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Postoperative Infection


To date there is no test that produces “absolute” accuracy in the diagnosis of a peri- prosthetic joint infection (PJI) after joint replacement. Therefore, due to this lack of such a “gold standard,” diverse and sometimes conflicting criteria have been proposed

[13]. Based on the review of the TMJ TJR infection literature [12, 13, 29, 35] and the American Academy of Orthopedic Surgeons’ (AAOS) Clinical Practice Guideline for Diagnosis of Periprosthetic Joint Infections [36], practical diagnostic and management algorithms were developed for early and delayed TMJ TJR infections.


As with any diagnosis, the clinical history and physical examination are important. A suspected PJI occurring within days or <3 weeks after TMJ TJR typically manifests as increasing pain, low grade fever, swelling, and erythema at the preauricular and/or retromandibular incisions, as well as drainage from either or both surgical sites [35]. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) serology will be elevated as will the peripheral white blood cell count (WBC). There is no need to aspirate the joint, but if aspiration wound cultures are taken, they should be obtained before antibiotics are employed in order to assure proper identification of the etiologic organisms. (Fig. 10.1)

In early PJI cases, CT imaging will typically reveal a fluid collection and stable component fixation. Should there be any evidence of component or fixation loosening, these issues must be addressed along with the PJI to ensure resolution. Magnetic resonance imaging, ultrasound, and nuclear medicine scans are unnecessary in the diagnosis of an early TMJ TJR infection [35]. Wolford et al. discuss the management of early TMJ TJR infections [35]. The initial recommendation is that via the preauricular incision, the surface of the mandibular condyle and fossa component of the prostheses be thoroughly scrubbed with iodine solution using a sterile toothbrush. Next, irrigating catheters are placed through separate stab incisions above the preauricular incision and secured with sutures. One is placed on the lateral side of the mandibular component and ramus. The second is placed on the medial side of the articulating portion of the prosthesis. A Penrose drain is inserted through the retromandibular incision and positioned on the lateral aspect of the mandibular component

Early Infection3


Days to <3 weeks


Pain, swelling, redness, drainage


ESR and CRP f

Synovial fluid WBC


Synovial fluid culture


Imaging (Plain, CT)

Stable components

Nuclear medicine



Incision and drainage, debridement, antibiotics

Fig. 10.1 Left TJR in a patient with hemifacial microsomia. Erythema, fluctuance, and suppuration with preauricular wound breakdown at 2 weeks postoperatively

Table 10.1 Algorithm for the management of an early TMJ TJR infection

Key: ESR Erythrocyte sedimentation rate (>30 mm/h), CRP C-reactive protein (>10 mg/L) aWolford et al. [35]

and ramus. A double antibiotic solution (neomycin and polymyxin B) is then irrigated through the catheters for 5 days and a peripherally inserted central catheter (PICC line) placed to deliver intravenous antibiotics based on culture and sensitivity results. On discharge from the hospital the patient is placed on the appropriate antibiotic for 4-6 weeks and monitored closely (Table 10.1). Eighty percent (4 out of 5) of patients with an acute infection in their study responded to this treatment [35].

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