SA3 - Inferior Joint Space Arthroscopy of the Temporomandibular Joint Using a Seldinger Technique: A Feasibility Study With Preliminary Findings

Abstract: Statement of the problem: Traditional temporomandibular joint (TMJ) arthroscopy is limited to the superior joint space. Prior studies have identified adhesions and synovitis within the IJS that may contribute to persistent symptoms or progressive pathology.¹ However, the technique and surgical access remain challenging, restricting its routine use. We propose a novel minimally invasive technique utilizing the Seldinger technique under direct visualization to safely and reproducibly access the IJS.

Methods: A retrospective case series of 5 patients (6 joints) undergoing TMJ arthroscopy of the superior and IJS was performed. All patients had abnormal MRI and symptoms refractory to conservative management. Wilkes V joints were excluded, as disc perforation allows for direct access. Age, sex, laterality, and Wilkes classification, MRI findings, and operative reports were reviewed.

Primary outcome was technical success, defined as successful entry and visualization of the IJS without iatrogenic injury. Secondary outcomes included changes in pain, function, jaw functional limitation scale (JFLS) and maximal incisal opening at 3 months.

Technique: An arthroscope is first introduced into the superior joint space through a posterior-lateral portal. Under direct visualization, a 17-gauge spinal needle is inserted into the IJS in a similar fashion to a posterior double pass discopexy approach.²

Site of insertion is determined by triangulation and direct visualization. The posterior aspect of the condylar head is sounded with the mandible in a jaw open position. The IJS is insufflated with visual confirmation, confirming correct positioning of the needle. Then an 18-gauge nitinol guidewire. The spinal needle is removed, tract is dilated, and an arthroscopic cannula is inserted. The arthroscope is moved to the inferior joint portal and inferior joint space arthroscopy can be performed. The scope is subsequently returned to the superior joint space to confirm absence of iatrogenic injury.

Results: All patients were female with mean age of 61.8 years, including 3 right- and 3 left-sided joints. Preoperative MRI demonstrated Wilkes II (33.3%) and Wilkes IV (33.3%) internal derangement. 33.3% of joints showed normal disc position but isolated condylar pathology. Additional findings included joint effusion (33.3%), subchondral edema (50%) and osteochondral defect (50%).

Arthroscopic findings in the superior joint space included dislocated disc without any obvious chondromalacia and synovitis (16.7%). In contrast, inferior joint space arthroscopy enabled direct visualization of condylar surface defects and undersurface of the disc, revealing condylar surface defects in 50% and grade 3 chondromalacia of the posterior band of the disc in 66.7% of joints, highlighting pathology not fully appreciated in the superior compartment alone. These findings may provide insight into the pathogenesis of disc degeneration, including progressive thinning, structural heterogeneity, and eventual disc displacement, closed locking, or perforation.

Outcomes Data: Mean pain scores improved from 65 preoperatively to 82. Functional scores improved on average from 44 to 86. No iatrogenic disc injuries or complications were observed.

Conclusion: Inferior joint space arthroscopy using a Seldinger technique has potential to be a safe and reproducible approach that enables direct visualization and access while minimizing risk to the articular disc. Preliminary findings demonstrate technical feasibility, promising early clinical outcomes.


References

1. Gonzalez-Garcia, R., Moreno-Sanchez, M., Moreno-Garcia, C. et al. Arthroscopy of the Inferior Compartment of the Temporomandibular Joint: A New Perspective. J. Maxillofac. Oral Surg. 17, 228-232 (2018). https://doi.org/10.1007/s12663-017-1023-x

2. Adame, C.C.G. and Munoz-Guerra, M.F., 2012. The posterior double pass suture in repositioning of the temporomandibular disc during arthroscopic surgery: a report of 16 cases. Journal of Cranio-Maxillofacial Surgery, 40(1), pp.86-91.