Superior Compartment Research Articles

顎関節の簡易診断鏡視法の開発と臨床応用について

The simple diagnostic arthroscopy in the out-patient clinic was developed and applicated to 28 patients (30 joints) with closed lock of the temporomandibular joint. The equipments were the needle arthroscope of 0.9 mm in diameter, its cannula, and the mandlin. The technique was consisted of superior compartment puncture by a 20 gage needle, local anesthesia by a pumping action, insertion of the mandlin through the needle, switching the needle to the cannula as a guide for the mandlin, and diagnostic arthroscopy under the circulation of saline.On all of 30 joints, the technique was completed successfully and safely, without any severe complications.This technique will expand via its diagnostic arthroscopy indication, similar to another diagnostic imaging.

Three irrigation systems for motorized arthroscopic surgery: A comparative experimental and clinical study

The purpose of this study was to compare experimentally and clinically three types of irrigation systems for arthroscopic suction surgery. A joint model was used in the experimental part of the study. It was found that a combination of inflow from a volume pump with extra gravity inflow through a separate cannula gave results comparable to those with more sophisticated automatic pumps. Clinically, none of the systems provided protection from high-pressure peaks during rapid movements of the knee joint. It was also found that the pressure differed in the superior and posteromedial compartments of the knee during rapid movement.

Arthroscopic surgery of the temporomandibular joint: Report of 64 patients with long-term follow-up

One hundred temporomandibular joints (64 patients) were examined arthroscopically. Complications from the procedure were low (4%). Eighty joints (50 patients) received superior compartment sweep and lavage. Patients with anteriorly displaced nonreducing discs (closed lock) had the highest success rate (83%) from this procedure when evaluated 9 to 30 months later.

Surgical Approaches to Orbital Tumors

Three approaches as used with modern technology, magnification with an operating microscope, and self-retained retraction have been presented. These approaches have allowed satisfactory exposure of difficult retrobulbar orbital areas from the various directions and have allowed us to more comfortably microdissect and remove orbital tumors. They also provide good exposure for the use of the carbon dioxide laser, which has been an aid in removing the intraorbital extensions of meningiomas, plexiform neurofibromas, and difficult lymphangiomas that occupy the intraconal compartments of the orbit. These approaches should only be undertaken by a skilled ophthalmic orbital surgical team in the case of the anterior medial and lateral approach, and definitely by a well-experienced neurosurgical/ophthalmic orbital team for tumors involving the orbital cranial junction and the superior orbital compartment. Experience gained over 17 years has convinced us that a team approach is mandatory for the difficult deep intraorbital tumors, even with the anterior medial or lateral approach.

MR imaging of cavernous sinus involvement by pituitary adenomas.

The ability of high-resolution MR imaging (1.5 T) to detect invasion of the cavernous sinuses by pituitary adenoma was determined through a retrospective review of 74 patients. These patients were divided into three groups: 25 normal subjects, 24 subjects with invasive pituitary adenomas, and 25 subjects with noninvasive pituitary adenomas. A fourth group of 30 patients, who subsequently underwent surgery for pituitary adenoma, was evaluated prospectively by MR for the presence or absence of cavernous sinus invasion. Several features were analyzed: (1) the detectability of the medial and lateral dural margins of the cavernous sinus (2) the size and variation in intensity of compartments within the cavernous sinus (3) the relationship of endocrine function to the surgical and MR appearance of the cavernous sinus and (4) carotid artery displacement or encasement by tumor. The normal cavernous sinuses were usually symmetric, but their sizes varied. The lateral dural margin of the cavernous sinus was always recognized on MR as a linear, discrete, low-intensity area. The medial dural margin (pituitary capsule) was seen on MR in only two of the 25 normal patients. In all 24 patients with cavernous sinus invasion involvement was unilateral and was most common with laterally positioned prolactin or adrenocorticotropic hormone secretory adenomas. Invasion of the cavernous sinus was suspected by MR in only two of the 13 invasive microadenomas and was questionable in three. In 10 of the 11 macroadenomas with surgically proved dural invasion, MR demonstrated an asymmetric increase in size and intensity of the superior and inferior cavernous sinus compartments. Noninvasive macroadenomas compressed and displaced the cavernous sinus bilaterally. The prospective MR evaluation of 30 patients undergoing surgery for pituitary tumor revealed a sensitivity for predicting cavernous sinus invasion of 55%, a specificity of 85.7%, a positive predictive value of 62.5%, and a negative predictive value of 81.8%. No feature permitted certain distinction between invasive and noninvasive microadenomas, as the medial dural wall of the cavernous sinus could not be reliably identified. The most specific sign of cavernous sinus invasion was carotid artery encasement.

Arthroscopy of the temporomandibular joint. A comparative study of arthroscopic and tomographic findings

Established radiographic criteria of temporomandibular joint osteoarthrosis were evaluated by comparison of arthroscopic and tomographic findings in the superior compartment. 34 joints of 30 patients with long-standing chronic pain and/or functional impairment were investigated according to standardized techniques. Agreement was found between arthroscopy and corrected sagittal tomography regarding diagnosis of osteoarthrosis in all advanced cases. Diagnostic accuracy as regards slight changes was, however, lower. At tomographic examination, the sensitivity was slightly higher than specificity, i.e., pathological changes were more frequently identified than normality. No radiographic sign of osteoarthrosis could be specifically associated with arthroscopic features of osteoarthrosis or synovitis. Predominant location of osteoarthrosis at both arthroscopy and tomography was the posterior slope of the eminence (latero-central part). Osteoarthrosis was more widespread in the fibrocartilage than in the subchondral bone.

Surgical Approaches to Orbital Tumors

Three approaches as used with modern technology, magnification with an operating microscope, and self-retained retraction have been presented. These approaches have allowed satisfactory exposure of difficult retrobulbar orbital areas from the various directions and have allowed us to more comfortably microdissect and remove orbital tumors. They also provide good exposure for the use of the carbon dioxide laser, which has been an aid in removing the intraorbital extensions of meningiomas, plexiform neurofibromas, and difficult lymphangiomas that occupy the intraconal compartments of the orbit. These approaches should only be undertaken by a skilled ophthalmic orbital surgical team in the case of the anterior medial and lateral approach, and definitely by a well-experienced neurosurgical/ophthalmic orbital team for tumors involving the orbital cranial junction and the superior orbital compartment. Experience gained over 17 years has convinced us that a team approach is mandatory for the difficult deep intraorbital tumors, even with the anterior medial or lateral approach.

Arthroscopy of the temporomandibular joint: occurrence and location of osteoarthrosis and synovitis in a patient material

The superior compartments of 42 temporomandibular joints of 38 patients with longstanding chronic pain and/or functional impairment were examined arthroscopically. Occurrence and location of ostoarthrosis and synovitis were investigated. Osteoarthrosis occurred in 31 joints (74%). In 17 of them more extensive changes were found. Predominant location of osteoarthrosis was the posterior slope of the eminence. The risk was less frequently affected and most commonly in the latero-central part. Synovitis occurred in 22 joints (52%) and was combined with osteoarthrosis in 17 of them. In 20 of them it was of mild and localised nature. The posterior disk attachment was affected in all of them.

Long-term effect of intra-articular injections of sodium hyaluronate and corticosteriod on temporomandibular joint arthritis

The long-term effect of intra-articular injections of sodium hyaluronate and corticosteroid (betamethasone) was compared in a sample of 24 patients who had pain and tenderness to palpation in the temporomandibular joint (TMJ arthritis) of at least six months duration, and who had not responded to conservative treatment. The two drugs were randomly allocated to the patients. The drugs, 0.5 ml, were injected twice into the superior joint compartment of the TMJ with a two-week interval between injections. The effect on subjective symptoms, clinical signs, and bite force was assessed. At the one and two-year follow-ups both the hyaluronate-and the corticosteriod-group had significantly reduced subjective symptoms as well as clinical signs, and the maximum voluntary bite force was significantly increased. The differences in effect between treatments were not statistically significant. It was concluded that both drugs have a significant long-term effect on chronic arthritis of the TMJ and that either of the drugs can be helpful; however, sodium hyaluronate might be the best alternative due to the least risk for side effects.

The short-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint pain and dysfunction

The short-term effect of intra-articular injections of sodium hyaluronate and a corticosteroid (betamethasone) was compared in a sample of 33 patients who had pain and tenderness to palpation in the temporomandibular joint of at least six months duration that had not responded to previous conservative treatment. The two drugs were randomly allocated to the patients. A volume of 0.5 ml of the drug was injected twice into the superior joint compartment of the TMJ with a two-week interval between injections. The effect on subjective symptoms, clinical signs, and bite force was assessed. Both drugs reduced the symptoms and signs significantly, and no statistically significant difference in effect could be found between drugs in this regard. The results indicate that the difference between the drugs in terms of short-term therapeutic effects is small, and that sodium hyaluronate could be used as an alternative to corticosteroid for patients who have signs of TMJ inflammation, especially for those who have symptomatic osteoarthrosis.

Surgical approaches to the orbit. Indications and techniques.

The authors review their experience with over 300 patients with orbital tumors, and summarize their surgical techniques and indications for each surgical approach. A fronto-orbital approach is described which is used for tumors with intracranial extension and for those located in the orbital apex and deep medial orbital compartment. Lateral micro- orbitotomy is used for tumors located in the superior, temporal, or inferior compartment of the orbit and those in the lateral apex. A medial microsurgical approach is used for tumors located medial to the optic nerve but not deep in the apex. By thus approaching tumors directly, optimal exposure is obtained and functional deficits are minimized. The pertinent surgical anatomy is illustrated and the technique of fine-needle aspiration biopsy is discussed.

Normal axial anatomy of the hip as demonstrated by computed tomography

The anatomy of four baseline transaxial computed tomography (CT) slices of the hip is described and compared with the corresponding anatomical cuts in cadavers. Level I demonstrates the superior compartment of the joint and the superior aspect of the femoral head. Level II is clinically the most important in that it demonstrates the bone thickness of the medial acetabular wall. Level III is through the femoral neck and allows measurements of femoral anteversion and acetabular inclination. The fourth level demonstrates the calcar femorale, but is seldom performed. An easy method of achieving reference levels II and III without a survey radiograph is described; the radiation dose can therefore be reduced by performing only the clinically relevant slice.

Arthroscopic examination of the posteromedial compartment of the knee joint.

In a series of 356 arthroscopies of the knee joint 127 patients were explored by arthrotomy. A Storz arthroscope was introduced through the patellar tendon, and we alternated between the 30 degrees and 70 degrees optical systems in the same trocar sheath. The 30 degrees system was used for inspection of the superior, anterior, medial and lateral compartments, and to lead the tip of the instrument to the posterior part of the joint. The 70 degrees telescope was then used, providing a good view of the posterior cruciate ligament and the posterior horn of the menisci and their attachments. It also allowed direct inspection of the posterolateral and posteromedial compartments. No major diagnostic error was made by the arthroscopist in the 127 patients operated on as a result of the findings of endoscopic examination. Arthroscopy with the use of both 30 degrees and 70 degrees telescopes at the same session gives high diagnostic accuracy and detailed, exact pre-operative diagnosis.

The early development of the human temporomandibular joint

1. 1. The early development of the human temporomandibular joint was examined and studied by microscopic techniques. Eighty fetal specimens plus one 2 1 2 -month postterm infant were used in this study. 2. 2. The critical time area in the formation of the human temporomandibular joint is from the eighth to the tenth weeks of fetal life. During this 2 week period proliferation and histodifferentiation of the embryonic mesenchyme take place and the condyle of the mandible assumes its mature morphologic pattern. 3. 3. The critical time area for the formation of the articular disc is from the twelfth to the fourteenth weeks of fetal life. Small clefts appear and coalesce to form the inferior and superior compartments. The articular disc has assumed its mature morphologic shape by the fetal age of 14 weeks, when it consists of a thin central area which increases in thickness as the peripheral regions of the disc are reached. The articular disc is composed of fibrous connective tissue and exhibits a high degree of vascularity except in the thin central area. No evidence of cartilage was found. 4. 4. First evidence of the temporal bone is seen in the 8-week specimen. Formation of the entire glenoid fossa and the articular eminence can be followed easily in this series. Both the articular eminence and the glenoid fossa are well formed by the twenty-second week of fetal life. 5. 5. Meckel's cartilage plays no part in the actual development of the temporomandibular joint. It is thought that its early function is to act as a framework or scaffolding for the developing mandible. 6. 6. The ramus of the mandible is formed of membrane bone. This grows only by surface apposition. The continued endochondral bone formation at the head of the mandibular condyle is the major contributing factor in the increase in height of the ramus of the mandible. 7. 7. The early attachment of the muscles of mastication is first noted in the 8-week fetus when the external pterygoid muscle is plainly demonstrated. Attachment of the internal pterygoid muscle is demonstrated at 13 weeks, and the masseter muscle is clearly evidenced at the fourteenth week. It is quite probable that the last two muscles were attached earlier, but no specific study was made to determine their attachment date.

Mediastinal Masses

The surgical availability of the mediastinum has stimulated interest in lesions of this area, but a review of the literature leads to confusion more than to clarity. The boundaries of the mediastinum vary from those stated by Maier, 1 who does not include neurogenic tumors because they are in the costovertebral gutter, and not the true mediastinum, through Peabody and others, 2 who include the middle mediastinum in the anterior portion and divide the mediastinum into superior and inferior compartments, each with an anterior and a posterior portion. The boundaries accepted by most authors will be used in this article and be delineated later. Blades, 3 Harrington, 4 and Laipply 5 reviewed this subject, and their combined statistics show that 75% of the anterior mediastinal tumors are of teratoid origin, 52% of the tumors of the middle mediastinum are bronchogenic cysts, 90% of all posterior mediastinal tumors are neuroblastomas, and