J Oral Maxillofac

Surg

49:1339-1340,199l

Infection of a Prosthetic Temporomandibular Joint in an Intravenous Drug Abuser JOSEPH NAWROCKI, DMD, MD* VINCENT ZICCARDI, AND GEORGE C. SOTEREANOS, DMDt Late infection of the temporomandibular joint (TMJ) prosthesis is a rare complication.’ To our knowledge, this is the first reported case of an infected total TMJ prosthesis occurring from possible hematogenous bacterial seeding in an intravenous (IV) drug abuser.

fact from the TMJ prosthesis. It was postulated that the TMJ prosthesis was the most likely source of infection. Intravenous cephalosporin was initiated and the patient was scheduled for joint exploration and possible removal of the prosthesis and debridement of the area. However, surgery was postponed because of elevated liver transaminase levels consistent with hepatitis. Antibiotic coverage was broadened to include nafcillan and gentamicin. The initial ear cultures showed coagulase positive staphylococci as the predominant organism. Over the next week, the transanimase levels slowly returned to normal and the swelling responded well to the IV antibiotic cov-

Report of Case A 39-year-old woman presented to the emergency department in April 1990 with a complaint of right-sided facial swelling accompanied by increasing pain and trismus of 1 week’s duration and purulent drainage from the right ear for the previous 3 days. The patient’s medical history was significant for a motor vehicle accident in 1985 in which she sustained multiple injuries including a severely cornminuted right mandibular condyle fracture for which total VK II TMJ prosthesis had been used for reconstruction. This allowed for adequate function and was asymptomatic up until the past week. There was a history of IV heroin and cocaine drug abuse of several years duration. The patient had recently resorted to cervical injection sites as peripheral sites had become increasingly scarce. The right neck had been her site of choice over the last several weeks. Examination showed a febrile patient with moderate swelling in the right masseteric region, which was painful to palpation. Interincisal opening was approximately 10 mm. There was a sinus tract in the right external auditory canal. Otolaryngologic examination showed no evidence of middle ear involvement. Computed tomography examination revealed swelling over the right masseter consistent with an inflammatory process; however, there was no discrete fluid collection visualized due to scatter arti-

erage with a decrease in trismus and pain. The patient underwent exploration of her TMJ through the previous preauricular and submandibular incision sites. Large amounts of purulent material and necrotic appearing granulation tissue were apparent in the area of the glenoid fossa and condylar prosthesis, and some bony erosion also was noted. A large sinus tract connecting the glenoid fossa to the external auditory canal was evident (Fig 1). Both the condylar and glenoid fossa prosthesis were removed along with the surrounding infected tissues. The area was carefully curetted and irrigated with copious amounts of antibiotic solution. The sinus tract was closed with a local rotation flap from the adjacent concha and the wounds were closed with a Jackson Pratt drain in place. The patient did well postoperatively but was kept in the hospital for an extended period to allow social services to initiate a methadone program. The patient was discharged on the 10th postoperative day and was instructed to return for follow-up in 2 weeks. At that time, plans were made to schedule the patient for costochondral reconstruction of her joint after resolution of the infection. However, she was lost to follow-up. Discussion

Received from the Division of Plastic and Maxillofacial Reconstructive Surgery, Department of Surgery, University of Pittsburgh. * Resident. t Associate Director. Address correspondence and reprint requests to Dr Sotereanos: Division of Plastic and Maxillofacial Reconstructive Surgery, Department of Surgery, University of Pittsburgh, 686 Scaife Hall, 3550 Terrace St. Pittsburgh, PA 15261. 0 1991 American geons

Association

of Oral and Maxillofacial

DMD,*

Given this patient’s history and clinical presentation, it was postulated that the infection of the TMJ prosthesis was caused by hematologic bacterial seeding. Presumably, this occurred by the organisms entering the vessel during cervical injection when aseptic technique was not used. This hypothesis is supported by the fact that staphylococcus was grown in initial cultures, this organism being the predominant pathogen involved in infections due to cervical intravenous drug abuse.2 Also con-

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cana1,3*4 or from penetrating trauma. There was no historical or clinical support for any of the above modes of infection. Our review of the literature showed no published reports in the oral and maxillofacial or orthopedic literature concerning infections of prosthetic joints in IV drug abusers. We suspect this is probably due to the small number of IV drug abusers who have prosthetic joints. Despite the fact that there are over 250,000 joint replacements per year in the world,5 it is assumed that for socioeconomic reasons, the number of IV drug abusers obtaining these prosthetic joint replacements is much less than in the general population. Our approach to management of this patient is in agreement with the orthopedic experience. Removal of the prosthesis was indicated because there was significant pain, a draining sinus, functional impairment, bone deterioration, and sepsis.‘*6 We elected to perform a delayed reconstruction, which the orthopedic literature has shown to be more reliable, particularly in cases of late infection.’ However, this patient unfortunately was lost to follow-up. References

FIGURE 1. Intraoperative view showing a hemostat inserted in the sinus tract leading from the TMJ to the external auditory canal.

vincing is the lack of evidence for any other source of infection, the most common which would be infections spreading from adjacent structures such as the mastoid air cells, the pterygoid space, or the ear

1. Haug R, et al: The infected prosthetic total temporomandibular joint replacement. J Oral Maxillofac Surg 47: 1210, 1989 2. Myers E, et al: The head and neck sequelae of cervical intravenous drug abuse. Laryngoscope 98, 1988 3. Goodman W, Strelzow V: Infection of the temporomandibular joint. J Otolaryngol 8:3, 1977 4. Thompson HG: Septic arthritis of the temporomandibular joint complicating otitis extema. J Laryngol Otol 103: 1989 5. Salvati E, et al: Re-implantation in infection, a 12 year experience. Clin Orthop 170:62, 1982 6. Rand JA: Management of the infected total joint arthroplasty. Orthop Clin North Am 15:451, 1984 7. Rosenberg AG, et al: Salvage of the infected total knee arthroplasty. Clin Orthop 226:29, 1988

Infection of a prosthetic temporomandibular joint in an intravenous drug abuser.

J Oral Maxillofac Surg 49:1339-1340,199l Infection of a Prosthetic Temporomandibular Joint in an Intravenous Drug Abuser JOSEPH NAWROCKI, DMD, MD*...
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