Reactive arthritis in relation to internal derangements of the temporomandibular joint: a case control study.

The aim of this study was to find out if reactive arthritis was involved in the aetiology of chronic closed lock of the temporomandibular joint (TMJ) by looking for bacterial antigens in the synovial membrane of the TMJ, and by studying the antibody serology and carriage of human leucocyte antigen (HLA) B27 in patients with chronic closed lock. Patients with reciprocal clicking and healthy subjects acted as controls. We studied a total of 43 consecutive patients, 15 with chronic closed lock, 13 with reciprocal clicking, and 15 healthy controls with no internal derangements of the TMJ. Venous blood samples were collected from all subjects for measurement of concentrations of HLA tissue antigen and serology against Chlamydia trachomatis, Yersinia enterocolitica, Salmonella spp., Campylobacter jejuni, and Mycoplasma pneumoniae. Samples of synovial tissue from patients with closed lock and reciprocal clicking were obtained during discectomy and divided into two pieces, the first of which was tested by strand displacement amplification for the presence of C trachomatis, and the second of which was analysed for the presence of species-specific bacterial DNA using 16s rRNA pan-polymerase chain reaction (PCR). There were no significant differences between the groups in the incidence of antibodies against M pneumoniae, Salmonella spp. or Y enterocolitica. No patient had antibodies towards C trachomatis or C jejuni. We found no bacterial DNA in the synovial fluid from any patient. The HLA B27 antigen was present in 2/15 subjects in both the closed lock and control groups, and none in the reciprocal clicking group. In conclusion, reactive arthritis does not seem to be the mechanism of internal derangement of the TMJ.

Microbiological investigation of retrodiscal tissues from patients with advanced internal derangement of the temporomandibular joint.

The aim of this study was to investigate the presence of bacteria in samples of retrodiscal tissues taken from patients suffering from advanced internal derangement of the temporomandibular joint (TMJ). 12 fresh retrodiscal tissue samples were taken from 12 consecutive patients who underwent unilateral TMJ discectomy for advanced TMJ internal derangement (Wilkes stage IV). The retrodiscal tissue samples were stained and cultured for the presence of micro-organisms in microbiology laboratories. No evidence of bacteria or other micro-organisms was found in any of the tissue specimens procured from the TMJ. This study failed to identify the presence of bacteria or other micro-organisms in fresh retrodiscal tissue specimens of the TMJ in patients with advanced TMJ internal derangement.

The importance of early diagnosis and appropriate treatment in Grisel's syndrome: report of two cases.

Grisel's syndrome designates subluxation of atlanto-axial joint unrelated to trauma or bone disease. Atlanto-axial subluxation is seen after the upper neck inflammatory processes of head and neck region. Moreover, this rare clinical entity has been observed after various otolaryngological surgical approaches including adenoidectomy, tonsillectomy and mastoidectomy. An 8-year-old girl and 14 year-old boy presented with complaints of painful torticollis. The first patient was operated on at another health center due to adenoid hypertrophy. She was referred to our clinic on the postoperative 5th day with painful torticollis. The diagnosis was established by computerized tomography and three-dimensional reconstructions. The second patient had a history of throat infection. Radiological investigation demonstrated atlantoaxial subluxation. The patients were treated with external fixation, antibiotic therapy, muscle relaxants, and anti-inflammatory therapy. Early diagnosis and appropriate treatment resulted in a good outcome in our patients. Grisel's syndrome must be considered in the differential diagnosis in children with painful torticollis associated with upper respiratory tract infection and after various otolaryngological surgical procedures. We report two cases of Grisel's syndrome which emphasize on the importance of early diagnosis for appropriate and successful treatment.

La maladie de Grisel treated by combined C1-2 transarticular and C1 lateral mass screw fixation.

The authors describe a novel posterior approach to atlantoaxial stabilization combining C1-2 transarticular and C1 lateral mass screws with vertical connecting rods to create a strong construct with four-point fixation. They present here a case of atlanto-axial instability secondary to infection, Grisel's syndrome, necessitating instrumented stabilization after a period of close clinical and radiological observation following the initial cervical decompression and evacuation of retropharyngeal and epidural abscesses.

Traumatic talus extrusion: case reports and literature review.

Total talar dislocation is a rare injury, which is usually open and with associated fractures. We report two cases of open anterolateral talar extrusions following high-energy traffic accidents. Both were treated with wound debridement, joint irrigation, closed reduction and external fixation. At 12 months follow-up, both patients had pain-free motion of the ankle without any signs of avascular necrosis or arthritis.

Bacterial diversity in synovial fluids of patients with TMD determined by cloning and sequencing analysis of the 16S ribosomal RNA gene.

OBJECTIVE: The purpose of this study was to examine the presence of bacteria in synovial fluids from patients with temporomandibular joint disorder (TMD) by polymerase chain reaction (PCR) targeting the 16S ribosomal RNA (rRNA) gene, followed by cloning and sequencing. STUDY DESIGN: Universal bacterial primers were used to amplify 16S rRNA genes in 28 synovial fluid samples from 27 patients with TMD (TMD group) as well as control subjects: 5 patients with dislocation of TMJ (non-TMD group). Subsequently, PCR amplicons were purified and cloned. Partial 16S rRNA sequences of the cloned insert were used to determine the species identities or closest relative by comparison with known sequences using GeneBank. RESULTS: Nineteen (67.86%) of 28 samples from patients in the TMD group were identified with the presence of bacterial DNA by PCR. The 5 control samples from the nonTMD group were all negative in this study. After cloning and sequencing, a total of 11 bacterial species was detected, including Granulicatella adiacen (6 samples), Pseudomonas sp. (6 samples), Methylobacterium sp. (5 samples), and Beta proteobacterium (4 samples). Other species, such as Acidovorax sp., Bradyrhizobium sp., Sphingomonas, Streptococcus, Leptothrix sp. oral clone, Thiobacillus denitrificans, and Comamonadaceae bacterium, were also identified. Eight patients were found with mixed bacteria, with 2-4 bacteria per sample. The patients with fastidious bacteria such as Granulicatella adiacen and mixed bacteria were more likely to be older than 45 years (P < .05). CONCLUSION: A wide variety of bacteria, including some not previously reported associated with TMD, were identified in the synovial fluids from patients with TMD.

Craniovertebral tuberculosis: a retrospective review of 13 cases managed conservatively.

STUDY DESIGN: Retrospective review of 13 cases with craniovertebral tuberculosis treated conservatively. OBJECTIVE: To evaluate the results of conservative treatment of craniovertebral tuberculosis and compare with the literature. SUMMARY OF BACKGROUND DATA: Craniovertebral tuberculosis is a rare entity even in endemic countries, and there is no consensus in the literature regarding conservative or surgical management for the same. Reports range from radical surgery to totally conservative approach. We report our experience in treating such patients conservatively. METHODS: A retrospective review of 13 patients diagnosed with craniovertebral tuberculosis was performed. All patients were treated conservatively with cervical traction for initial 3 months followed by a brace along with multidrug antitubercular drugs for 18 months. RESULTS: All patients responded favorably to conservative treatment. Follow-up averaged 43 months (range, 16-65 months). No patient deteriorated neurologically. All patients had symptomatic improvement. Failure to reduce atlantoaxial dislocation/lateral subluxation of the dens completely was seen in 2 cases. CONCLUSIONS: We think that all patients with craniovertebral junction tuberculosis can be managed adequately using conservative means regardless of the extent of bony destruction with a good patient outcome. Surgery should be reserved for only a selective few where diagnosis is in doubt and there is initial severe or progressive neural deficit with/without respiratory distress in presence of documented mechanical compression and documented dynamic instability following conservative treatment.

Reactive arthritis and internal derangement of the temporomandibular joint.

OBJECTIVE: The objective of this study was to determine if temporomandibular joint (TMJ) samples positive for Chlamydia trachomatis have a greater presence of tumor necrosis factor-alpha (TNFalpha) or interleukin-6 (IL-6) when compared with Chlamydia-negative samples. STUDY DESIGN: Posterior bilaminar tissue samples removed during TMJ surgery from 70 patients were evaluated. Cryosections were stained using monoclonal antibody that identifies C. trachomatis. The presence of IL-6 and TNFalpha were evaluated by immunostaining in 15 samples positive and in 25 samples negative for the presence of C. trachomatis. RESULTS: Of the 70 TMJ samples, 32 (46%) were positive for C. trachomatis. In 15 samples positive for C. trachomatis, 10 (67%) were positive for TNFalpha and 7 (47%) for IL-6. In 25 samples negative for C. trachomatis, only 4 (16%) were positive for TNFalpha and only 2 (8%) for IL-6. Differences in C. trachomatis-positive samples versus negative were significant for both TNFalpha (P < .002) and IL-6 (P < .008). CONCLUSION: The presence of C. trachomatis in the TMJ is associated with a significantly increased presence of TNFalpha and IL-6.

Medically treated paravertebral Brucella abscess presenting with acute torticollis: case report.

BACKGROUND: Atlantoaxial subluxation secondary to a paravertebral (retropharyngeal) abscess is a well known but rare event in children. CASE DESCRIPTION: The authors describe the clinical and radiologic findings of a case of 6-year-old child who presented with acute torticollis (duration, 4 days). Type 2 atlantoaxial rotatory fixation and upper cervical paravertebral (retropharyngeal) abscess were diagnosed on radiologic examination. Laboratory test results showed positive agglutination titer for Brucella melitensis, in the rate of 1/640 dilution. This is the first reported case of Brucella-related atlantoaxial subluxation in a child in the pediatric literature. The patient was treated successfully with anti-inflammatory drugs, Brucella-specific antibiotic regimen, and Philadelphia collar application. Possibly, effusion of the atlantoaxial joint, due to Brucella infection, led to the laxity of the ligaments and contributed to subluxation. CONCLUSIONS: Brucella abscess should be kept in mind for the differential diagnosis of retropharyngeal mass, and the torticollis may be the only presenting sign. The authors recommend a trial of medical treatment with adequate dosages for a reasonable length of time and immobilization before considering surgical intervention for the spinal paravertebral Brucella abscess and related atlantoaxial subluxation.

Tubercular atlantoaxial dislocation in children: an institutional experience.

OBJECT: In this paper the authors analyzed the clinical and imaging-documented profile of pediatric patients with tubercular atlantoaxial dislocation (AAD). METHODS: Seventeen children 16 years of age or younger with tubercular AAD were included in the study. Patients with reducible AAD underwent direct posterior stabilization. All patients were treated with a four-drug antituberculosis therapy (ATT) regimen (10-20 mg/kg/day rifampicin, 10-20 mg/kg/day isoniazid, and 15 mg/kg/day ethambutol in a single daily dose; and pyrazinamide 20-35 mg/kg/day in two divided doses) for 3 months. The pyrazinamide was then discontinued after 3 months and the ethambutol after 1 year. The rifampicin and isoniazid were continued for 18 months. RESULTS: Most of the patients had irreducible AAD. There was a high incidence of long tract signs, and the restriction of neck movements, as well as neck pain, was also very common. There was a significant delay in seeking neurosurgical consultation. Most patients were assigned poor preoperative grades, but they experienced excellent improvement postoperatively. CONCLUSIONS: The presence of tubercular AAD in children can have subtle manifestations leading to delayed diagnosis. The successful management of tubercular AAD can be achieved after determining the extent of the disease process and the underlying instability. The goal of surgery is tissue diagnosis and relief of neural compression and stabilization. Medical treatment with ATT is an integral part of the treatment protocol.

Complete osteolysis of the dens with atlantoaxial luxation caused by infection with Staphylococcus aureus: a case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVES: To present a case of complete osteolysis of the dens and accompanying luxation of the atlantoaxial joint, on the basis of a Staphylococcus aureus infection. SUMMARY OF BACKGROUND DATA: To date, complete osteolysis of the dens followed by atlantoaxial dislocation has only been reported as a rare complication in patients with tuberculosis but not as secondary to a Staphylococcus aureus infection. METHODS: Because of emerging neurological complications in both upper extremities, we chose closed reduction and temporary Halo-fixation together with appropriate antibiotic coverage as primary treatment followed by an operative stabilization with Magerl fusion (Galli fusion combined with transarticular screw fixation of C1 and C2). RESULTS: After the operative procedure (Magerl fusion), immediate pain relief was achieved as well as almost complete resolution of neurological deficits. CONCLUSIONS: To our knowledge, this presents the first reported case of a complete destruction of the dens, as a result of a purulent bacterial infection leading to atlantoaxial luxation. Our case demonstrates that infections of the atlantoaxial region are difficult to diagnose and are seen mostly in immunocompromised patients, such as patients with diabetes. Furthermore, it proves that other infections besides tuberculosis can lead to complete osteolytic destruction of the atlantoaxial joint.

Identification of Chlamydia trachomatis in the human temporomandibular joint.

PURPOSE: Reactive arthritis (ReA) as a consequence of triggering Chlamydia trachomatis infections has been extensively studied to better understand inflammatory arthritis. This study investigated whether the presence of C trachomatis can be shown in the TMJ of patients with internal derangement. PATIENTS AND METHODS: Posterior bilaminar tissue removed from 31 patients (29 F, 2 M) during TMJ articular disc repositioning and posterior ligament repair was tested for the presence of C trachomatis. Cryosections were stained using a monoclonal antibody that identifies all chlamydial serovars. Highly specific polymerase chain reaction (PCR) assays independently targeting two genes of C trachomatis also were performed; these assays also identify all serovars of this organism. RESULTS: TMJ tissue from 6 of 30 patients (20%) showed the presence of C trachomatis in the posterior bilaminar tissue on immunostaining. PCR screening identified 12 of 31 patients (39%) as having C trachomatis DNA in tissue, including four of six positive by immunostaining. All chlamydia-positive patients were female, with an average age of 36.7 years (15 to 48 years). CONCLUSIONS: The presence of C trachomatis in the human TMJ has not been previously shown. The presence of this organism may serve as the pathogenetic mechanism for TMJ dysfunction, as demonstrated in other joints. Nonapparent chlamydial infection in females may also explain the marked prevalence of TMJ symptoms in women.