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Arthroscopic management of septic arthritis of temporomandibular joint
Arthroscopic management of septic arthritis of temporomandibular joint Xie-Yi Cai, PhD,a Chi Yang, PhD,b Min-Jin Chen, MD,a Shan-Yong Zhang, DDS,c and Bai Yun,d Shanghai, China SHANGHAI JIAO TONG UNIVERSITY SCHOOL OF MEDICINE
This article reports on 7 patients with septic arthritis of the temporomandibular joint (TMJ) who were managed with arthroscopy between 1998 and 2007. The common symptoms were trismus and pain. A series of imaging studies showed widening of joint space in 1 patient with plain film; MRI demonstrated increased joint effusion in 4 patients; accompanying cellulitis in adjacent tissues was discerned by CT in 2 patients. Under the arthroscope, a reddened and swollen synovial membrane was found in 2 patients who were in the acute stage, whereas strong adhesions, destruction of cartilage, and bony defects were discovered in other 5 patients in the chronic stage. Additionally, the disc was ruptured in 3 patients, and fibrosis was confirmed for 2 patients. Lavage, lysis of adhesion, and debridement of articular surface were common procedures for treatments. The average follow-up period was 57.4 months, and no recurrence was found. Arthroscopy has proven to be a useful method for management of septic arthritis of TMJ, especially for patients in the chronic stage. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:24-30)
Septic arthritis of the temporomandibular joint (TMJ) has been reported infrequently. To the best of the authors’ knowledge, fewer than 40 cases have been published in the English language literature over 70 years. However, Leighty et al.1 thought that this small number of reported cases might be the result of misdiagnosis or underreporting owing to atypical symptoms and the absence of diagnostic criteria. Patients with septic arthritis of TMJ were commonly treated with antibiotic therapy, adequate drainage, and joint immobilization. Arthroscopy of the TMJ was introduced by Ohnishi in 1975,2 and is now thought to be a clinically useful procedure in the diagnosis and treatment of various TMJ diseases.3 A few patients with septic arThis project was supported by grants from the Science and Technology Commission of Shanghai (08DZ2271100) and Shanghai Municipal Health Bureau Fund (2007008). a Associate Professor, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. b Professor, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. c Lecturer, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. d Nurse, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. Received for publication Feb 16, 2009; returned for revision Jul 28, 2009; accepted for publication Aug 5, 2009. 1079-2104/$ - see front matter © 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2009.08.007
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thritis of TMJ were reported to be managed successfully through arthroscopy, and the authors thought it should be preferred as initial treatment because of the possibility of drainage and accurate lavage under direct visualization of joint space.4-6 However all of the reported cases were in the acute stage, and no detail about imaging studies, arthroscopic findings, and treatment in the chronic stage has been reported. This study is a retrospective review of 7 cases of septic arthritis of TMJ treated with arthroscopy. The findings of imaging studies and arthroscopy in acute and chronic stages are summarized, and operative procedures are recommended. PATIENTS AND METHODS A retrospective review was conducted of consecutive patients with septic arthritis of TMJ who were treated with arthroscopy in the Department of Oral and Maxillofacial Surgery, Shanghai Ninth People’s Hospital affiliated with Shanghai Jiaotong University, School of Medicine from June 1998 to Nov 2007. The diagnosis of septic arthritis was based on clinical manifestations, aspiration of the joint, and imaging studies. The patients whose duration of symptoms was shorter than 1 month were thought to be in an acute stage, otherwise they were presumed to be in the chronic stage. The demographics, predisposing factors (including associated systemic diseases and preexisting disease in TMJ), clinical manifestation, imaging findings, joint aspiration, joint fluid culture, arthroscopic findings, treatments, and outcomes were collected. Then imaging and
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Table I. Summary for 7 patients with septic arthritis of the temporomandibular joint treated with arthroscopy Patient
Age
Gender
Predisposing factors
Duration of symptoms, d
Follow-up, mo
1 2 3 4 5 6 7
28 46 38 40 40 64 21
Female Male Female Male Male Female Female
Epilepsy, leucopenia Upper respiratory tract infection No Upper respiratory tract infection Extraction of 27 No Upper respiratory tract infection
7 5 52 55 35 80 430
66 104 15 50 48 13 106
Table II. The results of imaging studies for 7 patients before arthroscopy Patient
Schüler’s position
Arthrography
MRI
CT
1
—
—
—
2
—
3 4 5
Widening of joint space limitation of condyle movement — — —
Increased joint effusion anteriorly displaced disc —
— — —
Increased joint effusion Increased joint effusion —
6
—
—
7
—
Unsharp articular structure Little contrast medium in joint cavity
A large effusion in the joint and the adjacent soft tissues, obscure disc and abnormal condyle —
—
— — Collections of fluid in the joint space and infratemporal fossa Joint space widening, fluid collection in front of condyle —
MRI, magnetic resonance imaging; CT, computed tomography; —, not done.
arthroscopic findings in acute and chronic stages are summarized. RESULTS General patient information Seven Chinese patients were included in this report. Their demographics, predisposing factors, the duration of symptoms before hospitalization, and follow-up are shown in Table I. Patients 1 and 2 were in the acute stage, and the other 5 were in the chronic stage. Clinical symptoms and physical findings The left TMJ was involved in all patients. The predominant symptoms were trismus and pain, and there was an obvious tenderness in the TMJ region. The maximal incisal opening varied from 0.2 to 2.2 cm (average 1.5 cm). Preauricular swelling was observed in 4 of 7 patients. Acute malocclusion with ipsilateral posterior open-bite was discerned in 2 patients in the acute stage. One patient developed general malaise and fever after dental extraction. Four imaging studies were applied to these patients, including plain films, arthrography, computed tomog-
raphy (CT), and magnetic resonance imaging (MRI). The results of imaging for every patient are displayed in Table II and Figs. 1 to 3. Joint aspiration was conducted for patients 1, 2, and 5; 2.0 mL, 1.0 mL, and 3.5 mL of yellow turbid joint fluid was obtained, respectively. Hematoxylin-eosin stain of the joint fluid showed many polymorphonuclear cells and some histiocytes. Gram stain and bacteria culture were negative in these 3 patients. Arthroscopy was performed on the superior joint cavity of the left joint under local anesthesia for every patient. The delays before arthroscopy and arthroscopic findings are summarized in Table III and Figs. 4 to 6. Fibrosis was confirmed under arthroscopy for patients 5 and 7. Treatments and outcomes Before arthroscopic treatment, all patients received broad-spectrum antimicrobial therapy. Additionally, 2 patients in the acute stage underwent arthrocentesis, but they did not respond well. Arthrocentesis and drainage of infratemporal abscess through submandibular incision was performed for patient 5, but mandible move-
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Cai et al.
Fig. 1. MRI of a 28-year-old female showing a large effusion within the upper joint cavity and anteriorly displaced disc (arrow).
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Fig. 3. CT of a 64-year-old female showing fluid collection in front of the left condyle (arrow).
in 2004), mandible deviation and occlusal disturbance were found. MRI showed the disc had disappeared and the condyle was obviously hyperplastic (Fig. 8). Joint replacement was recommended, but the patient rejected it. After 13 to 106 months (average 57.4) of follow-up, no recurrence was found. No patients complained of obvious pain in the TMJ region when the mandible moved, and the range of mouth opening was from 3.5 to 5.5 cm (average 3.8 cm).
Fig. 2. MRI of a 64-year-old female showing a large effusion around the joint, obscure disc (arrow), and condyle in lowdensity signal.
ment was still limited. Arthroscopic management for every patient is shown in Table III and Figs. 6 and 7. Additional antibiotic therapy was prescribed for at least 1 week postoperatively. Four repeated arthroscopies were applied to patient 5 for arthralgia and crepitus in the following 6 years. Although the mandibular range of motion was obviously improved after the last arthroscopic procedure (maximal mouth opening was 45 mm
DISCUSSION Septic arthritis of the TMJ has been reported infrequently since the invention of antibiotics, and most of the articles are case reports. There has been no clear consensus on its diagnosis and management until now. Clinical manifestations, imaging studies, joint aspiration with joint fluid analysis, and laboratory tests are all helpful for diagnosis.7 After arthroscopy was introduced into the TMJ field, it has been reported as a clinically useful diagnostic and therapeutic method for patients with septic arthritis because of its direct visualization of the joint cavity. However, there are few reports of large series of septic arthritis of TMJ managed with arthroscopy in the literature, and no detailed report about the arthroscopic findings and treatment in the chronic stage has been published. Seven patients were included in our series, including 2 patients in the acute stage and 5 patients in the chronic stage. According to our results, there are many differences in imaging results and arthroscopic findings between the acute stage and the chronic stage, which are discussed in the following sections.
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Table III. Summary of arthroscopy for 7 patients with septic arthritis of the temporomandibular joint Patient
Delay before arthroscopy, d
Arthroscopic findings
1
18
2
18
3
60
4
60
5
60
6
90
7
450
Reddened and swollen synovium Anteriorly displaced disc Slight adhesions Reddened and swollen synovium Necrotic bleeding tissue, slight adhesions Proliferation of the slender synovial villi Pseudo-wall adhesions in the anterior recess Degeneration and bony defects in the fossa Strong adhesions, vascular proliferation Ruptured disc, destruction of cartilage, bony defects Strong adhesions, vascular proliferation Synovial hyperemia in the anterior recess Strong adhesions, ruptured disc Destruction of cartilage, bony defects Strong adhesions, ruptured disc Destruction of cartilage, bony defects
Fig. 4. Arthroscopic view showing the synovial membrane in anterior recess was reddened and swollen in the 46-year-old male.
Imaging diagnosis Imaging studies are helpful for diagnosis of septic arthritis of TMJ. In the acute stage, joint space widening and limitation of condyle movement are commonly demonstrated on plain film, which resulted from increased intracapsular fluid caused by accumulation of inflammatory exudates and pus. Bony changes are rare. Plain film could not provide useful diagnostic information in the evaluation of effusion, cartilage, and soft tissue. In comparison, CT could detect the inflammation of contiguous soft tissues besides joint space wid-
Arthroscopic procedures Lavage
Lavage
Lavage ⫹ lysis of the adhesions Lavage ⫹ lysis of the adhesions Lavage ⫹ lysis of the adhesions Lysis of adhesions ⫹ lavage debridement of articular surface Lysis of adhesions ⫹ lavage debridement of articular surface
Fig. 5. Arthroscopy showing adhesions in the anterior recess (green arrow) and ruptured disc (black arrow) in the 64-yearold female.
ening, which is helpful in treatment planning. MRI is highly recommended for acute septic arthritis because its imaging sensitivity allows for early detection of increased joint effusion, especially on T2-weighted imaging. Furthermore, the condition of cartilage, disc, and adjacent soft tissues can be evaluated simultaneously. However, all of the imaging studies did not reveal synovial changes, which is the main characteristic of the acute stage. In the chronic stage, bony changes will be demonstrated on plain film, and the articular surfaces may become more closely related because of the destruction
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Fig. 6. Lysis of adhesions with miniature forceps for a 38year-old female.
of bone or disc in long-standing infections. CT is advantageous for evaluating septic arthritis because it shows bony changes earlier than plain films. It can show abscesses, articular space widening, bone erosion within the joint, and cellulitis around the TMJ. It can also identify whether sequelae occur, including infectious osteoarthritis, osteomyelitis, or ankylosis. MRI could display effusion within or around the joint in this stage, and it may also display the changes in cortical and medullary bone. However, it is difficult to detect intracapsular adhesions and synovial lesions, which are the common manifestations for chronic septic arthritis of TMJ. Arthroscopic findings Our results and other reports have validated that arthroscopy is a supplementary method for diagnosis of acute septic arthritis. Its advantage is that it shows the whole upper joint cavity directly, including joint fluid, synovium, disc, and cartilage. The synovial membrane is usually reddened and swollen under arthroscopy, and necrotic bleeding tissue and proliferation of the slender synovial villi can also be found; but adhesions and bony changes are rare in the acute stage. In the chronic stage, adhesions within the joint cavity can be discovered under direct arthroscopic visualization, which usually cannot be seen on imaging. Most adhesions occur in the anterior recess of the upper joint cavity, for joint effusion commonly accumulates there. Extensive adhesions occur in the whole joint space in
Fig. 7. Fibrosis was confirmed under arthroscopy for a 40year-old male. A, Adhesions and degenerative eminence. B, Debridement of articular surface with an electromotive round bur.
some severe cases. Vascular proliferation and hyperemia are frequently noted in the synovium. Degeneration of cartilage and bony defects are also common on the surface of the eminence and fossa, but it is difficult to observe medullary bone destruction. The ruptured disc and fibrosis can be perceived in some severe patients. However, pure diagnostic arthroscopy is seldom used because it is an invasive procedure, in spite of the advantage of direct visualization of the joint space. It is usually carried out in conjunction with arthroscopic treatment procedures.
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Fig. 8. MRI of a 40-year-old male showing disappeared disc and hyperplastic condylar (arrow) 6 years after onset.
Arthroscopic treatment Antibiotic therapy, adequate drainage, and joint immobilization are considered to be important components for treatment of acute septic arthritis. Different surgical methods have been proposed for joint drainage and decompression: needle aspiration, arthroscopy, and arthrotomy. Arthroscopic wash-out has been widely applied to patients with septic arthritis of the knee,8 but it has seldom been reported in TMJ. Murakami et al.,4 Moses et al.,5 and Sembronio et al.6 reported a patient with acute septic arthritis who was treated with antibiotics and drainage and irrigation through the arthroscope, respectively. The results were excellent, and they emphasized that arthroscopic procedures could be carried out relatively atraumatically and should be preferred as initial treatment because of the possibility of drainage and accurate lavage under direct visualization of joint space. Arthroscopy has also proven to be a useful method for management of septic arthritis of TMJ according to our results. It can directly visualize the joint cavity, and the findings give us precise information sufficient to decide whether or not surgery should be performed, and which advanced procedures should be selected. In the acute stage, lavage with Ringer’s solution is recommended. It has been reported that microorganisms may remain in the synovial fluid and are not completely eradicated by the bactericidal action of antibiotics.9 Therefore, sterilization of the joint space requires both
Cai et al. 29
antibiotics and removal of the infected synovial fluid, as intra-articular damage caused by the activity of lysosomal enzymes can continue in the absence of viable organisms.10 Infectious joints become sterile within 48 to 72 hours after drainage; therefore, arthroscopic lavage can not only restrain dissemination of infection to adjacent structures, but also avoid permanent destruction of cartilage and bone. However, it should be carried out under appropriate pressure because immoderate pressure may lead to spread of infection. According to our experience, needle aspiration and arthrocentesis might be considered as the initial choice owing to their minor damage to the TMJ. If they fail to decompress the joints and the effusion persists beyond 7 days, arthroscopy could be chosen as an aggressive treatment. However, in Sembronio et al.’s6 opinion, arthroscopy should be chosen as the initial treatment and not only after needle aspiration failure, because they thought it ensures more accurate removal of the infected synovial fluid, making sterilization of the joint space easier. Controversy exists as to the use of joint antimicrobial irrigation. Several studies have shown that systemic antibiotics achieve adequate concentrations in normal joints for the treatment of septic arthritis, and it has been reported that antimicrobial joint irrigation may induce chemical synovitis.11 Direct irrigation of the joint cavity with antibiotics was used by Murakami et al.,4 whereas saline solution was used by Sembronio et al.6 We prefer Ringer’s solution as an irrigant because antimicrobial joint irrigation might increase the risk of drug resistance. Underdiagnosis and delayed treatment usually result in extensive adhesions and destruction of cartilage and bone in patients with chronic infection of the TMJ. Arthroscopic lysis of adhesion and debridement of the articular surface are usually applied in this stage. Lysis of adhesion can be accomplished with miniature forceps or coblation, which would increase joint mobility. Degenerative tissues and bacterial product on the articular surface may be removed by debridement, so as to eliminate TMJ pain and avoid further destruction of cartilage and bone. The perforated disc in 3 patients remained untreated. The disc disappeared 6 years later in 1 patient, but it seems that it would not affect TMJ movement. The results in our series showed that arthroscopy is also an effective procedure for patients with chronic septic arthritis. TMJ ankylosis and fibrosis have been reported as the common complications of septic arthritis.12,13 Under arthroscope, fibrosis was confirmed in 2 of our patients, which resulted from underdiagnosis and delayed treatment. Besides stronger adhesions, bony destruction is severe, and the disc is often perforated or ruptured in
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this stage. Lysis of adhesion and debridement of the articular surface are usually applied. Compared with open arthrotomy, the advantages of arthroscopy are that it is minimally invasive and repeatable. One of our patients received 5 repeated arthroscopic procedures; however, it could not restrain the abnormal growth of the condyle. Mandible deviation and occlusal disturbance appeared because of condylar hyperplasia. Therefore, it is likely that joint replacement will have to be done if severe damage to cartilage and bone is confirmed. In summary, 7 cases of septic arthritis of TMJ treated with arthroscopy have been discussed with regard to imaging, arthroscopic findings, and arthroscopic treatment. Arthroscopy has proven to be a useful method for management of septic arthritis of TMJ in our series, especially for the patients in the chronic stage. REFERENCES 1. Leighty SM, Spach DH, Myall RWT, Burns JL. Septic arthritis of the temporomandibular joint: review of the literature and report of two cases in children. Int J Oral Maxillofac Surg 1993;22:292-7. 2. Ohnishi M. Arthroscopy of the temporomandibular joint. J Stomatol Soc Jpn 1975;42:207-13. 3. Goldschmidt MJ, Butterfield KJ, Goracy ES, Goldberg MH. Streptococcal infection of the temporomandibular joint of hematogenous origin: a case report and contemporary therapy. J Oral Maxillofac Surg 2002;60:1347-53. 4. Murakami K, Matsumoto K, Ilzuka T. Suppurative arthritis of the temporomandibular joint. J Maxillofac Surg 1984;12:41-5.
5. Moses JJ, Lange CR, Arredondo A. Septic arthritis of the temporomandibular joint after the removal of third molars. J Oral Maxillofac Surg 1998;56:510-2. 6. Sembronio S, Albiero AM, Robiony M, Costa F, Toro C, Politi M. Septic arthritis of the temporomandibular joint successfully treated with arthroscopic lysis and lavage: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e1-6. 7. Cai XY, Yang C, Zhang ZY, Qiu WL, Ha Q, Zhu M. A murine model for septic arthritis of the temporomandibular joint. J Oral Maxillofac Surg 2008;66:864-9. 8. O’Meara PM, Bartal E. Septic arthritis: process, etiology, treatment outcome: a literature review. Orthopedics 1988;11:623-8. 9. Dwosh I. Infectious arthritis: diagnosis and management. Med North Am 1988;2:4833-5. 10. Ivey M, Clar R. Arthroscopic debridement of the knee for septic arthritis. Clin Orthop 1985;199:201-6. 11. Warner WC. Infectious arthritis. In: Crenshaw AH, editor. Campbell’s operative orthopaedics. 8th ed. St Louis, MO: Mosby Year Book; 1992. p. 151-75. 12. Topazian RG. Etiology of ankylosis of the temporomandibular joint: analysis of 44 cases. J Oral Surg 1964;22:227-33. 13. Regev E, Koplewitz BZ, Nitzan DW, Bar-Ziv J. Ankylosis of the temporomandibular joint as a sequela of septic arthritis and neonatal sepsis. Pediatr Infect Dis 2003;22:99-101. Reprint requests: Chi Yang, PhD Department of Oral & Maxillofacial Surgery Shanghai Ninth People’s Hospital Shanghai Jiaotong University School of Medicine 639 Zhi Zao Ju Road Shanghai 200011, P.R. China [email protected]
This article reports on 7 patients with septic arthritis of the temporomandibular joint (TMJ) who were managed with arthroscopy between 1998 and 2007. The common symptoms were trismus and pain. A series of imaging studies showed widening of joint space in 1 patient with plain film; MRI demonstrated increased joint effusion in 4 patients; accompanying cellulitis in adjacent tissues was discerned by CT in 2 patients. Under the arthroscope, a reddened and swollen synovial membrane was found in 2 patients who were in the acute stage, whereas strong adhesions, destruction of cartilage, and bony defects were discovered in other 5 patients in the chronic stage. Additionally, the disc was ruptured in 3 patients, and fibrosis was confirmed for 2 patients. Lavage, lysis of adhesion, and debridement of articular surface were common procedures for treatments. The average follow-up period was 57.4 months, and no recurrence was found. Arthroscopy has proven to be a useful method for management of septic arthritis of TMJ, especially for patients in the chronic stage. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:24-30)
Septic arthritis of the temporomandibular joint (TMJ) has been reported infrequently. To the best of the authors’ knowledge, fewer than 40 cases have been published in the English language literature over 70 years. However, Leighty et al.1 thought that this small number of reported cases might be the result of misdiagnosis or underreporting owing to atypical symptoms and the absence of diagnostic criteria. Patients with septic arthritis of TMJ were commonly treated with antibiotic therapy, adequate drainage, and joint immobilization. Arthroscopy of the TMJ was introduced by Ohnishi in 1975,2 and is now thought to be a clinically useful procedure in the diagnosis and treatment of various TMJ diseases.3 A few patients with septic arThis project was supported by grants from the Science and Technology Commission of Shanghai (08DZ2271100) and Shanghai Municipal Health Bureau Fund (2007008). a Associate Professor, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. b Professor, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. c Lecturer, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. d Nurse, Department of Oral and Maxillofacial Surgery, Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China. Received for publication Feb 16, 2009; returned for revision Jul 28, 2009; accepted for publication Aug 5, 2009. 1079-2104/$ - see front matter © 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2009.08.007
24
thritis of TMJ were reported to be managed successfully through arthroscopy, and the authors thought it should be preferred as initial treatment because of the possibility of drainage and accurate lavage under direct visualization of joint space.4-6 However all of the reported cases were in the acute stage, and no detail about imaging studies, arthroscopic findings, and treatment in the chronic stage has been reported. This study is a retrospective review of 7 cases of septic arthritis of TMJ treated with arthroscopy. The findings of imaging studies and arthroscopy in acute and chronic stages are summarized, and operative procedures are recommended. PATIENTS AND METHODS A retrospective review was conducted of consecutive patients with septic arthritis of TMJ who were treated with arthroscopy in the Department of Oral and Maxillofacial Surgery, Shanghai Ninth People’s Hospital affiliated with Shanghai Jiaotong University, School of Medicine from June 1998 to Nov 2007. The diagnosis of septic arthritis was based on clinical manifestations, aspiration of the joint, and imaging studies. The patients whose duration of symptoms was shorter than 1 month were thought to be in an acute stage, otherwise they were presumed to be in the chronic stage. The demographics, predisposing factors (including associated systemic diseases and preexisting disease in TMJ), clinical manifestation, imaging findings, joint aspiration, joint fluid culture, arthroscopic findings, treatments, and outcomes were collected. Then imaging and
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Table I. Summary for 7 patients with septic arthritis of the temporomandibular joint treated with arthroscopy Patient
Age
Gender
Predisposing factors
Duration of symptoms, d
Follow-up, mo
1 2 3 4 5 6 7
28 46 38 40 40 64 21
Female Male Female Male Male Female Female
Epilepsy, leucopenia Upper respiratory tract infection No Upper respiratory tract infection Extraction of 27 No Upper respiratory tract infection
7 5 52 55 35 80 430
66 104 15 50 48 13 106
Table II. The results of imaging studies for 7 patients before arthroscopy Patient
Schüler’s position
Arthrography
MRI
CT
1
—
—
—
2
—
3 4 5
Widening of joint space limitation of condyle movement — — —
Increased joint effusion anteriorly displaced disc —
— — —
Increased joint effusion Increased joint effusion —
6
—
—
7
—
Unsharp articular structure Little contrast medium in joint cavity
A large effusion in the joint and the adjacent soft tissues, obscure disc and abnormal condyle —
—
— — Collections of fluid in the joint space and infratemporal fossa Joint space widening, fluid collection in front of condyle —
MRI, magnetic resonance imaging; CT, computed tomography; —, not done.
arthroscopic findings in acute and chronic stages are summarized. RESULTS General patient information Seven Chinese patients were included in this report. Their demographics, predisposing factors, the duration of symptoms before hospitalization, and follow-up are shown in Table I. Patients 1 and 2 were in the acute stage, and the other 5 were in the chronic stage. Clinical symptoms and physical findings The left TMJ was involved in all patients. The predominant symptoms were trismus and pain, and there was an obvious tenderness in the TMJ region. The maximal incisal opening varied from 0.2 to 2.2 cm (average 1.5 cm). Preauricular swelling was observed in 4 of 7 patients. Acute malocclusion with ipsilateral posterior open-bite was discerned in 2 patients in the acute stage. One patient developed general malaise and fever after dental extraction. Four imaging studies were applied to these patients, including plain films, arthrography, computed tomog-
raphy (CT), and magnetic resonance imaging (MRI). The results of imaging for every patient are displayed in Table II and Figs. 1 to 3. Joint aspiration was conducted for patients 1, 2, and 5; 2.0 mL, 1.0 mL, and 3.5 mL of yellow turbid joint fluid was obtained, respectively. Hematoxylin-eosin stain of the joint fluid showed many polymorphonuclear cells and some histiocytes. Gram stain and bacteria culture were negative in these 3 patients. Arthroscopy was performed on the superior joint cavity of the left joint under local anesthesia for every patient. The delays before arthroscopy and arthroscopic findings are summarized in Table III and Figs. 4 to 6. Fibrosis was confirmed under arthroscopy for patients 5 and 7. Treatments and outcomes Before arthroscopic treatment, all patients received broad-spectrum antimicrobial therapy. Additionally, 2 patients in the acute stage underwent arthrocentesis, but they did not respond well. Arthrocentesis and drainage of infratemporal abscess through submandibular incision was performed for patient 5, but mandible move-
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Cai et al.
Fig. 1. MRI of a 28-year-old female showing a large effusion within the upper joint cavity and anteriorly displaced disc (arrow).
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Fig. 3. CT of a 64-year-old female showing fluid collection in front of the left condyle (arrow).
in 2004), mandible deviation and occlusal disturbance were found. MRI showed the disc had disappeared and the condyle was obviously hyperplastic (Fig. 8). Joint replacement was recommended, but the patient rejected it. After 13 to 106 months (average 57.4) of follow-up, no recurrence was found. No patients complained of obvious pain in the TMJ region when the mandible moved, and the range of mouth opening was from 3.5 to 5.5 cm (average 3.8 cm).
Fig. 2. MRI of a 64-year-old female showing a large effusion around the joint, obscure disc (arrow), and condyle in lowdensity signal.
ment was still limited. Arthroscopic management for every patient is shown in Table III and Figs. 6 and 7. Additional antibiotic therapy was prescribed for at least 1 week postoperatively. Four repeated arthroscopies were applied to patient 5 for arthralgia and crepitus in the following 6 years. Although the mandibular range of motion was obviously improved after the last arthroscopic procedure (maximal mouth opening was 45 mm
DISCUSSION Septic arthritis of the TMJ has been reported infrequently since the invention of antibiotics, and most of the articles are case reports. There has been no clear consensus on its diagnosis and management until now. Clinical manifestations, imaging studies, joint aspiration with joint fluid analysis, and laboratory tests are all helpful for diagnosis.7 After arthroscopy was introduced into the TMJ field, it has been reported as a clinically useful diagnostic and therapeutic method for patients with septic arthritis because of its direct visualization of the joint cavity. However, there are few reports of large series of septic arthritis of TMJ managed with arthroscopy in the literature, and no detailed report about the arthroscopic findings and treatment in the chronic stage has been published. Seven patients were included in our series, including 2 patients in the acute stage and 5 patients in the chronic stage. According to our results, there are many differences in imaging results and arthroscopic findings between the acute stage and the chronic stage, which are discussed in the following sections.
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Table III. Summary of arthroscopy for 7 patients with septic arthritis of the temporomandibular joint Patient
Delay before arthroscopy, d
Arthroscopic findings
1
18
2
18
3
60
4
60
5
60
6
90
7
450
Reddened and swollen synovium Anteriorly displaced disc Slight adhesions Reddened and swollen synovium Necrotic bleeding tissue, slight adhesions Proliferation of the slender synovial villi Pseudo-wall adhesions in the anterior recess Degeneration and bony defects in the fossa Strong adhesions, vascular proliferation Ruptured disc, destruction of cartilage, bony defects Strong adhesions, vascular proliferation Synovial hyperemia in the anterior recess Strong adhesions, ruptured disc Destruction of cartilage, bony defects Strong adhesions, ruptured disc Destruction of cartilage, bony defects
Fig. 4. Arthroscopic view showing the synovial membrane in anterior recess was reddened and swollen in the 46-year-old male.
Imaging diagnosis Imaging studies are helpful for diagnosis of septic arthritis of TMJ. In the acute stage, joint space widening and limitation of condyle movement are commonly demonstrated on plain film, which resulted from increased intracapsular fluid caused by accumulation of inflammatory exudates and pus. Bony changes are rare. Plain film could not provide useful diagnostic information in the evaluation of effusion, cartilage, and soft tissue. In comparison, CT could detect the inflammation of contiguous soft tissues besides joint space wid-
Arthroscopic procedures Lavage
Lavage
Lavage ⫹ lysis of the adhesions Lavage ⫹ lysis of the adhesions Lavage ⫹ lysis of the adhesions Lysis of adhesions ⫹ lavage debridement of articular surface Lysis of adhesions ⫹ lavage debridement of articular surface
Fig. 5. Arthroscopy showing adhesions in the anterior recess (green arrow) and ruptured disc (black arrow) in the 64-yearold female.
ening, which is helpful in treatment planning. MRI is highly recommended for acute septic arthritis because its imaging sensitivity allows for early detection of increased joint effusion, especially on T2-weighted imaging. Furthermore, the condition of cartilage, disc, and adjacent soft tissues can be evaluated simultaneously. However, all of the imaging studies did not reveal synovial changes, which is the main characteristic of the acute stage. In the chronic stage, bony changes will be demonstrated on plain film, and the articular surfaces may become more closely related because of the destruction
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Fig. 6. Lysis of adhesions with miniature forceps for a 38year-old female.
of bone or disc in long-standing infections. CT is advantageous for evaluating septic arthritis because it shows bony changes earlier than plain films. It can show abscesses, articular space widening, bone erosion within the joint, and cellulitis around the TMJ. It can also identify whether sequelae occur, including infectious osteoarthritis, osteomyelitis, or ankylosis. MRI could display effusion within or around the joint in this stage, and it may also display the changes in cortical and medullary bone. However, it is difficult to detect intracapsular adhesions and synovial lesions, which are the common manifestations for chronic septic arthritis of TMJ. Arthroscopic findings Our results and other reports have validated that arthroscopy is a supplementary method for diagnosis of acute septic arthritis. Its advantage is that it shows the whole upper joint cavity directly, including joint fluid, synovium, disc, and cartilage. The synovial membrane is usually reddened and swollen under arthroscopy, and necrotic bleeding tissue and proliferation of the slender synovial villi can also be found; but adhesions and bony changes are rare in the acute stage. In the chronic stage, adhesions within the joint cavity can be discovered under direct arthroscopic visualization, which usually cannot be seen on imaging. Most adhesions occur in the anterior recess of the upper joint cavity, for joint effusion commonly accumulates there. Extensive adhesions occur in the whole joint space in
Fig. 7. Fibrosis was confirmed under arthroscopy for a 40year-old male. A, Adhesions and degenerative eminence. B, Debridement of articular surface with an electromotive round bur.
some severe cases. Vascular proliferation and hyperemia are frequently noted in the synovium. Degeneration of cartilage and bony defects are also common on the surface of the eminence and fossa, but it is difficult to observe medullary bone destruction. The ruptured disc and fibrosis can be perceived in some severe patients. However, pure diagnostic arthroscopy is seldom used because it is an invasive procedure, in spite of the advantage of direct visualization of the joint space. It is usually carried out in conjunction with arthroscopic treatment procedures.
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Fig. 8. MRI of a 40-year-old male showing disappeared disc and hyperplastic condylar (arrow) 6 years after onset.
Arthroscopic treatment Antibiotic therapy, adequate drainage, and joint immobilization are considered to be important components for treatment of acute septic arthritis. Different surgical methods have been proposed for joint drainage and decompression: needle aspiration, arthroscopy, and arthrotomy. Arthroscopic wash-out has been widely applied to patients with septic arthritis of the knee,8 but it has seldom been reported in TMJ. Murakami et al.,4 Moses et al.,5 and Sembronio et al.6 reported a patient with acute septic arthritis who was treated with antibiotics and drainage and irrigation through the arthroscope, respectively. The results were excellent, and they emphasized that arthroscopic procedures could be carried out relatively atraumatically and should be preferred as initial treatment because of the possibility of drainage and accurate lavage under direct visualization of joint space. Arthroscopy has also proven to be a useful method for management of septic arthritis of TMJ according to our results. It can directly visualize the joint cavity, and the findings give us precise information sufficient to decide whether or not surgery should be performed, and which advanced procedures should be selected. In the acute stage, lavage with Ringer’s solution is recommended. It has been reported that microorganisms may remain in the synovial fluid and are not completely eradicated by the bactericidal action of antibiotics.9 Therefore, sterilization of the joint space requires both
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antibiotics and removal of the infected synovial fluid, as intra-articular damage caused by the activity of lysosomal enzymes can continue in the absence of viable organisms.10 Infectious joints become sterile within 48 to 72 hours after drainage; therefore, arthroscopic lavage can not only restrain dissemination of infection to adjacent structures, but also avoid permanent destruction of cartilage and bone. However, it should be carried out under appropriate pressure because immoderate pressure may lead to spread of infection. According to our experience, needle aspiration and arthrocentesis might be considered as the initial choice owing to their minor damage to the TMJ. If they fail to decompress the joints and the effusion persists beyond 7 days, arthroscopy could be chosen as an aggressive treatment. However, in Sembronio et al.’s6 opinion, arthroscopy should be chosen as the initial treatment and not only after needle aspiration failure, because they thought it ensures more accurate removal of the infected synovial fluid, making sterilization of the joint space easier. Controversy exists as to the use of joint antimicrobial irrigation. Several studies have shown that systemic antibiotics achieve adequate concentrations in normal joints for the treatment of septic arthritis, and it has been reported that antimicrobial joint irrigation may induce chemical synovitis.11 Direct irrigation of the joint cavity with antibiotics was used by Murakami et al.,4 whereas saline solution was used by Sembronio et al.6 We prefer Ringer’s solution as an irrigant because antimicrobial joint irrigation might increase the risk of drug resistance. Underdiagnosis and delayed treatment usually result in extensive adhesions and destruction of cartilage and bone in patients with chronic infection of the TMJ. Arthroscopic lysis of adhesion and debridement of the articular surface are usually applied in this stage. Lysis of adhesion can be accomplished with miniature forceps or coblation, which would increase joint mobility. Degenerative tissues and bacterial product on the articular surface may be removed by debridement, so as to eliminate TMJ pain and avoid further destruction of cartilage and bone. The perforated disc in 3 patients remained untreated. The disc disappeared 6 years later in 1 patient, but it seems that it would not affect TMJ movement. The results in our series showed that arthroscopy is also an effective procedure for patients with chronic septic arthritis. TMJ ankylosis and fibrosis have been reported as the common complications of septic arthritis.12,13 Under arthroscope, fibrosis was confirmed in 2 of our patients, which resulted from underdiagnosis and delayed treatment. Besides stronger adhesions, bony destruction is severe, and the disc is often perforated or ruptured in
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this stage. Lysis of adhesion and debridement of the articular surface are usually applied. Compared with open arthrotomy, the advantages of arthroscopy are that it is minimally invasive and repeatable. One of our patients received 5 repeated arthroscopic procedures; however, it could not restrain the abnormal growth of the condyle. Mandible deviation and occlusal disturbance appeared because of condylar hyperplasia. Therefore, it is likely that joint replacement will have to be done if severe damage to cartilage and bone is confirmed. In summary, 7 cases of septic arthritis of TMJ treated with arthroscopy have been discussed with regard to imaging, arthroscopic findings, and arthroscopic treatment. Arthroscopy has proven to be a useful method for management of septic arthritis of TMJ in our series, especially for the patients in the chronic stage. REFERENCES 1. Leighty SM, Spach DH, Myall RWT, Burns JL. Septic arthritis of the temporomandibular joint: review of the literature and report of two cases in children. Int J Oral Maxillofac Surg 1993;22:292-7. 2. Ohnishi M. Arthroscopy of the temporomandibular joint. J Stomatol Soc Jpn 1975;42:207-13. 3. Goldschmidt MJ, Butterfield KJ, Goracy ES, Goldberg MH. Streptococcal infection of the temporomandibular joint of hematogenous origin: a case report and contemporary therapy. J Oral Maxillofac Surg 2002;60:1347-53. 4. Murakami K, Matsumoto K, Ilzuka T. Suppurative arthritis of the temporomandibular joint. J Maxillofac Surg 1984;12:41-5.
5. Moses JJ, Lange CR, Arredondo A. Septic arthritis of the temporomandibular joint after the removal of third molars. J Oral Maxillofac Surg 1998;56:510-2. 6. Sembronio S, Albiero AM, Robiony M, Costa F, Toro C, Politi M. Septic arthritis of the temporomandibular joint successfully treated with arthroscopic lysis and lavage: case report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e1-6. 7. Cai XY, Yang C, Zhang ZY, Qiu WL, Ha Q, Zhu M. A murine model for septic arthritis of the temporomandibular joint. J Oral Maxillofac Surg 2008;66:864-9. 8. O’Meara PM, Bartal E. Septic arthritis: process, etiology, treatment outcome: a literature review. Orthopedics 1988;11:623-8. 9. Dwosh I. Infectious arthritis: diagnosis and management. Med North Am 1988;2:4833-5. 10. Ivey M, Clar R. Arthroscopic debridement of the knee for septic arthritis. Clin Orthop 1985;199:201-6. 11. Warner WC. Infectious arthritis. In: Crenshaw AH, editor. Campbell’s operative orthopaedics. 8th ed. St Louis, MO: Mosby Year Book; 1992. p. 151-75. 12. Topazian RG. Etiology of ankylosis of the temporomandibular joint: analysis of 44 cases. J Oral Surg 1964;22:227-33. 13. Regev E, Koplewitz BZ, Nitzan DW, Bar-Ziv J. Ankylosis of the temporomandibular joint as a sequela of septic arthritis and neonatal sepsis. Pediatr Infect Dis 2003;22:99-101. Reprint requests: Chi Yang, PhD Department of Oral & Maxillofacial Surgery Shanghai Ninth People’s Hospital Shanghai Jiaotong University School of Medicine 639 Zhi Zao Ju Road Shanghai 200011, P.R. China [email protected]