Randomized effectiveness study of four therapeutic strategies for TMJ closed lock. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements.
For individuals with temporomandibular joint (TMJ) disc displacement without reduction with limited mouth opening (closed lock), interventions vary from minimal treatment to surgery. In a single-blind trial, 106 individuals with TMJ closed lock were randomized among medical management, rehabilitation, arthroscopic surgery with post-operative rehabilitation, or arthroplasty with post-operative rehabilitation. Evaluations at baseline, 3, 6, 12, 18, 24, and 60 months used the Craniomandibular Index (CMI) and Symptom Severity Index (SSI) for jaw function and TMJ pain respectively. Using an intention-to-treat analysis, we observed no between-group difference at any follow-up for CMI (p > or = 0.33) or SSI (p > or = 0.08). Both outcomes showed within-group improvement (p < 0.0001) for all groups. The findings of this study suggest that primary treatment for individuals with TMJ closed lock should consist of medical management or rehabilitation. The use of this approach will avoid unnecessary surgical procedures. A prospective randomized controlled trial (RCT) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer.
                This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT.
                Patients for elective resection for colorectal cancer were offered trial entry. Participants were stratified by sex and requirement for a total mesorectal excision and centrally randomized. Multimodal patients received intravenous fluid restriction, unrestricted oral intake with prokinetic agents, early ambulation, and fixed regimen epidural analgesia. Control patients received intravenous fluids to prevent oliguria, restricted oral intake until return of bowel motility, and weaning regimen epidural analgesia. Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets. Discharge decision was made using pre-agreed criteria. The primary endpoint was postoperative stay, and achievement of independence milestones. Secondary endpoints were postoperative complications, readmission rates, and mortality. Analysis was by intention to treat.
                Seventy patients were recruited. Approximately one fourth underwent TME. Median ages were similar (69.3 vs. 73.0 years). The median stay was significantly reduced in the multimodal group (5 vs. 7 days; P < 0.001, Mann-Whitney U test). Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days. Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions. There were 2 deaths, both controls.
                This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery. Morbidity and mortality are not increased. This study was designed to investigate the efficacy of arthrocentesis with and without injection of sodium hyaluronate (SH) into the upper joint space in the treatment of temporomandibular joint (TMJ) internal derangements.
                Forty-one TMJs in 5 males and 26 females aged 14 to 53 years comprised the study material. The patients' complaints were limited mouth opening, TMJ pain and tenderness, and joint noises during function. Patients were randomly divided into 2 groups in which only arthrocentesis was performed in 1 group and arthrocentesis plus intra-articular injection of sodium hyaluronate was performed in the other group. Both groups contained patients with disc displacement with reduction and with closed lock. Clinical evaluation of the patients was done before the procedure, immediately after the procedure, on postoperative day 1, and at 1, 2, 3, 4, 5, 6, 9, 12, 18, and 24 months postoperatively. Intensity of TMJ pain, jaw function, and clicking sounds in the TMJ were assessed using visual analog scales. Maximal mouth opening and lateral jaw movements also were recorded at each follow-up visit.
                Both techniques increased maximal mouth opening, lateral movements, and function, while reducing TMJ pain and noise.
                Although patients benefitted from both techniques, arthrocentesis with injection of SH seemed to be superior to arthrocentesis alone.
                Copyright 2001 American Association of Oral and Maxillofacial Surgeons.
In view of the paucity of high level evidence for the effectiveness of interventions for the management of TMJ OA, small parallel group RCTs which include participants with a clear diagnosis of TMJ OA should be encouraged and especially studies evaluating some of the possible surgical interventions.