Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1118_Библиотеки_им_академика_М_И_Перельмана

of platelet-rich plasma (PRP), a subtype of PC, to

tions, such as HA and steroids, in pain reduction

and mouth opening improvement.

6.8–7.5) in physiologic saline. The authors believe that hyaluronate can serve as an excellent intra-articular lubricating agent to facilitate navi­gation while minimizing iatrogenic intra- articular injury.

branch should be anterior to the entry point. Yet, injury to the temporal nerve and the adjacent zygomatic branch may occur, resulting in direct nerve damage arising from scarring of the nerve fibers or perineural tissue. Alternatively, the dam­age can be the consequence of extravasation, dur­ing which irrigation solution is forced beyond the joint capsule into adjacent tissues, resulting in compressive forces on the nerve, subsequent release of ischemic factors, localized nerve fiber changes, and segmental demyelinization. Extravasation of irrigation solution usually occurs upon blockage of the irrigation system or an excessively high-inflow current. While it is a common and self-limiting condition, quickly reabsorbed via the venous and lymphatic sys­tems, it is imperative to visualize the soft palate and clear the airway before extubation. Injury to the temporal branch results in inability to elevate the eyebrow, while injury to the zygomatic branch results in inability to tightly close the eyes. Such assessments are made 24 surgery. Typically, the duration of nerve weak­ness varies from 1 week to 6 months.

13], manubrium of the sternum [14], shoulder,

tarsus, wrist, ankle, and even the first metatarsal and metacarpal phalangeal joints [15–21]. In order to master the technique and enhance reli­ability it has been recommended that physicians practice the procedure on cadavers, or simulate it on plastic models before they apply it to patients

The aspiration of relatively clear fluid from perfused joints is indicative of acute, nonspecific arthritis, such as pseudogout and lupus erythema­tosus [44–46]. Arthrocentesis is especially criti­cal for immediate diagnosis in disputed cases, such as suspicion of septic arthritis in hemophilic patients [47] or in patients with rheumatoid arthritis (RA) controlled by cytotoxic drugs [48]. Microscopic analysis of the synovial fluid is a

Other studies on substances aspirated by arthrocentesis have provided insight into the pathogenesis of diseases of the joint. For exam­ple, the role of kinins in pain in inflamed joints was determined from the analyses of synovial fluid [51], and the use of kinin agonists and kal­likrein inhibitors is warranted. Other pain media­tors, including prostaglandins and thromboxane B, have been detected in osteoarthritis. Another study found that IgE-containing immune com­plexes were produced intra-articulary, thus pro­viding evidence of their role in rheumatoid synovitis [52]. Calpain, an intracellular protein­ase that also has proteoglycan-degrading activity, together with its inhibitor calpastatin, contributes to the turnover of the cartilage matrix in osteoar­thritic joints [53]. The concentration of cartilage proteoglycan components in the synovial fluid reflects the synthesis and degradation of the joint cartilage matrix, and as such has been used for diagnosis, grading, and prediction of outcome of various joint diseases, such as gout, pseudogout, and reactive arthritis. Interleukin (IL)-6 induces antibody activity when present in the synovial fluid of chronically and actively diseased joints, e.g., in rheumatoid arthritis and psoriatic arthri­tis. Matrix metalloproteinase (MMP)-1 is a bio­marker for joint disease and prognosis, although

While these findings represent a respectable amount of information regarding the synovial fluid, much still remains unknown about it.

Reports on the efficiency of arthrocentesis are often related to diagnoses such as temporoman­dibular disorders (TMD) or even internal derangement (ID). Regrettably, both these terms are “catch phrases,” often used in a commitment­free manner by clinicians and researchers alike, avoiding well-defined, established diagnostic cri­teria for clinical research, and treatment. Pain and dysfunction of the temporomandibular joint (TMJ) itself only account for a small proportion of the conditions included under the umbrella of TMD. Furthermore, the effectiveness of TMJ arthrocentesis, i.e., non-arthroscopic lysis and lavage, in some disorders and ineffectiveness in others has led to a refinement of our understand­ing of TMJ function and dysfunction. The rela­tively simple nature of the procedure has dramatically decreased the need for surgical interventions for a variety of disorders [56, 57].

In a healthy TMJ the articular surfaces are smooth with large contact areas and high surface energy [64]. When lubrication is adequate the friction coefficient between these surfaces is almost zero [65]. Conversely, inadequate lubrication enables the generation of various physical phenomena such as increased friction, generation of adhesive force, shear stress, and rupture of articular sur­faces [66].

lage and by synovial lining cells. It general it plays essential roles in boundary lubrication and move­ment in synovial joints and in the TMJ it helps pre­serve structural and cellular integrity [67]. Lack of lubricin in the TMJ causes osteoarthritis- like degeneration that affects the articular cartilage as well as the integrity of multiple joint tissues [68]. Chang et al. noted that the articular cartilage sur­face contains both hydrophilic and hydrophobic elements, and lubricin is able to mediate the fric­tional response between these surfaces equally, likely preventing direct surface-to-surface contact at sufficient concentrations, whereas HA provides considerably less boundary lubrication [

77, 78].