Temporomandibular joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of progression to open surgery

Accepted Manuscript Temporomandibular Joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of progression to open surgery Dr Omar Breik, BDSc MBBS MClinSc, Registrar, Vishakha Devrukhkar, BDS MDS, Visiting Fellow, George Dimitroulis, Consultant PII:

S1010-5182(16)30231-1

DOI:

10.1016/j.jcms.2016.09.017

Reference:

YJCMS 2494

To appear in:

Journal of Cranio-Maxillo-Facial Surgery

Received Date: 9 May 2016 Revised Date:

26 August 2016

Accepted Date: 28 September 2016

Please cite this article as: Breik O, Devrukhkar V, Dimitroulis G, Temporomandibular Joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of progression to open surgery, Journal of CranioMaxillofacial Surgery (2016), doi: 10.1016/j.jcms.2016.09.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Temporomandibular Joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of progression to open surgery Omar Breik1

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Vishakha Devrukhkar2 George Dimitroulis3

1 BDSc

MBBS MClinSc, Registrar, Oral and Maxillofacial Surgery Unit, Department

of Surgery, St Vincent’s Hospital, Melbourne, The University of Melbourne,

BDS MDS, Visiting Fellow, Oral and Maxillofacial Surgery Unit, Department of

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2

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Australia

Surgery, St Vincent’s Hospital, Melbourne, The University of Melbourne, Australia

3

Consultant, Oral and Maxillofacial Surgery Unit, Department of Surgery, St

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Vincent’s Hospital, Melbourne, The University of Melbourne, Australia

Oral and Maxillofacial Surgery Unit, Department of Surgery, St Vincent’s Hospital,

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Melbourne, The University of Melbourne, Australia

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Corresponding Author Dr Omar Breik

Registrar, Oral and Maxillofacial Surgery Unit, Department of Surgery, St Vincent’s Hospital, Melbourne, Victoria [email protected]

Keywords: arthroscopy, TMJ, Internal derangement, arthrotomy

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Temporomandibular Joint (TMJ) arthroscopic lysis and lavage: Outcomes and rate of

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progression to open surgery

Abstract

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Purpose

Arthroscopic lysis and lavage has been shown to be effective in the management of a variety of

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TMJ (Temporomandibular joint) diseases. The purpose of this study was to evaluate the medium to long-term outcomes of TMJ arthroscopic lysis and lavage and determine factors associated with progression to open surgery.

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Materials and methods

A retrospective cohort study of a single operator series was performed over a 6-year period from 2006-2012. The variables of gender, age and category (Dimitroulis classification) were

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compared to evaluate factors associated with success of arthroscopy and progression to open surgery. The data were analyzed via Kaplan Meier method for time-to event analyses and Chi-

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squared tests for trend analyses. Pre-operative and post-operative Visual analogue scores and maximum inter-incisal opening results were analysed with the Student’s t-test. Results

A total of 167 patients and 216 joints underwent arthroscopy with a mean follow up of 6.9 years. Overall 77.7% of joints had a successful result and required no further surgery. There was no gender difference with respect to progression to surgery. Males underwent open surgery after a

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mean of 6.2 months from arthroscopy and Females after a mean of 15.6 months from arthroscopy (p <0.005). The highest failure rate between age groups was in the 21-30 year age group (p<0.04). There was a statistically significant rate of progression to open surgery

disease progressing to open surgery (p< 0.0001).

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Conclusion

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depending on the classification at the time of arthroscopy, with all patients with category 4 and 5

Arthroscopic lysis and lavage of the TMJ is a reliable and effective operation for patients with

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early stage (i.e, Categories 1,2 and 3) disorders of the TMJ. Patients with more advanced joint disease (ie., Categories 4 & 5) gained only temporary relief from TMJ arthroscopy and often

Introduction

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progress to open TMJ surgery.

Since the introduction of arthroscopy in the 1970’s by Ohnishi(Ohnishi 1990), we have

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developed a better understanding of the nature of internal derangement and the clinical and histological changes that occur in the TMJ. Arthroscopy of the TMJ allows the direct observation

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of the disc function, fibrocartilage degeneration, and other soft and hard tissue pathology. It is complementary to clinical examination and imaging at confirming and identifying TMJ pathology, hence completing the diagnostic picture(McCain, de la Rua et al. 1989). In a study comparing findings during arthroscopy with those at subsequent open operation in the same patients, the sensitivity of arthroscopy was found to be 87% and the specificity was 99%(Tzanidakis and Sidebottom 2013). It also serves a therapeutic benefit, by allowing for lysis

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and lavage of the joint at the same time with excellent results in chronic closed lock. (Sanders 1986, Indresano 1989, Dimitroulis 2002)

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The success rate of arthroscopy in chronic closed lock varies and has been found to be approximately 70-86% (Indresano 1989, Holmlund, Gynther et al. 1994, Dimitroulis 2002,

Hamada, Kondoh et al. 2006). A long-term study of 33 patients by Murakami et al., 2000 found

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that over a 10 year follow up, there was a success rate of 83.8% for arthroscopy(Murakami, Segami et al. 2000).

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These arthroscopy studies did not report rate of progression to open surgery and factors associated with failure. They also did not report which open procedures were performed in patients who failed arthroscopy. These factors are important in appropriately informing the patients of expected outcomes of TMJ arthroscopy, and potential future interventions that may be

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needed if the arthroscopy fails to relieve symptoms in the long term. The purpose of this study was to evaluate the medium to long-term outcomes of TMJ arthroscopic lysis and lavage for a variety of TMJ diseases according to the recently introduced

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TMJ surgery classification(Dimitroulis 2013). The specific aims were to evaluate factors

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associated with progression to open surgery such as age, gender and classification of TMJ pathology at the time of arthroscopy.

Materials and Methods STUDY DESIGN

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To address the research question, the investigators designed and implemented a retrospective cohort study of a single operator (Senior author GD) outcomes of TMJ arthroscopic lysis and lavage. The study population was composed of all patients presenting for evaluation and

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management of TMJ dysfunction over a 6 year period from January 1st 2006 to January 1st 2012. This study was approved by the Quality Assurance ethics committee of St Vincent’s Hospital,

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Melbourne, Australia.

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STUDY SAMPLE

The patients were identified through an electronic clinic database. All patients included in this study presented with limitation of mouth opening and / or localized pain on function which failed to respond to non- surgical treatment which included, but not limited to physiotherapy,

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medications and bite appliance therapy. All patients had preoperative panoramic radiographs to access condylar morphology and to exclude dental causes of pain.

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The following inclusion criteria applied: 1) clinical evidence of TMJ pain and dysfunction which failed conservative/non-surgical treatment, 2) bilateral or unilateral TMJ arthroscopic lysis and

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lavage under general anesthesia, 3) Single operator (senior author (GD)), 4) Minimum of 3 years follow up, and 5) Adequate clinical notes. Patients were excluded as study subjects if there were 1) inadequate documentation, 2) visiting fellows or registrars operated on the patients, 3) open TMJ surgery by other surgeons prior to referral, or if there was 4) inadequate follow up.

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All patients in this study underwent TMJ arthroscopic lavage and lysis under naso-endotracheal general anesthesia. A 1.9-mm Dyonics 30˚ arthroscope (Smith & Nephew, Melbourne, Australia) was used with 150-300 ml of chilled Hartmann’s solution as a lavage fluid. Intra-articular steroid

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injection (i.e., 40 mg depomedrol) was also injected into the joints. The TMJ surgical

classification proposed by Dimitroulis in 2013(Dimitroulis 2013) was allocated to each case according to the clinical and surgical findings during arthroscopy (Table 1). A week after the

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arthroscopy, all patients underwent physiotherapy that involved mandibular manipulation and

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joint mobilization procedures with a program of jaw exercise to be undertaken at home.

DATA VARIABLES

The following data was collected when reviewing the clinical records: age at presentation,

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clinical symptoms before surgery (measured in visual analogue scale (VAS) and maximum interincisal opening (MIO)), date of arthroscopy, Surgical TMJ classification proposed by Dimitroulis(Dimitroulis 2013), symptoms after arthroscopy (VAS and MIO), follow up period

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and outcomes, and further surgical treatment offered and performed. When further treatment was

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offered, the time between arthroscopy and surgery, and type of surgery offered was recorded. The primary outcomes are: 1) Success of arthroscopy (defined as a post-operative VAS of ≤2 or ≥50% improvement in VAS 2) Need for open surgery (offered to patients with <50% improvement in VAS or significant limitation in mouth opening and 3) Time to open surgery. The variables were grouped into gender (male and female), age groups (10-20, 20-30, 30-40, 4050 and >60 years of age), Dimitroulis classification(Dimitroulis 2013) (Class 1-5 depending on panoramic imaging and surgical findings at the time of arthroscopy).

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STATISTICAL ANALYSIS

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The data analysis was performed using the statistical program Prism 6™ (GraphPad Inc., San Diego, CA). VAS and MIO data between patients who had successful arthroscopy and those who required surgery were analyzed with a student’s t-test. Chi squared trend analyses were

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performed to compare the different variables in each analysis. Kaplan Meier time to event analyses were performed to compare male and female time to surgery, and classification

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category and time to surgery. Logrank tests were performed to calculate significance in the Kaplan Meier analyses. A cox proportional regreesion hazard analysis was also performed to compare multiple covariates and their relation to time to surgery. Statistical Significant was

Results

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determined as a p value of <0.05.

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A total of 167 patients underwent arthroscopy between 2006 and 2012 in the senior author’s (GD) practice. The total number of joints scoped was 216, of which 111 were right sided, and

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105 left sided. The age ranged from 14-80 years with a mean age of 40yr. The male to female ratio was approximately 1:5.4. The follow up ranged from 3 to 9 yr (mean 6.9 yr). Of the 167 patients, 127 (76%) patients had significant symptomatic improvement without the need for further surgical intervention. Thirty-eight patients (24%), however, went on to have further surgery following their TMJ arthroscopy. In terms of the number of joints involved, 168 of the original 216 joints required no further surgery (77.7%), and the remaining 48 joints

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(22.3%) underwent further surgery after arthroscopy. The mean time lapsed between arthroscopy and further surgery was 13 months (range of 1-85 months). The demographics for these patient groups are given in tables 2 and 3. Pre-operative and post-operative VAS scores and MIO were

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compared between patients that did not progress to surgery and those that did progress to

surgery. Although pre-operative VAS and MIO were not significantly different between the two groups, the post-operative improvement in both VAS and MIO were significantly different

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between the two groups (table 4). Three patients underwent repeat arthroscopy after failure to improve after an initial arthroscopy, two of these patients required no further treatment, and one

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required open surgery. Among the patients who progressed to open surgery, 71% (27/38 patients) showed initial improvement in VAS and MIO after arthroscopy (improvement of >50% improvement in VAS), and 29% (11 patients) showed no significant improvement. Among the 27 patients who showed improvement initially, 23 patients (85%) relapsed within 6 months of

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arthroscopy, with the remaining 4 patients relapsing within a year of arthroscopy.

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Gender and progression to surgery

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The majority of patients (84.4%) were female in this series. Out of 32 joints in males, 27 (84.4%) did not require further surgery, and 5 (15.6%) underwent surgical intervention after arthroscopy. Among 184 female joints, 141 (76.6%) joints did not require any further surgery, and 43 (23.4%) underwent further surgery after arthroscopy. This difference was evaluated using the chi-squared test and found to not be statistically significant (p = 0.46). The time lapse between arthroscopy and surgery also differed between genders. Males who underwent surgery, often underwent surgery after a mean of 6.2 months (95% Confidence

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interval (CI) 1.77 -10.62) from arthroscopy and Females after a mean of 15.6 months (95% CI 9.92 – 21.34) from arthroscopy (Figure 1). This difference was statistically significant (p <0.005)

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on chi-squared test and cox proportional regression analysis (Table 7).

Age groups and progression to surgery

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The age group at the time of arthroscopy was also evaluated for rates of progression to surgery.

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The age groups were divided into decades (Table 5)(Figure 2). Overall the highest rate of progression to surgery was in the 21-30 year old group (28.8% converting to surgery). The lowest rate of progression to surgery was in the greater than 60 years of age group (8.3%). The trend between these groups was found to be statistically significant using the chi-squared test for trend (p <0.04). The time lapse between age groups was also compared between age groups

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(Figure 3). Although age group was associated with need for surgery, age group was not associated with time to surgery for those patients who underwent surgery on cox proportional

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regression analysis (Table 7).

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TMJ Surgery classification(Dimitroulis 2013) and progression to surgery The TMJ Surgery classification(Dimitroulis 2013) at the time of arthroscopy was compared with rates of progression to surgery. Each individual joint was classified according to the TMJ Surgery classification by panoramic imaging and the findings at the time of arthroscopy. Category 1 joints had successful symptomatic improvements with arthroscopy alone and no patients in this group underwent further surgery. Category 2 and 3 joints had greater than 90%

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success rate for arthroscopy alone. Categories 4 and 5 all required open surgery at a later date and only had short-term improvement or no improvement of symptoms with arthroscopy (Table 6)(Figure 4). Kaplan Meier analysis was also performed comparing the different categories

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(Figure 5). These comparisons were statistically significant on chi-squared trend testing (p < 0.0001) and cox proportional regression analysis which identified that Dimitroulis classification

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Open Surgery offered in patients post arthroscopy

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and gender were statistically significantly associated with time to surgery (Table 7).

Patients who had minimal improvement after arthroscopy then underwent an MRI for further investigation. The majority of patients, who underwent open surgery after arthroscopy had a discectomy (72.9%). Two patients (4.2%) underwent arthroplasty with disc plication. Eleven

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patients (22.9%) underwent total joint replacement; 7 with costochondral grafts, and 4 with prosthetic joint replacements (Figure 6). Among the 11 patients who underwent joint replacement surgery, 2 had no evidence of bony change on the condyles (were classified as a

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category 4), 8 had subtle bony changes on the condyles on initial panoramic imaging, and the remaining 3 had significant bony changes on imaging suggestive of advanced osteoarthritis, but

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preferred the option of arthroscopic lysis and lavage rather than open surgery. The degree of osteoarthritis was identified on arthroscopy and further imaging (such as MRI or CT) once arthroscopy failed to relieve their symptoms. One patient in the group of patients who underwent open surgery had a repeat TMJ arthroscopy before requiring open surgery. This patient had a category 4 joint on presentation.

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Discussion The purpose of this study was to evaluate the overall medium to long-term success rate of

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arthroscopic lysis and lavage across a range of TMJ diseases, and determine the rate of and factors related to progression to open TMJ surgery. This study showed that the overall success rate of arthroscopic lysis and lavage for TMJ dysfunction (TMD) over a mean follow up of 6.9

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years was 77.7%. Factors associated with progression to open surgery include arthroscopy in the 21-30 year age group, and more advanced joint disease (Dimitroulis categories 4 and 5).

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Although gender differences did not affect outcome of arthroscopy, males who failed arthroscopy appeared to progress to surgery faster than females. The majority of patients who progressed to open surgery underwent discectomies.

The overall success rates of arthroscopic lysis and lavage are consistent with outcomes in the

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literature.(Indresano 1989, Holmlund, Gynther et al. 1994, Dimitroulis 2002) There have been several studies showing success rates of approximately 80-86% with medium to long-term follow up for arthroscopic lysis and lavage in chronic closed lock(Indresano 1989, Murakami,

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Segami et al. 2000). The reason for the slightly lower rate of success in our cohort likely relates to the fact that all severities of joint disease have been included in this calculation. As will be

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discussed below, patients with less advanced disease tend to have much higher overall success rates than those with severe disease. While there were no gender differences in success of arthroscopy observed, there were, however, several factors associated with a higher rate of progression to open surgery from arthroscopy that have been identified in this study. Patients within the 21-30 year old age group had a greater rate of progression to surgery than the older age groups. The reason for this observation is unclear. It

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may be related to the role of chronic pain and the perceived need for treatment observed in adolescents with TMD(List, Wahlund et al. 1999). Do adults presenting with chronic TMJ pain have more realistic expectations of treatment outcomes? Future long-term studies are needed to

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determine if this finding is identified elsewhere. Other factors identified that correlate with

progression to open surgery is the classification at the time of arthroscopy. Using the Dimitroulis TMJ Surgery(Dimitroulis 2013) classification, no category 1 joints progressed to open surgery.

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This phenomenon of success for arthroscopy in relatively normal joints has been previously reported by Dimitroulis in 2015(Dimitroulis 2015), who found six out of 10 category 1 patients

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reported reduction of joint pain despite being informed that their joints were normal on arthroscopy. For those with mild inflammation in their joints, arthroscopic lysis and lavage may serve to clear inflammatory markers and by-products(Indresano 2001) and this may explain the reduction in pain and improvement in function.

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In the present study, Category 2 and 3 joints also demonstrated a very high success rate for arthroscopy (97.4% and 90.6% respectively) without the need for further surgery. These success rates correlate well with the available literature cited above and demonstrate a clear role for

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arthroscopic lysis and lavage in reducing pain and improving function in patients with chronic

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closed lock and other salvageable disc related disorders. However, where the TMJ’s demonstrate significant pathology (ie., categories 4 and 5), the medium to long term success of arthroscopy alone was 0% in this case series, and all patients eventually underwent open surgery. These results provide validation for the Dimitroulis TMJ Surgery classification in identifying patients who will or will not respond to arthroscopy. In another study correlating the efficiency of arthroscopic lysis and lavage with the Wilke’s classification, there was a trend toward reduced success with advancing Wilke’s stage, the difference however was not found to be statistically

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significant.(Smolka, Yanai et al. 2008). Patients with category 4 or 5 joints often also have greater dysfunction in the form of initial pain and impairment in mouth opening, which may be related to failure of arthroscopic treatments. In another study evaluating patients with disc

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displacement without reduction, the authors found that patients with a worse MIO before arthroscopy were more likely to have a poor outcome to arthroscopy and required open

surgery(Kurita, Goss et al. 1998). Hence, overall, the worse the severity of the TMJ dysfunction,

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the greater the likelihood of needing open surgery for adequate long term improvement.

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Among the patients who underwent open surgery, 71% showed substantial improvement in their TMD symptoms (> 50% improvement in VAS) initially after arthroscopy, but symptoms recurred within 2-12 months. These patients subsequently underwent a thorough clinical exam, and an MRI/CT was arranged, and they were offered open TMJ surgery depending on their condition. The mean time period between arthroscopy and open surgery was 13 months in this

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series. The time period for males who failed to improve with arthroscopy was shorter than for females (6.2 months and 15.6 months respectively p <0.005). Hence, male patients who progressed to open surgery often had a shorter period of improvement in their clinical symptoms

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after arthroscopy, and required surgery earlier.

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Patients who underwent open surgery in our series most commonly underwent discectomy due to persistent symptomatic disc displacement, closed lock or evidence of disc degeneration or perforation at the time of arthroscopy. In a study by Holmlund et al.,(Holmlund, Gynther et al. 1994) 50% of patients with chronic closed lock had an unsuccessful outcome with arthroscopy. All of these patients underwent discectomy with 86% success rate overall. Eleven patients with Category 5 disease in our series confirmed on arthroscopy underwent TMJ replacement (7 costochondral grafts and 4 prosthetic joints) due to osteoarthritis. Advanced osteoarthritis was

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not clearly evident in these patients on initial panoramic radiography, but was confirmed during arthroscopy. Once they failed to improve, further imaging supported the diagnosis and TMJ replacement was recommended. With advances in prosthetic joint replacement, the operating

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surgeons’ preference has shifted from costochondral grafts to prosthetic joint replacements over the past 10 years. Although this study showed that arthroscopy was not successful in end-stage

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disease, it provided further diagnostic information, and delayed the need for TMJ replacement. Should a second arthroscopy be considered in patients who only improved in the short-term?

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Most patients in this study did not have a repeat TMJ arthroscopy. Among the three patients who underwent repeat arthroscopy, two were category 2 joints that improved with subsequent arthroscopy. The third patient had a category 4 joint, and did not improve with repeat arthroscopy, and proceeded to open surgery. In a study by Mancha de la Plata et al., 2008(Mancha de la Plata, Munoz-Guerra et al. 2008), over a minimum 2-year follow up period,

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16% of patients who underwent a second arthroscopy subsequently required open surgery. In another study by Abd-Ul-Salam et al., 2002(Abd-Ul-Salam, Weinberg et al. 2002), the incidence of reoperation post arthroscopy was 20%, but the majority improved with only a second

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arthroscopy, with 10% of those who underwent a second arthroscopy failing to improve. Those

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who failed to improve after a second arthroscopy had advanced joint disease on initial arthroscopy and underwent open surgery. Although the follow up period in this study is unclear, these findings are in keeping with our findings and suggest that patients with advanced joint disease (categories 4 or 5) will often eventually require open surgery. Although arthroscopic lysis and lavage has reduced the need for open surgery(Tzanidakis and Sidebottom 2013), the results of this study suggest that open surgery should be considered in patients who do not respond to arthroscopy or have a short-term response to arthroscopy. Several

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recent studies have shown excellent success rates for open disc plication surgery(Dolwick and Nitzan 1990), and discectomy(Wilkes 1991, Nyberg, Adell et al. 2004, Miloro and Henriksen 2010) for internal derangement of the TMJ. In a recent Cochrane review in 2011, open surgery

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was found to be more effective at reducing pain than arthroscopic lysis and lavage at 12 months, suggesting better long-term results with open surgery(Rigon, Pereira et al. 2011). Also, despite significant advances in techniques for interventional arthroscopic surgery in experienced

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hands(McCain, Sanders et al. 1992), another systematic review showed better improvement in VAS and comparable improvement in MIO and jaw function for open surgery compared with

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arthroscopic surgery(Al-Moraissi 2015) Further research is needed to help the clinician in selecting which cases are most likely to respond to TMJ arthroscopy and which cases are better to have open TMJ surgery. The present study suggests that TMJ arthroscopy is effective for cases with less severe disease (ie. Categories 1,2 and 3) while those joints with more severe

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disease levels (ie, Categories 4 and 5) only gain temporary relief and are most likely to go on to have open TMJ surgery. In other words, TMJ arthroscopic lysis and lavage has limited benefit for patients with moderate to severe TMJ disease.

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These findings have guided our treatment algorithm to better inform patients of the expected

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outcomes of arthroscopic lysis and lavage (figure 7). For patients presenting with TMJ dysfunction, clinical examination and investigations including OPG and CT/MRI are initially performed, and the joints are categorized depending on the pathology. For patients with category 1 joints, all are expected to improve with arthroscopy, and open surgery is not indicated. For patients with category 2/3 joints, the vast majority will have improvement of symptoms with arthroscopic lysis and lavage. Only a small percentage will need open surgery. For patients with category 4/5 joints, arthroscopy may improve symptoms temporarily, but in our hands, all

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patients will eventually require open surgery.

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Conclusion

This study has shown that arthroscopic lysis and lavage of the TMJ is a reliable and effective operation for patients with early stage (ie, Categories 1,2 and 3) disorders of the TMJ with an

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overall success rate of 77% over a mean 6.9 year follow up period. Patients between the ages of

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21-30 have a higher rate of progression to open surgery and the reason for this finding is unclear. TMJ arthroscopy for more advanced TMJ disease (i.e., categories 4 and 5) has been shown to have limited/temporary benefits and so TMJ arthrotomy (open surgery) is more appropriate for

Acknowledgements

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these cases.

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statistical analysis.

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The authors would like to acknowledge the help of Deepak Langade for his help with the

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derangement with persistent closed lock. Oral Surg Oral Med Oral Pathol 62(4): 361-372, 1986. Smolka W, Yanai C, Smolka K, Iizuka T: Efficiency of arthroscopic lysis and lavage for internal

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derangement of the temporomandibular joint correlated with Wilkes classification. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106(3): 317-323, 2008. Tzanidakis K, Sidebottom AJ: How accurate is arthroscopy of the temporomandibular joint? A comparison of findings in patients who had open operations after arthroscopic management failed. Br J Oral Maxillofac Surg 51(8): 968-970, 2013. Tzanidakis K, Sidebottom AJ: Outcomes of open temporomandibular joint surgery following

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failure to improve after arthroscopy: is there an algorithm for success? Br J Oral Maxillofac Surg 51(8): 818-821, 2013.

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Wilkes CH: Surgical treatment of internal derangements of the temporomandibular joint. A long-

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term study. Arch Otolaryngol Head Neck Surg 117(1): 64-72, 1991.

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Tables Legend:

Table 1: The TMJ Surgical Classification as proposed by Dimitroulis (2013)(Dimitroulis 2013)

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Table 2: Demographics for patients who required no further surgery after arthroscopy

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Table 3: Demographics for patients who required surgery after arthroscopy

Table 4: Comparison between pre-operative and post-operative VAS and MIO scores for patients who did not progress to surgery (No surgery) and those who did progress to surgery (Surgery).

Table 5: Comparison between different age groups and progression to surgery with Chi-squared test results for statistical analysis.

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Table 6: Comparison of TMJ Surgery classification(Dimitroulis 2013) with rate of progression to

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surgery

Table 7: Results of Cox proportional regression hazard analysis aimed at identifying variable

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associated with time to surgery.

Figures Legend:

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Figure 1: Gender and time lapse for patients who underwent surgery after arthroscopy. Range

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demonstrates standard deviation from the mean.

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Figure 2: Graph showing different age groups and rates of progression to surgery

Figure 3: Graph showing mean time lapse to surgery for different age groups. Range demonstrates standard deviation from the mean.

Figure 4: Graph showing rates of arthroscopy alone and progression to surgery with TMJ

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Surgery classification at time of arthroscopy

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Figure 5: Kaplan Meier analysis comparing different categories and percentage of arthroscopy

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alone

Figure 6: Pie chart showing type of surgery offered in patients post arthroscopy (% of joints, n =

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48)

Figure 7: Flowchart showing the treatment algorithm for patients presenting with TMJ dysfunction. The thickness of the arrows signifies the approximate proportion of patients heading

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in each direction.

* In select cases of Cat2/3, may consider second arthroscopic lysis and lavage if symptoms persist.

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** Type of open surgery depends on TMJ pathology

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Category

Possible Diagnoses

1: Normal TMJ

- Joint contusion – acute trauma - Myofascial pain

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- Neuropathic - Psychogenic 2: Minor TMJ

- Early internal derangement

changes (all

- Joint inflammation/adhesions

salvageable) - Moderate TMJ internal derangement

changes (Mostly

(including chronic closed lock)

salvageable)

- Recurrent TMJ dislocation

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3: Moderate TMJ

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components

- TMJ synovial chondromatosis

- Advanced TMJ internal derangement

changes (Partly

- Rare TMJ disorder – metabolic,

salvageable)

inflammatory or developmental joint disease

5: Catastrophic

- TMJ osteoarthritis

TMJ changes

- TMJ condylysis

(Nothing is

- Ankylosis

salvageable)

- Tumour of TMJ

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4: Severe TMJ

Table 2: Demographics for patients who required no further surgery after

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arthroscopy

Arthroscopy with no further surgery Total patients

127 (76%)

Total joints

168 (77.7%)

Age range

15-80 yr

Mean age

40yr +/- 16yr

M:F ratio

1:4.5

yr: years, mn - months

Table 3: Demographics for patients who required surgery after arthroscopy

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38 (24%)

Total joints

48 (22.3%)

Age range

14-72 yr

Mean age

37yr +/- 15yr

M:F ratio

1:8.5

Time lapsed

Range: 1-85 months

between

Mean – 13 mn +/- 18mn

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Surgery after arthroscopy group

surgery Arthroplasty – 2

performed

Discectomy – 35 Rib graft – 7

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Type of surgery

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arthroscopy and

Total prosthetic joint replacement - 4

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Table 4: Comparison between pre-operative and post-operative VAS and MIO scores for patients who did not progress to surgery (No surgery) and those who

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did progress to surgery (Surgery).

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Variable No Surgery Surgery Analysis Pre-op VAS (score 1-10) 7.8 +/- 1.5 8.0 +/- 1.3 p = 0.67 Post-op VAS (score 1-10) 1.7 +/- 1.2 6.5 +/- 1.6 p <0.0001 Pre-op MIO (mm) 28.3 +/- 7.6 25.7 +/- 8.0 p = 0.30 Post-op MIO (mm) 35.3 +/- 4.8 27.9 +/- 10 p = 0.007 Data shows mean +/- SD. Unpaired Student’s t-test performed for statistical analysis

Table 5: Comparison between different age groups and progression to surgery with Chi-squared test results for statistical analysis.

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31-40 yrs

41-50 yrs

51-60 yrs

60 yrs. & above

6 26.1% RT 12.5% CT 2.8% GT 15 28.8% RT 31.2% CT 6.9% GT 10 22.7% RT 20.8% CT 4.6% GT 11 25.0% RT 22.9% CT 5.1% GT 4 13.8% RT 8.3% CT 1.9% GT 2 8.3% RT 4.2% CT 0.9% GT 48 (22.2%)

23 (10.6%)

52 (24.1%)

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21-30 yrs

Surgery

17 73.9% RT 10.1% CT 7.9% GT 37 71.2% RT 22.0% CT 17.1% GT 34 77.3% RT 20.2% CT 15.7% GT 33 75.0% RT 19.6% CT 15.3% GT 25 86.2% RT 14.9% CT 11.6% GT 22 91.7% RT 13.1% CT 10.2% GT 168 (77.8%)

44 (20.4%)

44 (20.4%)

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10 -20 yrs.

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Age groups

Intervention Arthroscopy alone

29 (13.4%)

24 (11.1%)

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RT: % of Row Total; CT: % of Column Total; GT: % of Grand Total

Chi-squared test for trend Chi-squared (trend) 4.185 DF 1 Significance level P = 0.0408

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Table 6: Comparison of TMJ Surgery classification(Dimitroulis 2013) with rate of

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progression to surgery Dimitroulis TMJ Surgery Classification(Dimitroulis 2013) Category 1

Category 2

Category 3

Intervention Arthroscopy alone

Surgery

28 100.0% RT 16.7% CT 13.0% GT 111 97.4% RT 66.1% CT 51.4% GT 29 90.6% RT 17.3% CT

0 0.0% RT 0.0% CT 0.0% GT 3 2.6% RT 6.2% CT 1.4% GT 3 9.4% RT 6.2% CT

28 (13.0%)

114 (52.8%)

32 (14.8%)

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Category 5

1.4% GT 33 100.0% RT 68.7% CT 15.3% GT 9 100.0% RT 18.8% CT 4.2% GT 48 (22.2%)

RT: % of Row Total; CT: % of Column Total; GT: % of Grand Total

9 (4.2%)

216

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Chi-squared test Chi-squared 183.370 DF 4 Significance level P < 0.0001 Chi-squared test for trend Chi-squared (trend) 139.750 DF 1 Significance level P < 0.0001

33 (15.3%)

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13.4% GT 0 0.0% RT 0.0% CT 0.0% GT 0 0.0% RT 0.0% CT 0.0% GT 168 (77.8%)

Table 7: Results of Cox proportional regression hazard analysis aimed at identifying variable associated with time to surgery.

285.446 277.331 8.114 3 P = 0.0437

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Overall Model Fit Null model -2 Log Likelihood Full model -2 Log Likelihood Chi-squared DF Significance level

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Coefficients and Standard Errors Covariate b Gender -1.0446 Age Groups 0.1933 Category -0.4121

SE 0.5141 0.1215 0.1911

Wald 4.1284 2.5301 4.6503

P 0.0422 0.1117 0.0310

Exp(b) 0.3518 1.2132 0.6623

95% CI of Exp(b) 0.1284 to 0.9637 0.9561 to 1.5395 0.4554 to 0.9632

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