Abstract
A retrospective review of 178 total temporomandibular joint replacements (TJR) performed on 106 patients at the University of Alabama at Birmingham during the years 2000–2010 was completed. Data regarding sex, past medical history, prosthesis manufacturer, microbiology, antibiotic therapy, and the need for additional procedures were obtained from the medical records of patients who developed a prosthetic joint infection following TJR. Of the 106 patients, 95 (89.6%) were female and 11 (10.4%) were male. The average age of the patients was 47 years (range 19–68 years). Sixty patients underwent bilateral TJR. The average length of follow-up was 41 months. Of the 178 TJR performed, eight joints (4.5%) developed an infection of the prosthesis, all requiring removal despite antibiotic therapy. The average time to onset of infection was 14.3 months (range 6 days to 72 months), while the average time to removal of the prosthesis was 26.9 months (range 10 weeks to 84 months). Microbiology data from the infected joints revealed colonization with coagulase-negative Staphylococcus (4/8 joints) and Propionibacterium (2/8 joints), as well as Serratia and Peptostreptococcus species. Three of the prostheses had negative cultures.
Infection of a total joint prosthesis is a difficult complication to treat effectively and often requires removal of the prosthesis. Bacterial biofilm formation and a poor blood supply often render intravenous (IV) antibiotics ineffective. While total joint replacement (TJR) infections have been studied extensively in the field of orthopaedic surgery, data are scarce within the oral and maxillofacial surgery literature. The aim of this study was to review the incidence of temporomandibular joint (TMJ) TJR infection, the microbiology of the infections, and the treatment outcomes of 178 TJR procedures performed in the Department of Oral and Maxillofacial Surgery of the University of Alabama at Birmingham from 2000 to 2010. Furthermore, perioperative factors to consider in preventing, diagnosing, and managing prosthesis infections were explored.
Materials and methods
A retrospective review of 178 TJR performed on 106 patients at the University of Alabama at Birmingham from 2000 to 2010 was completed. Institutional review board approval for this review was obtained. Data regarding sex, comorbidities, prosthesis manufacturer, microbiology, antibiotic therapy, and the need for additional procedures were obtained from the medical records of patients who developed a prosthetic joint infection following TJR. The data were analyzed using standard mean and range calculations.
All patients were treated by the same attending surgeon (PJL). Patients did not routinely undergo preoperative erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and allergy testing, or nutritional assessments. Preoperative laboratory tests were performed based on individual patient factors, but generally included basic metabolic panel, complete blood count, coagulation studies, and electrocardiogram or chest radiograph if indicated by the anaesthesia department.
All patients received preoperative antibiotics (cefazolin or clindamycin) within 1 h of skin incision. Nasotracheal intubation was completed by anaesthesia; the tube was secured with a head wrap utilizing a skin stapler and plastic tape. The patient was then placed in maxillomandibular fixation using either arch bars or intermaxillary fixation (IMF) screws. Next, the eyes and oral and nasal cavities were sealed with Tegaderm prior to skin preparation to reduce oral or nasal contamination. Povidone–iodine (Betadine) skin preparation of the entire face, neck, and ear canals was completed in the standard fashion (chlorhexidine was used if the patient was allergic to povidone–iodine). The ear canal was then packed with povidone–iodine soaked cotton. Following this, the patient was draped with sterile towels and sterile drapes, and an Ioban sheet was placed over the surgical field ( Fig. 1 ).
The dissection was completed with either a pre-auricular approach combined with a modified submandibular approach or a rhytidectomy incision. The device was inserted and the surgical wounds irrigated with dilute povidone–iodine solution ( Figs. 2 and 3 ). Following closure of the wounds in a sterile, layered fashion, sterile towels were placed over the incisions.
Next, the attending surgeon (PJL) would break sterility by going into the oral cavity to release the maxillomandibular fixation and verify the correct occlusion. The incisions and instruments were kept sterile in the event that the prosthesis position needed revision. If no revision was needed, the wounds were dressed with bacitracin/polymyxin ointment (Polysporin) and a pressure dressing.
Postoperatively, all patients received IV antibiotics (cefazolin or clindamycin) during their hospital stay. This was followed by 7 days of oral antibiotics (cephalexin or clindamycin) upon discharge. Patients were instructed to maintain a pureed diet and had scheduled follow-up 2 weeks postoperatively.
Results
Of the 106 patients, 95 (89.6%) were female and 11 (10.4%) were male. The average age of the patients was 47 years (range 19–68 years). Sixty patients underwent bilateral TJR. The average length of follow-up was 41 months. Of the 178 TJR performed, eight joints (4.5%) developed an infection of the prosthesis, all requiring removal despite antibiotic therapy. The average time to onset of infection was 14.3 months (range 6 days to 72 months), while the average time to removal of the prosthesis was 26.9 months (range 10 weeks to 84 months). Forty of the 178 joints (22.5%) were Biomet prostheses, while 138 (77.5%) were TMJ Concepts devices. All of the prosthesis infections occurred with TMJ Concepts devices; however, the majority of the cohort received this type of prosthesis.
Microbiology data from the infected joints revealed colonization with coagulase-negative Staphylococcus (4/8 joints) and Propionibacterium (2/8 joints), as well as Serratia and Peptostreptococcus species. Three of the prostheses had negative cultures. A summary of the patients with prosthetic joint infections, including comorbidities and the timing of infection/prosthesis removal, is given in Table 1 .
