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Delayed TMJ TJR PJI

Patients presenting >3 weeks or longer after TMJ TJR with complaints increasing pain and diffuse swelling with no evidence of localized erythema, no fever and no drainage present a difficult diagnostic dilemma unless there is clinical evidence of a draining skin or auditory canal fistula directly communicating with the device. This sign is pathognomonic of a TMJ TJR PJI and requires delayed TMJ TJR infection management [30] (Table 10.2). Intrinsic causes for pain and diffuse swelling should be ruled out by imaging (plain film or CT). Since ESR and CRP can be equivocal in a late TMJ TJR infection, their value as diagnostic tests is diminished in suspected delayed TMJ TJR infection. Late infections often represent insidious biofilm infection which increases the challenge of making the correct diagnosis.

Sterile aspiration of the TMJ TJR articulation to obtain fluid for WBC analysis (>1100-4000 cells/pL; 64-68% polymorphonucleocytes) and culture is indicated. A CT scan with contrast remains the most cost-effective initial diagnostic study (Fig. 10.2).

Late Infection3

History

>3 weeks to years

Clinical

Pain, swelling, ± fistula

Serology

ESR and CRP ±

Synovial fluid WBC

+

Synovial fluid culture

+

Imaging (Plain, CT)

Unstable component(s)

Nuclear medicine

+

Management

2-stage removal/replacement

Key: ESR Erythrocyte sedimentation rate (>30 mm/h), CRP C-reactive protein (>10 mg/L) a Mercuri [16]

Table 10.2 Algorithm for the management of a late TMJ TJR infection

Fig. 10.2 Axial CT scan with contrast in a patient with bilateral TJR at 12 months. White arrow indicates small collection adjacent to the fossa component

(a) Removal of an MRSA infected TMJ TJR at 12 months postoperatively. (b) A firmly adherent biofilm on the fossa component (white arrow)

Fig. 10.3 (a) Removal of an MRSA infected TMJ TJR at 12 months postoperatively. (b) A firmly adherent biofilm on the fossa component (white arrow)

Labeled-leucocyte imaging (e.g., leucocytes labeled with indium-111) alone or combined with bone marrow imaging with the use of technetium-99 m- labeled sulfur colloid is considered the test of choice when nuclear imaging is utilized [37].

If a preauricular or auricular canal sinus tract is present suggesting an infection, a large endodontic gutta percha point can be inserted into the fistula and an anterior- posterior skull image made. This will demonstrate the gutta percha point in the TMJ TJR joint space indicative of a biofilm infection. Following the delayed infection management protocol (Table 10.2), the TMJ TJR device involved in the biofilm infection must be removed along with associated affected tissue. This tissue should be sent for aerobic and anaerobic culture as should any associated purulence (Fig. 10.3a, b).

Once the device components have been removed, the patient should be placed in maxillomandibular fixation, and antibiotic impregnated polymethyl methacrylate (orthopedic bone cement) should be mixed to a doughy consistence and inserted into the joint space to deliver antibiotic directly to the affected area. Appropriate antibiotic therapy, either oral or parenteral, as determined by culture and sensitivity is instituted for a period of 2-3 months [38]. It is beneficial, although not essential, to maintain the patient in maxillomandibular fixation while the antibiotic spacer is in place to avoid spacer migration or fracture and to avoid possible bony anatomical or occlusal changes with function. When it is time to replace the TMJ TJR components, the maxillomandibular fixation can be released, the antibiotic spacer removed, and the new TMJ TJR device components can be implanted [8].

Early and delayed infections are the most common cause for postimplantation pain and swelling [8, 12, 13, 15, 16]. However, if infection is ruled out, the surgeon should consider the following other common potential intrinsic and extrinsic causes for post-TMJ TJR pain. Intrinsic causes include heterotopic bone formation, dislocation, material sensitivity, aseptic component/screw loosening or fracture, osteolysis, neuroma formation, or synovial entrapment syndrome. Most of these can be diagnosed by imaging and/or diagnostic local anesthetic blocks or lab testing (i.e., lymphocyte transformation test (LTT) for metal sensitivity) and then managed appropriately with revision or replacement surgery [8].

Extrinsic causes include prior misdiagnosis, chronic centrally mediated pain, persistent myofascial/muscular pain, complex regional pain syndrome (CPRS I), neurologic injury (CPRS II), temporalis tendonitis, coronoid impingement, Frey neuralgia, and integrin formation. Extrinsic issues are the most complicated and difficult to diagnose and manage [8].

 
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