Open Procedures

Open Discopexy

Although described more than 100 years ago by Annandale, disc repositioning gained popularity following description of the technique and favorable outcomes by McCarty and Farrar in 1979 [24]. Open discopexy can be completed using several techniques including suture plication and the use of anchors and screws although the most ideal technique to plicate the disc remains unclear and outcomes following all techniques appear to be similar. Patient-reported outcomes suggest a success rate of more than 90% in terms of pain, MIO, and function [24-33]. The most ideal indication for this procedure include Wilkes II and early III internal derangement (ID) [34]. It may also be performed on late Wilkes III and IV ID although it is more challenging in part due to the presence of a dysmorphic disc.

After access to the joint is obtained, and the lateral collateral check ligament incised, a small portion of the lax lateral retrodiscal tissue is excised. The disc is then mobilized by releasing its anterior portion through instrumentation and reduced back over the condylar head. A lateral pterygoid myotomy can be performed simultaneously to increase disc mobility although the effect this has on the joint vascularity remains unknown. Following disc mobilization, a posterior and lateral plication is completed with sutures. Discopexy can also be completed with a non-resorbable Mitek®[1] or resorbable JuggerKnot™1 [2] anchor. When placing an anchor, it is different from suture discopexy in that it employs rigid fixation of the disc to the condylar head. At this point, the anchor drill is used to drill a small pilot hole through the posterior lateral aspect of the condylar head approximately 8 mm from the superior aspect of the condyle. The anchor is then inserted and secured in the prepared position through a cleat system. The double-threaded 0/0 non-resorbable suture is passed through the posterior aspect of the disc on both the medial and lateral sides prior to securing it in place. Additional plication of the disc to the retrodiscal tissue and lateral inferior capsule is then completed typically using a smaller suture such as 4/0 or 3/0 Vicryl®[3] or Mersilene®. Once it is secure, the joint is irrigated and the wound is closed.

Potential complications specific to discopexy include the long-term stability of the disc position. Although the immediate postoperative disc position following discopexy appears to be normal in more than 90% of subjects [35], the disc position appears to be less stable with disc displacement reported in many subjects in the long term [31, 36]. Long-term disc stability does not appear to correlate with pain and function [31, 37]. Nevertheless, the potential for subsequent disc displacement with symptoms and the need for a second surgical procedure exist. As with any open joint procedure, discopexy can also result in disc adhesions and progressive degenerative joint disease. The risk can be lessened with attention to technique, meticulous hemostasis, and early joint movement. Initial concerns with the use of the anchor technique revolved around the potential for condylar head resorption as a result of placing the anchor. This appears to be more theoretical than real-based 3-year follow-up data [38].

  • [1] ®Depuy Synthes, Raynham, MA.
  • [2] ™Zimmer Biomet, Jacksonville, FL.
  • [3] ®Ethicon, Johnson and Johnson
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