flexor muscles.

RESULTS

The DAA has considerable advantages, such as allowing more precise targeting during surgery, avoiding the risk of pseudoarthrosis due to the absence of a trochanteric osteotomy, preserving the abductors, and allowing an easier-to-use of intraoperative fluoroscopy due to the supine position. Besides, the use of a standard table reduces surgical time and allows assessment of limb length, hip stability, and impingement in all planes in an intraoperative dynamic range, which decreases postoperative complications.

CONCLUSION

Conversion from hip fusion to THA is a rare and complex procedure. The use of DAA with a standard table and fluoroscopy helps to avoid high complications since it allows a dynamic intra-operative examination of the range of motion to rule out impingements, reduces the risk of dislocation, and allows leg lengthening verification.

Sequential surgery for the treatment of type I knee ankylosis: a series of 62 cases

BACKGROUNDS

The lack of systematic classification and standard treatment principles for knee ankylosis prevents optimal treatments. This study explored treatments for type I (mild) knee joint ankylosis.

METHOD

This retrospective study analysed patients with knee joint ankylosis admitted from March 2013 to January 2018 who underwent sequential arthroscopic release.

RESULT

The 62 patients had 12-36 (average, 18) months of follow-up. Thirty-eight patients were released; of these, 18 were assisted by limited incision with partial quadriceps femoris expansion myotomy and released according to arthroscopy. Six patients underwent lengthening and release of the quadriceps femoris. All surgeries combined with full-course rehabilitation resulted in improved joint mobility. The range of motion (ROM) of the knee joint recovered to a range of 0° to 85°-140° (mean: 118.32 ± 9.42°) from the preoperative range of 30°-70° (mean: 45° ± 15.50°). The clinical effect was evaluated according to the Judet criteria at the final follow-up. The outcomes at the last follow-up (at least for 1 year) were excellent in 55 cases, good in six cases, and fair in one case.

CONCLUSION

Sequential arthroscopic release, minimal selective invasion of limited incision of partial quadriceps femoris expansion myotomy, assisted by pie-crusting technique to release, or quadriceps femoris lengthening, and release surgery for type I knee joint ankylosis, accompanied by early rehabilitation training provided satisfactory results without significant complications.

Complications of Mandibular Fracture Repair

Mandible fracture management has evolved dramatically. Therefore, the variety of surgical complications associated with mandibular fractures, and their incidences, have continued to change as well. This article aims to assess the most common and most concerning complications that can occur secondary to management of mandibular fractures by examining categories of complication types. This article also explores factors and techniques associated with reduced rates of complications as well as the management of complications.

[Management of traumatic temporomandibular joint ankylosis: a perspective]

Traumatic injury to the temporomandibular joint (TMJ) was the most common cause of TMJ ankylosis (85%), while sagittal fracture of the mandibular condyle was identified as the high risk fracture pattern. TMJ disc displacement is one of the prerequisite factors of TMJ ankylosis. The severe damage and close contacts of both the articular surface of glenoid fossa and condyle were also crucial pathogenic factors in the development of TMJ ankylosis. The mechanism and development of TMJ ankylosis may be similar to hypertrophic non-union, and the persistence of radiolucent zone within the ankylotic callus governs the clinical and pathological process of TMJ ankylosis. In type Ⅰ traumatic TMJ ankylosis, repositioning of the displaced disk is required, while the preservation of pseudo-joint is essential in the management of the type Ⅱ traumatic TMJ ankylosis. Nevertheless, the rate of TMJ reankylosis still remains high. Higher rate of TMJ reankylosis was observed in paediatric population, bilateral involvement of TMJ ankylosis, and in cases with reconstruction of mandibular condyle with coronoid process.

Long term complications of costochondral graft reconstruction in temporomandibular joint ankylosis of the young- a systematic review

Costochondral graft has been a popular reconstruction choice in the past for temporomandibular joint ankylosis in young individuals. However, accounts of growth hampering complications have also been observed. Our systematic review aims to compile all existing evidence to determine the occurrence of these unfavourable clinical outcomes as well as factors affecting them to provide a better judgement on further use of these grafts. A systematic review was conducted following PRISMA guidelines where databases like PubMed, Web of science and Google Scholar were searched for the purpose of data extraction. Observational studies performed on patients younger than 18 years of age with a minimum follow-up of one year were selected. Incidence of long term complications like reankylosis, abnormal graft growth, facial asymmetry and others were considered as outcome variables. Eight articles with a total of 95 patients were selected where complications like reankylosis (6.32%), graft overgrowth (13.70%), insufficient graft growth (22.11%), no graft growth (3.20%) and facial asymmetry (20%) were reported. Other complications like mandibular deviation (3.20%), retrognathia (1.05%) and prognathic mandible (3.20%) were also observed. Our review concludes that the occurrence of these complications was noteworthy. Thus use of costochondral graft for reconstruction in temporomandibular ankylosis in young patients holds significant risk in development of growth abnormalities. However, modifications in surgical procedure such as use of appropriate graft cartilage thickness and the presence and type of interpositional material can favourably affect the frequency and type of growth abnormality.

Rehabilitation of Dentofacial Asymmetry Secondary to Unilateral Temporomandibular Joint Ankylosis with Dual Distraction and Fixed Orthodontics - Stability at Three-year Follow-up

Optimal rehabilitation of asymmetric dentofacial deformity secondary to unilateral temporomandibular joint (TMJ) ankylosis is often a challenge. The purpose of this case series is to present an insight into esthetic, occlusal and functional rehabilitation of two patients with varying degree of asymmetric Class II dentofacial deformities secondary to long-standing unilateral TMJ ankylosis. The patients were treated with one-stage surgical protocol employing simultaneous dual distraction technique along with interpositional arthroplasty. Dual distraction technique entailed the simultaneous use of two distractors which allowed for proper control of proximal condylar segment during the course of distraction and lowering the risk of ankylosis recurrence. Thereafter, comprehensive fixed orthodontic mechanotherapy involving the use of temporary anchorage devices was instituted to align and level the compensated dentition. Post-treatment records showed significant improvements in skeletal disharmony and functional stability with good functional occlusion. At the three-year follow-up, the morphological and functionally acceptable results were reasonably well-maintained, with no signs of relapse. Through the two cases reported here, we would like to highlight that one-stage concurrent arthroplasty and dual distraction technique is a safe, stable, and reliable approach for surgical and functional rehabilitation of an adult asymmetric dentofacial deformity secondary to unilateral TMJ ankylosis. Meticulously executed comprehensive orthodontic manipulations involving use of acrylic bite-blocks, elastic traction, and temporary skeletal anchorage device play a crucial role in enhancing the final occlusal outcomes.

A Modified Technique for Treating Post-Traumatic Temporomandibular Joint Ankylosis in a Pediatric Patient

Treatment of post-traumatic temporomandibular joint ankylosis is still a challenge. A modified technique that included surgery navigation technique, ultrasonic osteotome, bovine acellular dermal matrix, and abdominal dermis fat transplantation, was applied to treat a case of post-traumatic temporomandibular joint ankylosis. A 11-year-old girl with right temporomandibular joint bony ankylosis received surgical treatment in our department. Immediately restoration of functions and prevention of re-ankylosis have been achieved. Therefore, this case report demonstrated the safety and effectiveness of this modified technique in the management of temporomandibular joint ankylosis surgery.

Extraarticular joint ankylosis: a rare presentation

Pseudoankylosis is a rare condition that causes inability to open the mouth due to condition related to outside of the temporomandibular joint. Most literature refers to this hypomobility disorder, a result of fusion of the zygomatic bone to the coronoid process, and very rarely is insidious coronoid hyperplasia causing mechanical interference with the posterior maxilla has been reported. We present a case of a 45-year-old woman, who presented with coronoid malformation and overgrowth resulting in progressive decrease in mouth opening. She was managed with coronoidectomy, following which good mouth opening was obtained. In this paper we discuss about the diagnosis and management of this rare disorder.

Mandibular osteoma as a cause of ankylosis and progressive trismus

Osteomas are benign tumours of bone tissue restricted to the craniofacial skeleton. The aim of this article is to present and discuss the demographic and clinical aspects and the management of craniomaxillofacial osteomas. When the patient was submitted from primary care to our hospital, he was 68 years old, and he had ankylosis of the temporomandibular joint for the previos 4 years. A CT scan was performed, finding a giant mandibular osteoma. Conservative treatment and radiological follow-up were carried out with clinical stability. Osteomas more often are seen in the paranasal sinuses and in young adults, with no differences in gender. Most are asymptomatic, but they can cause local problems. For its diagnosis, CT is usually performed. Treatment options are conservative management and follow-up or surgery. Although rarely, they can recur. Mandibular peripheral osteoma is a rare entity. Depending on the symptoms, a conservative or surgical treatment can be chosen. A clinical and radiological follow-up is necessary to detect possible recurrences or enlargement.

Manipulation under anesthesia following total knee arthroplasty: a comprehensive review of literature

INTRODUCTION

The etiology of the stiff knee after total knee arthroplasty (TKA) is largely unknown, although excessive scar tissue due to arthrofibrosis is an important reason for a limited range of motion (ROM) after this procedure. Persistent limited ROM after TKA results in poor patient-reported outcomes and is increasingly becoming a more prominent reason for TKA revision surgery.

METHODS

A narrative review of current literature on manipulation under anesthesia (MUA) after TKA analyzing etiology and risk factors for stiffness after TKA, effectiveness of MUA and what is known about rehabilitation after MUA.

RESULTS

Literature describes numerous risk factors for insufficient knee ROM after TKA, but a comprehensive valid risk model is lacking. MUA is an effective treatment option with evidence suggesting better outcomes if performed within the first 3 months after TKA. The wide variety in both the indication and timing for MUA, and the lack of scientific evidence on how to rehabilitate patients after MUA, complicates the interpretation of available literature. This is even more so the case on the reporting of one versus two or more MUAs after TKA.

CONCLUSION

Future comparative trials, preferably with a randomized study design, should be conducted to elude more clear indications for MUA, to give clinical guidance on correct timing for MUA and on how to rehabilitate patients afterward.

Turning the backbone into an ankylosed concrete-like structure: Case report

RATIONALE

Progressive restriction of the spinal bio-mechanics is not-uncommon deformity encountered in spine clinics. Congenital spinal fusion as seen in Klippel-Feil-anomaly, progressive non-infectious anterior vertebral fusion, and progressive spinal hyperostosis secondary to ossification of the anterior longitudinal spinal ligament are well delineated and recognized.

PATIENT CONCERNS

A 24-year-old girl has history of osteoporosis since her early childhood, associated with multiple axial and appendicular fractures and scoliosis. Recently she presented with episodes of severe back pain, spinal rigidity/stiffness with total loss of spine biomechanics.

DIAGNOSES

She was provisionally diagnosed as having osteogenesis imperfecta and was investigated for COL1A1/A2 mutations which have been proven to be negative. Autosomal recessive type of osteogenesis imperfecta was proposed as well, no mutations have been encountered. A homozygous for CTSA gene mutation, the gene associated with Galactosialidosis was identified via whole exome sequencing (Next-Generation Sequencing projects) has been identified.

INTERVENTIONS

Early in her life she had a history of frequent fractures of the long bones since she was 4 years which was followed by vertebral fractures at the age of 12 years. She manifested lower serum 25OH-D levels and were associated with lower LS-aBMD Z-scores with higher urinary bone turnover indexes (urinary NTX/Cr).

OUTCOMES

Lysosomal storage diseases (LSD) have a strong correlation with the development of osteoporosis. LSD causes skeletal abnormalities results from a lack of skeletal remodeling and ossification abnormalities owing to abnormal deposition of GAGs (impaired degradation of glycosaminoglycans ) in bone and cartilage. 3D reconstruction CT scan of the spine showed diffuse hyperostosis of almost the entire spine (begins at the level of T4- extending downwards to involve the whole thoraco-lumbar and upper part of the sacrum) with total diffuse fusion of the pedicles, the transverse and articular processes, the laminae and the spinous processes.

LESSONS

This is the first clinical report of adult patient with a history of osteoporosis and fractures with the late diagnosis of Galactosialidosis. Osteogenesis imperfecta (autosomal dominant and recessive) were the first given diagnoses which proven negative. The pathophysiology of the spine ankylosis in our current patient and its correlation with LSD, antiresorptive medications, vitamin D3 and supplemental calcium is not fully understood. Therefore, further studies are needed to elucidate this sort of correlation.

Surgical treatment of hip ankylosis due to heterotopic ossification secondary to spinal cord injury

OBJECTIVES

To expose our experience in the diagnostic and surgical treatment of neurogenic heterotopic ossification of the hip.

MATERIAL AND METHODS

We designed an observational retrospective descriptive study including 20 patients (30 hips) with neurogenic heterotopic ossification of the hip secondary to spinal cord injury attended in our institution in the last 10 years, with a minimum of one year follow-up. Medical files and imaging studies were reviewed. The study variables analyzed were: type and localization of neurogenic heterotopic ossification, pre-post excision range of motion, level and aetiology of spinal cord injury, ASIA score, smoking history, surgical approach and complications associated with surgery.

RESULTS

A total of 20 patients were treated with resection of heterotopic ossification in 30 hips. 16 patients presented ASIA A spinal cord injury and 4 ASIA B spinal cord injury. Preoperatively all the patients had severe ankylosis in the hip that made sitting in a wheel chair and activities such as repositioning and hygiene difficult. The average postoperative motion at the follow-up evaluation was 90° in flexion, 20° of internal rotation and 40° of external rotation. Immediately after surgery all the patients followed a specific intensive physiotherapy regime for the hip and celecoxib 200 mg was administrated daily orally for a month to prevent recurrence of heterotopic bone formation. None of the patients reviewed suffered a recurrence of heterotopic bone formation.

CONCLUSIONS

Surgical excision of hip ossification in order to achieve functional ROM of the hip is the best treatment for patients with neurogenic heterotopic ossification of the hip.

Skeletal complications of rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with local and systemic inflammation that induces many changes in the skeletal health. Locally, periarticular bone loss and juxta-articular bone erosions may occur while joint ankylosis, generalized bone loss, osteoporosis, and fractures may develop secondary to inflammation. The aim of this narrative review is to summarize the clinical evidence for abnormal skeletal health in RA, the effects of disease modifying anti-rheumatic drugs (DMARDS) on bone health, and the effects of drugs for the prevention or treatment of osteoporosis in the RA population.

Total knee arthroplasty conversion for patients with ankylosed knees

INTRODUCTION

The purpose of this study was to evaluate the results of total knee arthroplasty for patients with ankylosed knees.

METHODS

We evaluated seven patients (10 knees) who underwent total knee arthroplasties for ankylosed knees from 1995 to 2008. There were two men and five women, with a mean age of 44.1 years (42-48 years). The mean follow-up period was 10.2 years (1-19.5 years). A rectus snip was performed in all cases, and V-Y quadricepsplasty was used in one case of severe quadriceps contracture. In all cases, we used the PFC Sigma PS fixed model (DePuy Orthopaedics Inc., Warsaw, Indiana, USA). The goal was more than 90° of flexion. Clinical evaluation was performed using range of motion (ROM), Knee Society (KS) Knee Score, KS Function Score, and complications. Radiographs were used to evaluate loosening or osteolysis.

RESULTS

The ROF was improved from 9.5° (0-30°) to 78.5° (15-115°), The Knee Score improved from 42.6 (25-70) to 68.6 (41-97), and the Function Score improved from 39 (0-60) to 66 (40-90). A radiolucent line was detected in two cases (one patient) around the tibial component, and one case had a necrosis of skin edge. Only one case had no improvement of motion.

CONCLUSION

Total knee arthroplasty conversion for patients with ankylosed knees can achieve good results for motion and function without osteotomy of the tibial tuberosity when there is good quality soft tissue of the thigh.

Clinical Evaluation of Fused/Ankylosed Hip with Severe Flexion Deformity after Conversion to Total Hip Arthroplasty

INTRODUCTION

Fused or Ankylosed hip is late complication of chronic inflammatory disorder with progressive changes in and around articular as well as periarticular structures with alteration in bio-force line of body which later lead to severe flexion deformity of joint. This not only results decreased movements of hip, it's also increase pain around the hip, back and contralateral hip.

METHODS

Retrospectively, all patients aged 18 years or older undergoing THA between June 2006 to June 2012 were reviewed with selection criteria. The five ankylosed hips (three left and two right) with severe flexion deformities which ankylosed spontaneously were successfully converted to THA at time period of 2006 to June 2012. Range of motion, Harris Hip Score and flexion deformity angle at preoperative, postoperative and follow-up periods were used as evaluation.

RESULTS

Mean follow up is 42 months. Mean HHS increased from 21.6±4.97 to 81.8±4.02 points with one excellent, two good and two fair cases. The FDA is corrected to mean 8°±10.95 postoperatively and 4°±5.47 at final follow up from 81.6°±4.39 with two hips of 10° residual deformity. Hip ROM is improved as flexion 70° to 100°, adduction 10° to 20°, abduction 10° to 30°, internal rotation 5° to 10° and external rotation 2° to 50° from 0° activity. As complications, one hip had loose prosthesis, two had early postoperative dislocations, one had Deep Vein Thrombosis and one had femoral nerve palsy with quadriceps weakness.

CONCLUSIONS

THA is an effective treatment for ankylosed hip with severe flexion deformity although complications are noted more than routine hip arthroplasties.

Bony ankylosis of hydroxyapatite prostheses in the middle ear

BACKGROUND

Ossiculoplasty is a commonly performed middle ear procedure. Ossicular chain reconstruction (OCR) prostheses should be made of a biocompatible material; one such common material is hydroxyapatite (HA).

METHODS

2 patients were identified who had HA OCR prostheses which had fused to the middle ear bony structures. One HA OCR had fused to the fallopian canal in the tympanic segment and represented a management dilemma. The other fused to the scutum.

CONCLUSION

Bony ankylosis of a HA containing OCR prosthesis should be considered in the differential diagnosis of a failed ossiculoplasty. Depending on the location of the fusion, special measures may be needed to free the prosthesis from the underlying middle ear structures.

TMJ ANKYLOSIS: MANAGEMENT WITH RECONSTRUCTION AND INTERPOSITIONAL ARTHROPLASTY

Temporomandibular joint (TMJ) ankylosis is a very desolating structural condition that involves fusion of the mandibular condyle to the base of the skull. It causes difficulty in mastication and breathing. Trauma and Infections are usually responsible. If trauma occurs in young age, it leads to disturbance in growth & facial asymmetry. Treatment of temporomandibular joint (TMJ) ankylosis usually requires adequate excision of the involved ankylotic block (arthroplasty) or interpositional arthroplasty using autogenous or alloplastic materials. Early mobilization, physiotherapy & strict follow up are essential to prevent postop adhesions. In our cases fascia lata was used as an interpositional grafting material. One case was treated by gap arthroplasty, second case by costochondral graft & third case was managed with titanium condylar prosthesis.

Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis

Traumatic temporomandibular joint (TMJ) ankylosis can be classified into fibrous, fibro-osseous and bony ankylosis. It is still a huge challenge for oral and maxillofacial surgeons due to the technical difficulty and high incidence of recurrence. The poor outcome of disease may be partially attributed to the limited understanding of its pathogenesis. The purpose of this article was to comprehensively review the literature and summarise results from both human and animal studies related to the genesis of TMJ ankylosis.

Undiagnosed mandibular condylar fractures causing temporomandibular joint ankylosis: A problem in northern India

BACKGROUND

Temporomandibular joint (TMJ) ankylosis due to undiagnosed condylar fractures has a high incidence in India compared to western countries. We evaluated the demographics, injury pattern, hospital reporting and referral pattern of undiagnosed condylar fractures complicating TMJ ankylosis in northern India.

METHODS

We did a retrospective analysis by retrieving medical records of patients with post-traumatic TMJ ankylosis reporting to the Department of Oral and Maxillofacial Surgery, All India Institute of Medical Sciences between 1 July 2012 and 30 June 2013.

RESULTS

Of 90 patients with post-traumatic TMJ ankylosis, 74 (82.2%) resided in rural areas. Sixty-three (70%) patients were from the states of Uttar Pradesh, Bihar and Jharkhand. Only 8.8% had higher education and 10% had an annual income of more than `2 lakh. In 69 (84.4%) patients, fall was the aetiological factor. Primary health centres (42%) and private clinics (20.5%) received the major share of patients immediately following injury. Few patients (19.3%) had some radiographic examination done and only 17% were referred by the primary healthcare provider. Of those referred only 3 were examined by a dental practitioner. Only 10% of all were diagnosed with condylar fractures.

CONCLUSION

Patients with TMJ ankylosis presenting to us have poor literacy and income levels. A missed diagnosis of condylar fractures by rural healthcare providers contributes to its high incidence in India. Improving awareness of clinicians and improved rural healthcare infrastructure can help prevent this complication.

[Temporomandibular joint ankylosis caused by systemic (distal) infection: a case report and literature review]

There were many causes for temporomandibular joint (TMJ) ankylosis including infection, trauma, degenerative changes and space-occupying lesion. This article reported a case of bilateral TMJ ankylosis caused by systemic (distal) infection. A 35-year old female patient complained of difficulty of opening mouth for about 20 years. She developed abscess in several places all over the body including bilateral TMJ 20 years ago. CT indicated that the condylar process was fused with the temporal bone. The patient was treated with resection of bilateral condylar/coracoid process and total joint prosthesis replacement. The maximal incisal opening was 2.5 cm 3 months post operation. The patient obtained a satisfied function of eating and speaking.

[Zygomatic arch fracture extended to the glenoid fossa: a cause of TMJ pain]

INTRODUCTION

Fractures of the zygomatic arch extended to the glenoid fossa are rare and seldom reported.

OBSERVATION

A 26-year-old man with a slightly dislocated fracture of the zygoma associated with trismus, and localized pain in the right Temporo-Mandibular Joint (TMJ) on palpation, but without any condylar fracture. The craniofacial CT scan revealed a fracture of the zygoma extended to the glenoid fossa. The treatment was an intraoral reduction of the zygoma and screw fixation of the glenoid fossa lateral region.

DISCUSSION

The risk of delayed healing by mobilization of the bone fragments was opposed to the risk of TMJ ankylosis due to a prolonged immobilization of the joint. Osteosynthesis of the fracture was finally chosen.

Ankylosis of temporomandibular joint caused by psoriatic arthritis: a report of four cases with literature review

Psoriatic arthritis (PsA) is an inflammatory joint disease associated with psoriasis. PsA is often confused with other diseases such as osteoarthritis and rheumatoid arthritis. PsA involving temporomandibular joints (TMJs) are uncommon: only 19 articles with 43 cases have been documented in the literature. TMJ ankylosis caused by PsA is rare, with only six cases having been reported. The authors present four cases of ankylosis of the TMJ secondary to PsA and review the literature. The findings of this study suggest that more attention should be paid to psoriasis patients with TMJ symptoms and proper treatment should be taken to prevent irreversible TMJ damage.

Axial involvement with facet joint arthropathy and bony ankylosis in a case of camptodactyly, arthropathy, coxa vara, pericarditis (CACP) syndrome

Familial arthropathy associated with congenital camptodactyly has been previously recognized as a definite clinical entity in the literature. The clinical spectrum of this disease seems to be variable. The typical features of congenital camptodactyly, arthropathy, coxa vara and pericarditis (CACP syndrome) appear to be a more frequent presentation in children from the Middle East and North Africa. Musculoskeletal presentation of this rare familial form of arthropathy is unique and heterogeneous. In all previous reports, non-inflammatory pattern of arthropathy involving the peripheral joints with typical coxa vara deformity were described, and in a few cases spine abnormalities, including kyphosis, lordosis, or scoliosis. We describe the first case of axial involvement in a typical case of CACP syndrome with facet joint arthropathy and ankylosis at L5/S1 levels.

Dysmorphic facies and diffuse posterior spine ankylosis in a patient with unusual form of spondyloenchondrodysplasia (Spranger type IV)

We describe a male patient, who was seen for the first time at the age of 8 years because of short trunk dwarfism. Spine radiographs showed platyspondyly with irregular areas of increased and decreased mineralization (irregular spotted appearance within lytic lesions located along the posterior vertebral bodies of the entire spine). Skeletal survey showed no enchondromatous lesions of the short/long tubular bones. At the age of 17, progressive spine stiffness associated with stooping posture developed. 3DCT scanning showed pathological transformation of the spinal enchondromas into generalized ossification and thickening of the posterior vertebral elements (vertebral laminae, supraspinal, and interspinal ligaments, respectively) causing effectively the development of a diffuse posterior spinal ankylosis. We report what might be a unique subtype of spondyloenchondrodysplasia (Spranger type IV).

[The therapeutic effect analysis of three kinds of methods for the management of post traumatic knee stiffness]

OBJECTIVES

To investigate the therapeutic effect of rehabilitation, arthroscopy and "hybrid technique" for posttraumatic knee stiffness (PTKS), and to make the best choice for the treatment.

METHODS

From February 2004 to November 2009, 66 patients suffered from PTKS were treated, and the clinical data were studied retrospectively, 36 male and 30 female patients with an average age of 41 years were analyzed, knee stiffness time averaged 15 months (0.5 - 108.0 months), 21 cases of patients were treated with rehabilitation (rehabilitation group), 22 cases of patients with arthroscopy + rehabilitation (arthroscopy group) and 23 cases of patients with mini-invasive "hybrid technique" + rehabilitation (hybrid technique group). For each case, the difference of range of motion (ROM) and hospital for special surgery (HSS) score of the knee before and after the treatment were analyzed statistically. The characters of PTKS including the course of the disease, the degree of extensor mechanism involving, physical examination and other ancillary data were also analyzed. The management methods for PTKS were summarized.

RESULTS

Total 66 cases were followed up ranging from 24.0-72.5 months and the mean time was 34.2 months. The average ROM was improved obviously: rehabilitation group increased from 45° ± 22° to 95° ± 24° (t = -11.2, P < 0.05), arthroscopy group from 47° ± 26° to 118° ± 11° (t = -11.0, P < 0.05) and hybrid technique group from 36° ± 22° to 110° ± 14° (t = -13.4, P < 0.05). Both ROM and HSS score of the knee before and after the treatment for each group showed significant difference statistically (t = -9.1, -6.0, -5.2, P < 0.05). Wound necrosis, tearing, re-fracture and extension lag were not found. According to Judet standard at final follow-up, 15 cases were excellent, 3 cases good and 3 cases normal in rehabilitation group; 15 cases were excellent, 5 cases good and 2 cases normal in arthroscopy group; 14 cases were excellent, 8 cases good and 1 case bad.

CONCLUSIONS

Pathology of PTKS is complex, satisfactory result could be obtained through individualized treatment program, which were established depend on the course of the disease, the degree of extensor mechanism involving, physical examination and ancillary data. The timely and effective surgical interference followed by a comprehensive rehabilitation program is the key point for satisfied outcome.

[Experimental establishment of animal model of temporomandibular joint ankylosis secondary to condylar sagittal fracture]

OBJECTIVE

To experimentally develop an animal model of traumatic temporomandibular joint ankylosis secondary to condylar fracture in small Tail Han sheep.

METHODS

Four sheep were used to make sagittal fracture of condyles. The cartilage layer of articular surface was damaged and lateral half of articular disc was removed in the right side and conserved in the left side as a control. All animals were sacrificed at the end of 6 months postoperatively. CT observation and histological examination were carried out to evaluate the formation of ankylosed joints.

RESULTS

All of the animals showed a change of mixed ankylosis on the right sides. On the CT image, the joint space became narrow and the articular surfaces became irregular with high-density callus formation. Histological observation validated that the bone-like and the cartilage-like matrix scattered between the condyle and temporal fossa. The ankylosis bone bridge could be figured out in some slices.

CONCLUSION

This study has successfully simulated the formation of temporomandibular joint ankylosis resulting from condylar fractures. The established ankylosis model is allowed to duplicate at a high successful rate.

TMJ ankylosis after neonatal septic arthritis: literature review and two case reports

Ankylosis of the temporomandibular joint (TMJ) can be a result of several causes such as trauma, degenerative changes, infection, and space-occupying lesion. When occurring during early childhood, it can result in severe functional disability and facial deformity. Septic arthritis is an uncommon disease associated with systemic and local factors being most commonly caused by Staphylococcus aureus, Neisseria gonorrhoeae, and Haemophilus influenzae. This paper presents two unusual cases of TMJ ankylosis following neonatal infections treated surgically and does a literature review about the topic.

Challenges of airway management in a patient with temporomandibular joint ankylosis complicating forceps delivery--a case report

Ankylosis of the temporomandibular joint following forceps delivery is a rare anomaly. The aetiopathogenesis involves wrongful application of the forceps or forceful closure of the forceps handle against the condyle with haemathrosis, organisation and subsequent ankylosis. Because of the lack of epidemiological data, there is little information about the true incidence and the management of this rare anomaly. The purpose of this presentation is to report the challenges encountered in the airway management of a six-year old female with right temporomandibular joint ankylosis following forceps delivery in a private hospital setting.

Temporomandibular joint ankylosis in a Nigerian teaching hospital

Twenty-six patients (12 males and 14 females) between two days and 41 years old with temporomandibular joint ankylosis were retrospectively reviewed. Thirty-three joints were involved; 19 unilateral and six bilateral. The aetiologies were trauma, 69.2%; infection, 15.4%; unknown, 11.5% and congenital, 3.9. The majority, 31 were intracapsular while the remaining two joints were extracapsular 51.6% were limited to the condyle, 32.2% extended to the coronoid process and the zygomatic, 9.7% extended to the sigmoid notch while the remaining 6.5% had maxillomandibular fusion. Tracheostomy (48%) was the most common mode of intubation. Gap arthroplasty was carried out in 20 joints while 11 joints had interposition arthroplasty. Postoperative complications were seven anterior open bite, three facial nerve weakness, three infections and two recurrences.

Inappropriate use of foreign materials in temporomandibular joint ankylosis surgery: report of two cases

Gap and interpositional arthroplasties are the most commonly used methods in the treatment of temporomandibular joint ankylosis. Complete resection of ankylotic segments, fibrotic band release and creating gap between the condyle and the glenoid fossa have great importance. Two patients were admitted to our clinic with complaints of difficulty in opening mouth and joint pain. In physical examination, maximum mouth opening values were recorded as 7 mm in one patient and 9 mm in another. An operation was planned due the presence of radiological grade 4 bilateral bony ankylosis. During the operation, foreign materials were found in the joint spaces of the patients. The first patient had a piece of nylon bag in the joint space, whereas the second patient had a silicon sheath used for wound therapy. Following removal of these materials, as a result of the recreation of joint spaces and the placement of suitable silicon blocks, 32 and 34 mm of mouth openings were noted during follow-up. In conclusion, recreated temporomandibular joint spaces after ankylosis surgery may be filled with a variety of autogenous or non-autogenously materials. However, the use of wrong materials inevitably causes recurrence and even worsens the primary condition.

A serious complication in the temporomandibular region due to insufficient follow-up

The aim of this case report is to point out follow-up insufficiency as a contributing factor of ankylotic development after condylar fractures as well as the significance of clinicians' familiarity with this complication and its prevention. Condylar fractures require close follow-up due to the potential emergence of delayed and distressing complications, such as ankylosis, regardless of their proper initial treatment. Regular follow-up for a minimum of 18 months is of crucial importance for the prevention of ankylosis. The clinician's contribution in alerting his patients could be considerable, given he or she is aware of the development of this complication. The case of a 17-year-old patient with bilateral condylar fractures and a mental fracture is presented. He was successfully treated with mental osteosynthesis and intermaxillary fixation. Strict instructions for kinesiotherapy were given and constant re-examinations were made, but the patient's compliance was poor. This resulted in his readmission 2 years later with a great limitation of mouth opening (0.5 cm), demanding more serious surgical procedures. Follow-up insufficiency could be identified as a contributing factor to traumatic temporomandibular joint ankylosis. Intense surveillance and harmonious collaboration is dictated from both the clinician and patient to prevent any untoward development.

[Posterior extensile approach to release a post-traumatic stiffness of the elbow]

PURPOSE OF THE STUDY

Restriction of joint motion is a frequent complication in the treatment of elbow injury. Grade 4 elbow stiffness up to its ankylosis is a strong limiting factor in the patient's daily activities. The surgical release of a stiff elbow has been a rare procedure. It can be done using either isolated or combined approaches. The aim of the study is to present our experience with and the results of elbow arthrolysis using a posterior extensile approach to the joint.

MATERIAL AND METHODS

Seven patients aged between 17 and 38 years with post-traumatic post-operative ankylosis, or grade 4 elbow stiffness were operated on. The average range of motion before surgery was 12.9° (range, 0° - 20°). The average interval between primary injury and arthrolysis was 21 months (range, 8 - 70 months). Clinical assessment before and after surgery was based on the Mayo Elbow Performance Score (MEPS). The average follow-up was 26 months (12 - 47). Arthrolysis was completed by application of an external fixator in four patients, by interposition arthroplasty in two patients, ulnar nerve transposition in five patients and radial head replacement in one patient. RESULTS The average MEPS score increased from 45.0 points (range, 30 - 65 points) to 87.9 points (range, 75 - 100 points). The average range of motion at the final follow-up was 99.3° (range, 65° - 135°). Most patients reported pain relief. There was no iatrogenic instability following surgery. Improvement was most marked in relation to joint function, as demonstrated by increase from an average score of 6.4 points (range, 0 - 15 points) before surgery to 24.3 points (range, 20 - 25 points) after surgery in the MEPS.

DISCUSSION

Surgical treatment of an ankylosed elbow is not a common procedure in the majority of hospitals. The use of a posterior extensile approach, which preserves the extensor mechanism, to release the elbow joint has been reported only occasionally in the international literature. The results, however, seem to be good. On the other hand, removal of the olecranon is associated with a high complication rate. Operative release of the elbow with total joint replacement is an extreme option. CONCLUSIONS In grade 4 stiff elbow release, the posterior extensile approach to the elbow joint as described here allows us to have a good view of all articular compartments. It maintains continuity of the extensor apparatus of the elbow, which is the essential requirement for effective post-operative rehabilitation and therefore its great advantage. This approach is not associated with serious complications.

The use of the radial recurrent fasciocutaneous flap in interposition arthroplasty of elbow ankylosis case report and review of literature

Elbow ankylosis and its management remain a challenge in the developing countries like Nigeria because of many factors, including the absence of elbow replacement surgery. Current operative management, which is interposition arthroplasty with fascia lata or arthrodesis in a more functional position, is commonly complicated with donor site morbidity and restricted functionality, respectively. We report the use of the regional radial recurrent fasciocutaneous flap of the arm as an interposition material for an ankylosed elbow after excision of the bone block, with no donor site morbidity and improved range of elbow motion. At 4 years postoperatively, patient is very satisfied with functionality. Additionally, this method of managing elbow ankylosis uses a vascularized and durable flap, is cheap, and has less operation time, and thus is highly recommended.

One-stage operation for noma-induced bilateral ankylosis accompanied with mouth verrucous carcinoma - a case report and review of literature

A rare case of a male patient who suffered from noma with sequelae of ankylosis in bilateral temporomandibular joints for 52 years and a neoplasm in the right commissure of the lips for 1 year, was operated on to resolve the ankylosis, remove the neoplasm and reconstruct the soft tissue defect with a forearm flap through a one-stage operation. The neoplasm pathology was verrucous carcinoma.

[Prosthetic replacement of condylar head for management of traumatic temporomandibular joint ankylosis]

OBJECTIVE

To preliminarily evaluate the method of using titanium condylar protheses in management of traumatic temporomandibular joint ankylosis.

METHODS

Between August 2006 and April 2008, titanium condylar replacement was performed in 5 male patients. Preoperative CT datum of patient was obtained and a resin model was then produced and used as a reference to select a suitable titanium condyle for reconstruction of the joint. In the operation, the bony ankylosis was removed. According to the preoperation planning, the selected prosthesis was inserted and fixed to the distal mandibular segment. The results were assessed by means of examinations and measurements postoperatively and during follow-up.

RESULTS

The 5 patients received alloplastic replacement of 6 condyles. Three patients were under follow-up and follow-up time ranged from 8 months to 2 years and 6 months. The mean mouth opening was 30 mm. Two patients had good occlusion and one patient developed a slight open bite.

CONCLUSIONS

Prosthetic condylar replacement can provide a choice for management of traumatic temporomandibular joint ankylosis.

From ankylosis to pencil-in-cup deformity in psoriatic arthritis: a case report

A 56-year-old woman with psoriatic arthritis is presented whose initially ankylosed digit was later found to develop pencil-in-cup change. The patient was treated over that period with etanercept and had no signs of active arthritis. The possible mechanisms for these changes are discussed.

Otosclerosis: an organ-specific inflammatory disease with sensorineural hearing loss

Otosclerosis is an inflammatory disease associated with persistent measles virus (MV) infection of the otic capsule. The nature of sensorineural hearing loss (SNHL) related to otosclerosis can be due to the chronic TNF-alpha release from the foci. TNF-alpha enters the inner ear fluid spaces in histologically active stages of otosclerosis and may cause outer hair cell functional disorder and subsequent SNHL without morphological changes of the organ of Corti. On the contrary, non-otosclerotic stapes ankylosis being a non-inflammatory disease is not harmful for hair cells. Theoretically, SNHL should not associate to this type of stapes fixation. Stapes footplates (N = 248) were examined by hematoxylin-eosin staining and corresponding MV-, OPG- and TNF-alpha-specific RT-PCR. Anti-measles IgG levels of serum specimens were measured by ELISA. Preoperative audiological results were correlated with otosclerotic and non-otosclerotic histopathologies. Among patients with stapes fixation, we found 93 active and 67 inactive otosclerosis, and 88 non-otosclerotic stapes ankylosis. MV could only be detected in otosclerotic stapes footplates. Audiometry revealed bone conduction threshold elevation toward the high frequencies in otosclerotic patients, which was associated to the duration of hearing loss. OPG mRNA expression was significantly lower in the TNF-alpha positive specimens, which was independent from virus positivity. In about one-third of stapes fixations, the etiology is non-otosclerotic stapes ankylosis. Histologic otosclerosis exhibits a strong correlation with MV presence in the bone as a sign of persistent MV infection and related inflammation with TNF-alpha release. This causes SNHL in the function of time. Non-otosclerotic stapes fixations do not cause high-frequency SNHL.

Management of condylar fractures

Management of condylar fractures remains a source of ongoing controversy. While it appears that many condylar fractures can be managed nonsurgically, recognition of cases that require surgical intervention and selection of an appropriate procedure are paramount to success in treating these injuries. There are a variety of special considerations that are peculiar to the condylar region. This article discusses anatomic considerations, classification of condylar fractures, indications for surgery, treatment options, and complications. The goals of treatment include restoration of function and esthetics. Careful consideration and attention to the principles of fracture management, and the role of the condyle as an articulating unit and growth center, must be taken into account for the successful management of these injuries.

Complications of mandibular fractures

Before any definitive treatment of mandibular fractures, the patient needs to be evaluated for more potentially life-threatening injuries. Complications can and do occur with treatment of mandibular fractures and can occur during any of the phases of treatment. The development of an accurate diagnosis and appropriate treatment plan is vital in achieving optimal success and decreasing complications. Knowledge of the anatomy and the principles of bone healing is also an important factor in preventing complications. To limit long-term untoward effects, complications should be recognized early and the appropriate treatment should be started before a minor complication becomes a complex one that is more difficult to manage.

Temporomandibular joint ankylosis in children

Ankylosis of the temporomandibular joint (TMJ) is a clinical manifestation with multiple etiologies that interferes with the growth of the affected condyle, owing to its fusion with both the glenoid cavity and the skull base with a limitation of mandibular movement, occlusion or forced semi-occlusion, speech and feeding difficulties, and facial asymmetry. Diagnosis and treatment of these oral manifestations are complex, involving several health practitioners such physicians, dental surgeons, physiotherapists, and psychologists. The purpose of this paper is to report a case of a 3-year-old female who presented with limited mouth opening and facial deformity due to birth trauma, which resulted in right TMJ ankylosis and consequently affected the child's growth and 'social' life.

Temporomandibular joint bilateral post-traumatic ankylosis: a report of a case treated with interpositional arthroplasty

Ankylosis of the temporomandibular joint (TMJ) is a severe disorder which leads to jaw function impairment and restricted mouth opening. The surgical approach to TMJ ankylosis can be performed according to different techniques. The present paper is a report of a bilateral post-traumatic case of TMJ ankylosis. The patient suffered bilateral condylar fractures as a consequence of a road accident and showed a limited mouth opening (22 mm) along with dental occlusion abnormalities. Conservative treatments were uneffective to improve jaw impairment, so a computerized tomography was requested for surgical treatment planning. Both temporomandibular joints showed severe ankylosis with a bone fragment located medially to the condyle. An arthroplasty with the interposition of a combined flap (temporalis muscle, fascia, periosteum) was performed. The post-treatment course was uneventful, and the patient has undergone physiatric rehabilitation immediately after the intervention. At the 5-years follow-up mouth opening was 46 mm. TMJ arthroplasty with the interposition of autogenous material is an effective technique to restore jaw function and to prevent recurrencies in cases of ankylosis.

Static progressive stretch for the treatment of knee stiffness

Persistent knee stiffness is common after knee arthroplasties, cruciate ligament repairs, and trauma. Static progressive stretch protocols have shown success in treating contractures of the elbow, ankle, and knee in case reports and small case series. This study evaluated static progressive stretch as a treatment method for patients who had refractory knee stiffness, and compared the outcomes to published results of other therapeutic modalities. Forty-one patients who had knee stiffness and who had not improved with conventional physical therapy modalities were treated with a patient-directed orthosis that utilized the principles of static progressive stretch. After a mean of 9 weeks of use (range, 3 to 27 weeks), the total arc of motion increased by a mean of 33 degrees (range, 0 to 85 degrees ). Forty of 41 patients had increased motion at a mean final follow-up time of 1 year (range, 6 months to 2 years), and 93% were satisfied with the results. The outcomes were comparable to other nonoperative treatments reported in the literature, but the results in the present study occurred in a shorter mean treatment time. An orthosis that utilizes the principles of static progressive stretch may be a successful treatment for improving the range of motion and satisfaction of patients who have knee contractures.