Infections following arthroscopic rotator cuff repair: incidence, risk factors, and prophylaxis

A systematic review of distinction of colonization and infection in studies that address Cutibacterium acnes and shoulder surgery

BACKGROUND

After shoulder surgery, infection is often diagnosed in the absence of an inflammatory host response (purulence, sepsis). In the absence of inflammation, the more appropriate diagnoses may be colonization or contamination. We reviewed the available data regarding culture of Cutibacterium acnes during primary and revision shoulder surgery and asked; 1) what is the prevalence of air, skin, and deep tissue colonization? 2) How often is an inflammatory host response associated with diagnosis of postoperative shoulder infection diagnosed on the basis of culture of C. acnes? 3) Is there any relation between culture of C. acnes and outcomes of shoulder surgery?

METHODS

Three databases were searched for studies that address C. acnes and colonization or infection related to shoulder surgery. We analyzed data from 80 studies addressing the rates of C. acnes colonization/infection in patients undergoing shoulder surgery, evidence of an inflammatory host response, and relationship of C. acnes culture to surgery outcomes.

RESULTS

C. acnes is often cultured in the air in the operating room (mean 10%), the skin before preparation (mean 47%), and deep tissue in primary shoulder arthroplasty (mean 29%), arthroscopy (mean 27%), and other shoulder surgery (mean 21%). C. acnes was cultured from a mean of 39% of deep tissue samples during revision arthroplasty. C. acnes was believed to be the causative organism of a high percentage of the infections diagnosed after surgery, 39% in primary shoulder arthroplasties, 53% in revisions, 55% in arthroscopic surgeries, and 44% in a mixture of shoulder surgeries. Infection was nearly always diagnosed in the absence of an inflammatory host response. Documented purulence and sepsis were not specifically ascribed to C. acnes (rather than more virulent organisms such as S. aureus). Diagnosis of infection, or unexpected positive culture, with C. acnes during shoulder surgery is associated with outcomes comparable to shoulders with no bacterial growth.

CONCLUSIONS

The evidence to date supports conceptualization of C. acnes as a common commensal (colonization), and perhaps a frequent contaminant, and an uncommon cause of an inflammatory host response (infection). This is supported by the observations that 1) unexpected positive culture for C. acnes is not associated with adverse outcomes after shoulder surgery, and 2) diagnosed infection with C. acnes is associated with outcomes comparable to noninfected revision shoulder arthroplasty. We speculate that diagnosis of C. acnes infection might represent an attempt to account for unexplained discomfort, incapability or stiffness after technically sound shoulder surgery. If so, the hypothesis that stiffness and pain are host responses to C. acnes needs better experimental support.

Risk of bacterial colonization by torniquet during arthroscopy of the knee joint

Purpose

The following study investigated the risk of transmission or spread of potentially pathogenic bacteria via surgical gloves and/or with an elastic bandage to achieve a bloodless surgical site during arthroscopy.

Methods

This was a single-center, prospective study performed at a level-1 trauma center. The included patients were between 18 and 65 years of age and underwent arthroscopy of the knee joint. Before arthroscopy, two skin swabs (one before and one after wrapping the leg with an elastic bandage) were taken for further microbiological analysis. In addition, the thumb and index finger of the right glove of the surgeon's gloves and the part of the bandage covering the knee joint was kept for microbiological examination.

Results

208 samples from 52 patients were included. No patient had a surgical site infection (SSI) during the follow-up period of at least 12 months. The evaluation of the microbiological findings detected contamination of the elastic wrapping material in 83% (43/52) of the cases, primarily with Bacillus spp. The gloves showed bacterial contamination in only two cases; a transfer to the patient's skin was not be detected. Overall, there was no evidence of contamination from the elastic bandage or the gloves to the skin or from the skin to the wrapping material during the surgical procedure.

Conclusion

Preoperative skin antisepsis is mandatory due to the risk of SSI caused by skin flora. However, in a population without a history of joint infection, the current preoperative standards for skin antisepsis seem to be sufficient to minimize SSIs during knee arthroscopy. A glove change after elastic wrapping is not necessary.

Glenohumeral joint septic arthritis and osteomyelitis caused by Moraxella catarrhalis after arthroscopic rotator cuff repair: case report and literature review

Moraxella catarrhalis commonly colonizes the upper respiratory tract of humans, but infection caused by M. catarrhalis after orthopedic surgery is rare. Here, we report the first case of septic arthritis of the shoulder caused by an M. catarrhalis infection and outline the diagnosis and treatment steps as well as differences compared with other cases.

Postoperative complications in rheumatic disease patients undergoing arthroscopy on immunosuppression

BACKGROUND

There are currently no guidelines on peri-arthroscopic management of immunosuppressive (IS) treatment in rheumatic disease patients.

PURPOSE

The purpose of this study is to characterize the rheumatic disease patient population undergoing arthroscopy, compare the incidence of postoperative complications among patients who either remained on IS perioperatively, held IS perioperatively or were not on IS at baseline, and compare the incidence of postoperative complications by rheumatic disease type, medication type, and procedure.

METHODS

We conducted a retrospective review of all arthroscopic sports medicine surgeries in patients with a rheumatic disease diagnosis at our institution over an 11-year period. Patients on IS at baseline were grouped into those who remained on IS perioperatively or held all IS before the date of their surgery. These two groups were compared to patients who were not on IS at baseline. Incidence of postoperative complications was calculated for the three cohorts and by medication class, rheumatic disease type, and procedure risk. Analysis of variance (ANOVA), chi-squared, and Fisher's exact tests were used to determine the statistical significance of between-group differences in postoperative complication incidence.

RESULTS

We identified 1,316 rheumatic disease patients undergoing arthroscopy, with 214 of them taking IS medications at baseline. In total, 8.4% (n = 110) remained on IS perioperatively, 7.9% (n = 104) held IS perioperatively, and 83.7% (n = 1102) were not on IS at baseline. In all cohorts, seven patients experienced postoperative complications; six of whom experienced infections. Two (1.82%) occurred in patients remaining on IS perioperatively, zero infections occured in patients who held all IS, and four (0.36%) occured in patients who were not on any IS at baseline. There was no statistically significant difference in postoperative infections or complication rates among the three cohorts or further subgroups.

CONCLUSION

The risk of postoperative complications including infectious, major, and minor complications in patients on IS at the time of arthroscopy is low and acceptable.

Suture Contamination During Arthroscopic Rotator Cuff Repair Is Associated With Significantly Higher Retear Rates in Magnetic Resonance Imaging: A Matched-Pair Analysis

PURPOSE

To evaluate the correlation between suture contamination and rotator cuff tendon retear after arthroscopic rotator cuff repair.

METHODS

Patients undergoing primary arthroscopic rotator cuff repair from April 1, 2020, to September 30, 2022, were enrolled. Those younger than 18 years, with a history of shoulder surgeries or shoulder infection episodes, or who declined participation were excluded. A 5-cm section of the first-cut suture, originating from the anchor eyelet ends, in each rotator cuff repair surgery was subjected to bacteria culture and polymerase chain reaction analysis. Patients with positive culture findings were matched 1:1 to those with negative culture reports based on age, sex, tear size as well as involved tendons, preoperative fatty infiltration grade (Goutallier grade), and preoperative muscle atrophy grade (Warner score). Postoperative rotator cuff tendon retear assessments were conducted at the 6-month mark using the Sugaya classification via magnetic resonance imaging. The Wilcoxon signed-rank test was used for matched-pair comparisons between the groups.

RESULTS

A total of 141 patients (60 men and 81 women) with a mean age of 61.0 ± 8 years were finally enrolled. Twenty-six patients (18 men and 8 women) had a positive culture, while 115 patients (42 men and 73 women) had a negative culture. After the propensity score matching process, 24 culture-negative patients (16 men and 8 women) were selected as the culture-negative group. Age, fatty infiltration grade, and muscle atrophy grade were not significantly different between matched groups. The retear grade in the culture-positive group was significantly higher than that in the culture-negative group (P = .020) under the matched-pair comparison. Cutibacterium acnes was the most prevalent bacterial species responsible for suture contamination.

CONCLUSIONS

The matched-pair analysis revealed that the presence of bacterial contamination on sutures was associated with a higher risk of retear on magnetic resonance imaging following arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Risk factors for infection in patients undergoing shoulder arthroscopy: a systematic review and meta-analysis

We conducted a meta-analysis to determine the risk of infection following shoulder arthroscopy and to identify risk factors for infection. We systematically searched the PubMed/Medline, Embase and Cochrane Library databases, as well as the reference lists of previous systematic reviews and meta-analyses; manual searches were also performed. A random-effects model was employed to estimate pooled odds ratios (ORs), based on sample size, the P-value of Egger's test and heterogeneity among studies. Of the 29,342 articles screened, 16 retrospective studies comprising 74,759 patients were included. High-quality evidence showed that patients with diabetes (OR, 1.30; 95% confidence interval (CI), 1.20-1.41) or hypertension (OR, 1.26; 95% CI, 1.10-1.44) had a higher risk of infection, while moderate quality evidence showed that patients with obesity (body mass index ≥30 kg/m2) (OR, 1.42; 95% CI, 1.28-1.57), those who were male (OR, 1.65; 95% CI, 1.12-2.44), those who had an American Society of Anesthesiologists (ASA) class ≥3 (OR, 2.02; 95% CI, 1.02-3.99) and those who had a history of smoking (OR, 2.44; 95% CI, 1.39-4.28) had a higher risk of infection. The meta-analysis revealed that there was no association between age, time of surgery, or alcohol consumption and infection. This meta-analysis identified six significant risk factors for infection following shoulder arthroscopy including diabetes, obesity, hypertension, male sex, ASA class, history of smoking. These patient-related risk factors may help identify postoperative patients at higher risk for infection following shoulder arthroscopy.

Concomitant Procedures, Black Race, Male Sex, and General Anesthesia Show Fair Predictive Value for Prolonged Rotator Cuff Repair Operative Time: Analysis of the National Quality Improvement Program Database Using Machine Learning

PURPOSE

To develop machine learning models using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database to predict prolonged operative time (POT) for rotator cuff repair (RCR), as well as use the trained machine learning models, cross-referenced with traditional multivariate logistic regression (MLR), to determine the key perioperative variables that may predict POT for RCR.

METHODS

Data were obtained from a large national database (ACS-NSQIP) from 2021. Patients with unilateral RCR procedures were included. Demographic, preoperative, and operative variables were analyzed. An MLR model and various other machine learning techniques, including random forest (RF) and artificial neural network, were compared using area under the curve, calibration, Brier score, and decision curve analysis. Feature importance was identified from the overall best-performing model.

RESULTS

A total of 6,690 patients met inclusion criteria. The RF machine learning model had the highest area under the curve upon internal validation (0.706) and the lowest Brier score (0.15), outperforming the other models. The RF model also demonstrated strong performance upon assessment of the calibration curves (slope = 0.86, intercept = 0.08) and decision curve analysis. The model identified concomitant procedure, specifically labral repair and biceps tenodesis, as the most important variable for determining POT, followed by age <30 years, Black or African American race, male sex, and general anesthesia.

CONCLUSIONS

Despite the advanced machine learning models used in this study, the ACS-NSQIP data set was only able to fairly predict POT following RCR. The RF model identified concomitant procedures, specifically labral repair and biceps tenodesis, as the most important variables for determining POT. Additionally, demographic factors such as age <30 years, Black race, and general anesthesia were significant predictors. While male sex was identified as important in the RF model, the MLR model indicated that its predictive value is primarily in conjunction with specific procedures like biceps tenodesis and subacromial decompression.

LEVEL OF EVIDENCE

Level IV, retrospective comparative prognostic trial.

Impact of surgeon volume, experience, and training on outcomes after arthroscopic rotator cuff repair: a nationwide analysis of 1489 surgeons

Background

Given the complexity of arthroscopic rotator cuff repair (ARCR) and increasing prevalence, there is a need for comprehensive, large-scale studies that investigate potential correlations between surgeon-specific factors and postoperative outcomes after ARCR. This study examines how surgeon-specific factors including case volume, career length, fellowship training, practice setting, and regional practice impact two-year reoperation rates, conversion to total shoulder arthroplasty (anatomic or reverse), and 90-day post-ARCR hospitalization.

Methods

The PearlDiver Mariner database was used to collect surgeon-specific variables and query patients who underwent ARCR from 2015 to 2018. Patient outcomes were tracked for two years, including reoperations, hospitalizations, and International Classification of Diseases, Tenth Revision codes for revision rotator cuff repair (RCR) laterality. Hospitalizations were defined as any emergency department (ED) visit or hospital readmission within 90 days after primary ARCR. Surgeon-specific factors including surgeon case volume, career length, fellowship training, practice setting, and regional practice were analyzed in relation to postoperative outcomes using both univariate and multivariate logistic regression.

Results

94,150 patients underwent ARCR by 1489 surgeons. On multivariate analysis, high-volume surgeons demonstrated a higher risk for two-year total reoperation (odds ratio [OR] = 1.06, 95% confidence interval [CI]: 1.01-1.12, P = .03) and revision RCR (OR = 1.06, 95% CI: 1.01-1.12, P = .02) compared to low-volume surgeons. Early-career surgeons showed higher rates of 90-day ED visits (mid-career surgeons: OR = 0.78, 95% CI: 0.73-0.83, P < .001; late-career surgeons: OR = 0.73, 95% CI: 0.68-0.78, P < .001) and hospital readmission (mid-career surgeons: OR = 0.74, 95% CI: 0.63-0.87, P < .001; late-career surgeons: OR = 0.73, 95% CI: 0.61-0.88, P = .006) compared to mid- and late-career surgeons. Sports medicine and/or shoulder and elbow fellowship-trained surgeons demonstrated lower two-year reoperation risk (OR = 0.95, CI: 0.91-0.99, P = .04) and fewer 90-day ED visits (OR = 0.93, 95% CI = 0.88-0.98, P = .002). Academic surgeons experienced higher readmission rates compared to community surgeons (OR = 1.16, 95% CI = 1.01-1.34, P = .03). Surgeons practicing in the Northeast demonstrated lower two-year reoperation (OR = 0.88, 95% CI: 0.83-0.93, P < .001) and revision (OR = 0.88, 95% CI: 0.83-0.94, P < .001) RCR risk compared to surgeons in the Southern United States.

Conclusion

High-volume surgeons exhibit higher two-year reoperation rates after ARCR compared to low-volume surgeons. Early-career surgeons demonstrate increased hospitalizations. Sports medicine or shoulder and elbow surgery fellowships correlate with reduced two-year reoperation rates and 90-day ED visits.

Revision Surgery for Shoulder Infection after Arthroscopic Rotator Cuff Repair: Functional Outcomes and Eradication Rate-A Systematic Review

The outcomes after arthroscopic rotator cuff repair (RCR) have been reported to be successful. The incidence of deep infections (defined as an infection involving any part of the anatomy other than the skin and subcutaneous tissue) after surgery ranges between 0.03% and 3.4%. This systematic review aims to investigate the outcomes of revision surgery for infection following arthroscopic RCR. Clinical outcomes and eradication rates among patients treated with different surgical and antibiotic therapies are analyzed. A total of five studies were eligible for systematic review. A total of 146 patients were treated and evaluated, of whom 71 (48%) and 75 (52%) underwent arthroscopic and open surgery to manage the infection, respectively. The most common causative bacterium was Cutibacterium acnes (50.4%). Two studies reported the pre-and postoperative ASES score and Constant-Murley score (CMS), and a statistically significant improvement was found after surgery (p < 0.001 for both). Eradication was observed in a total of 138 patients (94.5%); no difference was found between arthroscopic and open revision surgery (92.8% and 96%, respectively, p = 0.90). The frequency-weighted mean duration of the intravenous antibiotic therapy was 6.6 ± 5.4 days, while the overall mean duration of antibiotic therapy, considering intravenous and oral administration, was 43.5 ± 40 days. Patients with infection following arthroscopic RCR undergoing revision surgery experienced a high rate of eradication. A significant improvement in shoulder functionality and less residual pain can be expected.

Hand and Upper Extremity Surgical Site Infection Rates Associated With Perioperative Corticosteroid Injection: A Review of the Literature

BACKGROUND

Corticosteroid injection (CSI) has a relatively high benefit-to-risk ratio and is commonly administered to treat musculoskeletal conditions. However, perioperative CSI has been associated with an increased risk of postoperative infection. The literature suggests delaying surgery after CSI to minimize the risk of postoperative infection. We review the literature to summarize the most current knowledge on the association between perioperative CSI and infection rates for different hand and upper extremity procedures.

METHODS

Two independent reviewers conducted a literature search using PubMed and Web of Science databases (through October 1, 2022). The database searches used were (((injection) AND (infection)) AND (risk)) AND ((hand) OR (wrist) OR (elbow) OR (shoulder)). English-language articles were screened for infection rates associated with CSI given temporally around upper extremity surgery, focusing between 6 months preoperatively and 1 month postoperatively.

RESULTS

Nineteen articles including database queries and retrospective case-control or cohort studies were used after screening 465 articles. Most infection rates were increased in hand, wrist, elbow, and shoulder surgery between 3 months preoperatively and 1 month postoperatively. Intraoperative injection during elbow arthroscopy demonstrated increased infection rate relative to other upper extremity surgeries.

CONCLUSIONS

Corticosteroid injection increased the risk of infection temporally around upper extremity surgeries; however, CSI provides benefits. The consensus regarding CSI timeline perioperatively has yet to be determined. The evidence supports an increased benefit-to-risk ratio when giving corticosteroids greater than 3 months preoperatively and greater than 1 month postoperatively for most upper extremity procedures, with relative contraindications within 1 month of upper extremity surgery.

Epidemiology and Treatment of Surgical Infection after Ankle Arthroscopy: A Systematic Review

Background: Ankle arthroscopy is indicated for both diagnosis and treatment of a large spectrum of common ankle disorders. It has certain advantages over the open procedure; however, it is important to recognize that there are some complications associated with it. Infections after this procedure are quite uncommon, with an overall estimated incidence of 2%. Given the low incidence of infections after ankle arthroscopy, not a great deal of literature on the topic has been published. The present review aims to provide an overview of the incidence, diagnosis, and treatment of infections after ankle arthroscopy. Methods: A systematic review of the literature indexed in the PubMed, MEDLINE, and Cochrane Library databases using search term "ankle arthroscopy infections" was performed in November 2023. No restrictions were applied concerning the date of publication. The Preferred reporting items for systematic reviews and meta-analyses (PRISMA) were followed. Among all surgical operations for the treatment of ankle and foot pathologies, we included articles with a described superficial or deep infection after ankle arthroscopy. Results: The search resulted in 201 studies. Only 21 studies met our inclusion criteria, and they were included in this systematic review. We evaluated 1706 patients who underwent 1720 arthroscopic tibiotalar procedures at an average age of 42 years old. Out of the 1720 procedures, 41 (2%) were complicated by infection. We divided infectious complications into superficial (68%; 28/41) and deep (32%; 13/41) infections. The most common pathogen isolated was Staphylococcus aureus. Arthroscopic arthrodesis was found to be the most affected by deep infections. Conclusions: Infection after ankle arthroscopy is an uncommon complication. Superficial infections were successfully treated with antibiotics, while surgical debridement, arthroscopic drainage, and intravenous antibiotics were necessary in cases of deep infections. Considering the amount of information on pathogens associated with knee and shoulder infections, there is still a lack of literature on pathogens associated with ankle infections, which makes their management difficulty.

Preoperative Corticosteroid Injections Within 4 Weeks of Arthroscopic Shoulder Procedures Are Associated With Increased Postoperative Infection Rates

PURPOSE

To refine the understanding of the effect of timing of corticosteroid injections (CSIs) and shoulder arthroscopy on postoperative infection.

METHODS

An insurance database was used to determine all patients who underwent shoulder arthroscopy for a 5-year period with an associated preoperative ipsilateral corticosteroid injection. Patients were stratified into cohorts based on timing of preoperative CSI: (1) 0-<2 weeks, (2) 2-<4 weeks, (3) 4-<6 weeks, and (4) 6-<8 weeks. Patients were pooled to include all patients who had a CSI less than 4 weeks and those longer than 4 weeks. A cohort of patients who never had a corticosteroid injection before undergoing arthroscopy were used as a control. All patients had a follow-up of 2 years. Multivariable regression analyses were performed using R Studio with significance defined as P < .05.

RESULTS

Multivariate logistic regression showed a greater odds ratio (OR) for postoperative infection in patients who received CSI 0-<2 weeks before shoulder arthroscopy at 90 days (3.10, 95% confidence interval [CI] 1.62-5.57, P < .001), 1 year (2.51, 95% CI 1.46-4.12, P < .001), and 2 years (2.08, 95% CI 1.27-3.28, P = .002) compared with the control group. Patients who received CSI 2-<4 weeks before shoulder arthroscopy had greater OR for infection at 90 days (2.26, 95% CI 1.28-3.83, P = .03), 1 year (1.82, 95% CI 1.13-2,82, P = .01), and 2 years (1.62, 95% CI 1.10-2.47, P = .012). Patients who received CSI after 4 weeks had similar ORs of infection at 90 days (OR 1.15, 95% CI 0.78-1.69, P = .48) 1 year (OR 1.18, 95% CI 0.85-1.63 P = .33), and 2 years (OR 1.09, 95% CI 0.83-1.42, P = .54), compared with the control cohort.

CONCLUSIONS

The present study shows the postoperative infection risk is greatest when CSIs are given within 2 weeks of shoulder arthroscopy, whereas CSIs given within 2-<4 weeks also portend increased risk, albeit to a lesser degree. The risk of postoperative infection is not significantly increased when CSIs are given more than 1 month before surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative, prognosis study.

SARS-Cov-2 related shoulder pain and stiffness associated to humeral osteolysis after arthroscopic rotator cuff repair: A case report

INTRODUCTION AND IMPORTANCE

Complications using bioresorbable anchors in arthroscopic rotator cuff surgery include osteolysis, aseptic synovitis, and foreign body reaction. However, the precise triggering factors are unknown.

CASE PRESENTATION

A healthy, 63-year-old male patient underwent rotator cuff repair using 7PLGA/b-TCP anchors. Nine months after surgery he returned to the senior author because of right shoulder pain and stiffness, pain in the right hand, foot and leg, and presence of erythematous patches at the aforementioned joints following SARS-Cov-2 infection, as well as increasing in blood inflammatory markers. Magnetic Resonance Arthrography (Arthro-MRI) showed no rotator cuff tendons re-tear but intra-articular synovitis, subacromial bursitis and humeral osteitis. A diagnostic arthroscopy, intra-articular fluid collection, biopsy and joint lavage was performed to rule out a septic arthritis. Co-amoxicillin 2.2 g intravenous treatment was administered following samples. Histological analysis of synovial tissue showed fibrin-exudative synovitis, while humeral bone biopsy showed an anchor resorption reaction. All microbiological analysis showed sterile samples. Three months post-lavage follow-up physical examination showed painless, recovered mobility, while Arthro-MRI showed a significant post-refixation remodeling of the rotator cuff tendons and reduction in humeral head osteitis and synovitis.

CLINICAL DISCUSSION

The abrupt onset of symptomatology and the close chronological link with SARS-Cov-2 infection suggests a causal relationship between clinical and radiological manifestations and the infection itself, with clinical and radiological manifestation being a viral host response reaction to SARS-Cov-2 infection.

CONCLUSION

Shoulder pain, stiffness and humeral osteitis could be manifestations of a viral host response to SARS-Cov-2 infection.

Disruptions in Standard Care in Patients After Arthroscopic Rotator Cuff Repair During the COVID-19 Pandemic

Background

The coronavirus disease-2019 (COVID-19) pandemic led to disruptions in care for orthopaedic patients who underwent surgery just before the outbreak, rendering some unable to participate in standard postoperative care. Many of these patients underwent clinical follow-up and physical therapy via telehealth.

Purpose

To evaluate the methods of postoperative care in patients who underwent arthroscopic rotator cuff repair (RCR) and had follow-ups during the height of the pandemic versus those who received prior standard of care. We aimed to compare the 1-year outcomes between these cohorts.

Study Design

Cohort study; Level of evidence, 3.

Methods

A retrospective chart review was used to identify patients who underwent primary RCR in February and March 2020 (COVID cohort) and the same period in 2019 (control cohort) at a single institution. Excluded were patients who underwent revision RCR, used workers' compensation, or were incarcerated or deceased. The included patients reported the postoperative care received, their satisfaction with care, physical therapy appointment type (in person, home based, telehealth, or self-guided), satisfaction with physical therapy, and minimum 1-year postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Penn Shoulder Score (PSS) outcomes.

Results

Overall, 428 patients were included for final analysis--199 in the COVID cohort and 229 controls. Follow-up data were collected for 160 patients in the COVID group (80.4%) and 169 control patients (73.8%). In the COVID group, 110 patients (68.8%) had ≥1 clinical visit conducted via telehealth, compared with zero in the control group. There were no differences between the COVID and control groups in the ASES (84.2 ± 16.5 vs 86.5 ± 17; P = .27 ), SANE (83.9 ± 15.4 vs 84.8 ± 17.5; P = .66), PSS (84.8 ± 15.3 vs 87.1 ± 15.1; P = .22), or patient satisfaction with the care received (81.7 ± 22.6 vs 86.3 ± 23.5; P = .09). Satisfaction with physical therapy was significantly higher in the control group (88.3 ± 18.9 vs 81.9 ± 22.5; P = .01).

Conclusion

Despite disruptions in care, RCR patients had comparable 1-year outcomes during the pandemic versus before the pandemic. Telehealth clinical follow-up appointments did not adversely affect patient-reported outcome measures and may be appropriate for RCR patients beyond the pandemic.

Extended skin cleaning on the shoulder with chlorhexidine reduces the cutaneous bacterial load but fails to decrease suture contamination in patients undergoing arthroscopy rotator cuff repair

BACKGROUND

It remains unclear whether preoperative skin cleaning of the chin, neck, and chest with chlorhexidine soap can reduce suture contamination by Cutibacterium acnes in patients undergoing arthroscopic rotator cuff repair.

METHODS

This study included patients who underwent primary arthroscopic rotator cuff repair. Exclusion criteria included age <18 years, previous shoulder surgery, history of shoulder infection, and allergy to chlorhexidine. Patients were randomized into 3 groups. Patients in the control group cleaned their skin with soap and water, as usual. Patients in the shoulder group cleaned their shoulders with chlorhexidine soap 3 days before surgery, whereas patients in the extended shoulder group additionally cleaned their chest, back, neck, and face with chlorhexidine soap. On the day of surgery, skin swab samples were obtained from the shoulder after surgical draping. After rotator cuff repair, sutures were cut from the anchor ends. Both traditional culture methods and polymerase chain reaction (PCR) were used.

RESULTS

Ninety patients were enrolled (32 in the control group, 29 in the shoulder group, and 29 in the extended shoulder group) in the present study. The culture-positive rate from the posterior shoulder skin samples in the extended shoulder group (17.2%) was significantly lower than that in the control (40.6%) and shoulder (48.3%) groups (P = .036), whereas the culture-positive rates were not different among the 3 groups in other skin samples as well as the suture samples. The detection rates of C acnes in suture samples were 12.5%, 13.8%, and 17.2% in the control, shoulder, and extended shoulder groups, respectively (P = .603).

CONCLUSION

Extensive skin cleaning of the shoulder region with chlorhexidine helps reduce the shoulder cutaneous bacterial load, but the detection of C acnes suture contamination in patients undergoing arthroscopic rotator cuff repair remained untouched regardless of the use of chlorhexidine soap in skin cleaning on the preoperative days.

Determinants of Operative Time in Arthroscopic Rotator Cuff Repair

Arthroscopic rotator cuff repairs have been reported to take between 72 and 113 min to complete. This team has adopted its practice to reduce rotator cuff repair times. We aimed to determine (1) what factors reduced operative time, and (2) whether arthroscopic rotator cuff repairs could be performed in under 5 min. Consecutive rotator cuff repairs were filmed with the intent of capturing a <5-min repair. A retrospective analysis of prospectively collected data of 2232 patients who underwent primary arthroscopic rotator cuff repair by a single surgeon was performed using Spearman's correlations and multiple linear regression. Cohen's f² values were calculated to quantify effect size. Video footage of a 4-min arthroscopic repair was captured on the 4th case. Backwards stepwise multivariate linear regression found that an undersurface repair technique (f² = 0.08, p < 0.001), fewer surgical anchors (f² = 0.06, p < 0.001), more recent case number (f² = 0.01, p < 0.001), smaller tear size (f² = 0.01, p < 0.001), increased assistant case number (f² = 0.01, p < 0.001), female sex (f² = 0.004, p < 0.001), higher repair quality ranking (f² = 0.006, p < 0.001) and private hospital (f² = 0.005, p < 0.001) were independently associated with a faster operative time. Use of the undersurface repair technique, reduced anchor number, smaller tear size, increased surgeon and assistant surgeon case number, performing repairs in a private hospital and female sex independently lowered operative time. A <5-min repair was captured.

Schaalia (Formerly Actinomyces) turicensis Infection Following Open Rotator Cuff Repair

We report the case of a male in his early 70s who developed a deep infection after an open rotator cuff repair, with Schaalia turicensis as the only organism isolated from a surgical biopsy of the tendon remnants and phlegmatic/purulent material at the failed repair site. This species was originally within the genus Actinomyces. We report this case because it is the only one that we could locate where an infected open rotator cuff repair site grew S. turicensis. Our patient was not diabetic, did not smoke, and did not have other recent or concurrent infections. He had hypertension, hypothyroidism, depression, and a hyperactive bladder. Hence, he only had minor risk factors for infection. His postoperative shoulder infection was eradicated with surgical irrigation and debridement, and 6.5 weeks of primarily oral antibiotic treatment. We also review the literature on infections after any shoulder surgery where Schaalia or Actinomyces species were isolated.

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND

Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear.

METHODS

Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months).

RESULTS

The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3.

CONCLUSION

Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.

Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon

Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.

Management of the failed rotator cuff repair

Rotator cuff repair is increasingly being performed, and this is likely to continue to given the ageing population. An improvement in functional outcome can be achieved, with the best results noted in those tendons that go on to heal. Failure of repair following surgery can be associated with debilitating symptoms that are not always amenable to non-operative measures, so further surgery may be indicated for these patients. Several operative strategies have been described, but careful evaluation is required to determine the most suitable option. This review describes the decision-making strategies and treatment options available during management of a failed rotator cuff repair.

Infection complicating 794 primary and revision arthroscopies. Accuracy of actual prophylactic procedures against infection and results from a single orthopedic center in Poland

Introduction

Septic arthritis after arthroscopy (SAAA) is a devasting complication which reported frequency varies about 0.04%–5.7%. The aim of the study is to analyze frequency of SAAA at one orthopedic center, risk factors and accuracy of actual prophylactic measures.

Materials and Methods

A retrospective study (level of evidence: V) includes 794 (665 primary and 129 revision) “clean” arthroscopies performed in the years 2017–2018 with confirmed joint infection during 30 days after operation without the use of non-resorbable implants and up to 1 year after procedures with non-resorbable implants. Demographic and medical data about potential risk factors of SAAA were analyzed: patients age, sex, operated joint, type of procedure, primary or revision procedure, the use of drains, usage of non-absorbable implant, time of surgery, BMI, time lapse from index operation to diagnosis of SAAA, length of hospital stay, causative microorganisms. All operations were performed by eight different but experienced surgeons, in operation theatre with vertical laminar flow with the capacity of 50 air exchanges per hour. The perioperative antibiotic prophylaxis consisted of one preoperative dose 1 g cefazolin in simple arthroscopies, which was prolonged to 24 hours with 3 doses in cases of implantation of non-absorbable implant (55.8% of patients).

Results

From 794 cases 4 have been infected: 2 after knee arthrolysis, one after ACL reconstruction and one after rotator cuff repair. There were 2 early, with manifestation within 30 days, and 2 late-onset SAAA. Infections occurred in 0.5% of all arthroscopies and in 0.47% of knee arthroscopies alone. Patients age and time of surgery have not been found significantly different in infected and non-infected cases, whereas age and time of surgery have been significantly different in revision and non-revision cases.

Conclusions

Primarily aseptic arthroscopic procedures performed with respect to actual perioperative preventive measures have a low risk of postoperative septic arthritis. The risk increases with patients age and time of operation, but not significantly.

Arthroscopic rotator cuff repair without antibiotic prophylaxis does not increase the infection rate

PURPOSE

Rotator cuff repair is a commonly performed shoulder procedure. In the past 20 years, there has been a shift from mini-open towards arthroscopic repair, and many units exclusively use arthroscopic techniques for rotator cuff surgery. The aim of this study was to find out whether withholding antibiotics had any effect on the infection rate in patients undergoing arthroscopic rotator cuff repair.

METHODS

A retrospective analysis of 336 consecutive patients with an arthroscopic rotator cuff repair (RCR) and a minimum 2-year follow-up was performed. The control group received prophylactic antibiotics (controls) and the cases of interest did not receive perioperative antibiotics. A power analysis was performed according to literature regarding infection proportions. The primary outcome was an infection (superficial or deep) in the operated shoulder.

RESULTS

There were 336 patients who underwent a RCR. Two-hundred-and-twelve in the control group and 124 in the non-antibiotic group. Average ages were 57.3 ± 12.5 and 56.8 ± 13.2 years in each group, respectively. The follow-up times ranged from 24 to 76 months. Equipment used and surgical techniques were identical, only operating times were statistically different between the groups (control 77.2 ± 41.3 min versus no antibiotic cases 52.9 ± 16.7 min) (p = 0.000009). There was no recorded infection in either group.

CONCLUSION

Infection following arthroscopic surgery is uncommon. Small incisions, constant lavage with saline, minimal hardware insertion and short operating times all combine to minimise the risks. Current results point towards no detriment in withholding prophylactic antibiotics in low-risk patients undergoing routine rotator cuff repair surgery. Therefore, judicious use of prophylactic antibiotics in patients undergoing this procedure is advocated to prevent potential harm to those it is administered to.

LEVEL OF EVIDENCE

Level III.

Dynamics of skin microbiota in shoulder surgery infections

Post-surgical infections arise due to various contributing factors. Most important is the presence of potential pathogenic microorganisms in the skin complemented by the patient´s health status. Cutibacterium acnes is commonly present in the pilosebaceous glands and hair follicle funnels in human skin. After surgical intervention, these highly prevalent, slow-growing bacteria can be found in the deeper tissues and in proximity of implants. C. acnes is frequently implicated in post-surgical infections, often resulting in the need for revision surgery. This review summarizes the current understanding of microbial dynamics in shoulder surgical infections. In particular, we shed light on the contribution of C. acnes to post-surgical shoulder infections as well as their colonization and immune-modulatory potential. Despite being persistently found in post-surgical tissues, C. acnes is often underestimated as a causative organism due to its slow growth and the inefficient detection methods. We discuss the role of the skin environment constituted by microbial composition and host cellular status in influencing C. acnes recolonization potential. Future mapping of the individual skin microbiome in shoulder surgery patients using advanced molecular methods would be a useful approach for determining the risk of post-operative infections.

Benzoyl Peroxide is Cost-Effective for Preventing Infection by Cutibacterium Acnes in Arthroscopic Rotator Cuff Repair

Purpose

To evaluate the cost-effectiveness of benzoyl peroxide (BPO) in decreasing postoperative infections through a mathematical model in the setting of arthroscopic rotator cuff repair (RCR).

Methods

A break-even equation compared the costs associated with perioperative BPO use and postoperative infection following an arthroscopic RCR. The postoperative infection rate used for calculations was 0.28%, a value established in current literature. The break-even analysis produced a new infection rate, which defined how much BPO is needed to reduce the known infection rate in order for its prophylactic use to be cost-effective. The institution’s business office assessed the minimum itemized costs associated with the standard-of-care treatment of postoperative RCR infection. Sensitivity analysis was conducted to demonstrate how variability in the costs of BPO, in infection rates and in the cost of infection treatment affected the absolute risk reduction (ARR) and number needed to treat (NNT).

Results

Financial review yielded a minimum institutional cost of treating a postoperative infection following arthroscopic RCR of $24,991.31. Using the break-even formula to calculate the ARR at which the overhead costs of BPO and the treatment of infection were equal, BPO was economically viable if it decreased infection rate by 0.000734% (NNT = 1,361.92). This value was low because of the order of magnitude of difference between the costs of infection prevention when compared to the costs of treating postoperative infections.

Conclusions

This break-even analysis model suggests that the use of preoperative BPO in the setting of arthroscopic RCR is cost-effective for prevention of infection with Cutibacterium acnes, given the high cost of treating the infection versus the low cost of the solution.

Clinical Relevance

The economic feasibility of preoperative use of BPO in the setting of arthroscopic RCR could alter the standard of care.

Electrospun polycaprolactone/hydroxyapatite/ZnO films as potential biomaterials for application in bone-tendon interface repair

The bone-tendon interface (BTI) is a graded structure consisting of bone, mineralized and nonmineralized fibrocartilage, and tendons. Due to the complexity of the BTI structure, BTI healing is particularly challenging. To achieve a better material for BTI healing, polycaprolactone (PCL)/hydroxyapatite (HA)/ZnO films were constructed by the electrospinning method; in addition, the relevant material characteristics were tested. After culturing MC3T-E1 cells, ATDC5 cells, mouse primary fibrochondrocytes, and mouse primary tenocytes on films, PCL-5%HA-1%ZnO films (HA and ZnO weight ratios of 5% and 1%, respectively) displayed superior cell compatibility and cell adhesion. PCL-5%HA-1%ZnO films also promoted osteogenesis, chondrogenesis, fibrocartilage formation, and tendon healing. The antibacterial characteristics of PCL-5%HA-1%ZnO films were also identified in this study. The PCL-5%HA-1%ZnO films have great application potential in the field of BTI repair.

Post-operative septic arthritis after arthroscopy: modern diagnostic and therapeutic concepts

PURPOSE

Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy.

METHODS

Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention.

RESULTS

A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis.

CONCLUSION

The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6-12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases.

LEVEL OF EVIDENCE

IV.

Complications Within 6 Months After Arthroscopic Rotator Cuff Repair: Registry-Based Evaluation According to a Core Event Set and Severity Grading

PURPOSE

To report complications after arthroscopic rotator cuff repairs (ARCRs) in a large patient cohort based on clinical application of a newly defined core event set (CES) and severity grading.

METHODS

Consecutive primary ARCRs documented in a local clinical registry between February 2010 and September 2016 were included. Clinicians documented adverse events (AEs) reported until the final, 6-month postoperative follow-up according to the CES. The CES is an organized list of relevant AEs sorted into 3 intraoperative event groups (device, osteochondral, and soft tissue) and 9 postoperative event groups (device, osteochondral, pain, rotator cuff, surgical-site infection, peripheral neurologic, vascular, superficial soft tissue, and deep soft tissue). Severity was determined using an adaptation of the Clavien-Dindo classification. Cumulative complication risks were calculated per event group and stratified by severity and rotator cuff tear extent.

RESULTS

A total of 1,661 repairs were documented in 1,594 patients (mean age, 57 years [standard deviation, 9 years]; 38% women); 21% involved partial tears. All events were recorded according to the CES. Intraoperative events occurred in 2.2% of repairs. We identified 329 postoperative events in 307 repairs (305 patients); 93% had 1 AE. The cumulative AE risk at 6 months was 18.5%; AE risks were 21.8% for partial tears, 15.8% for full-thickness single-tendon tears, 18.0% for tears with 2 ruptured tendons, and 25.6% for tears with 3 ruptured tendons. AE risks per event group were as follows: 9.4% for deep soft tissue, with shoulder stiffness (7.6%) being the most common event; 3.4% for persistent or worsening pain; 3.1% for rotator cuff defects; 1.7% for neurologic lesions; 0.8% for surgical-site infection; 0.7% for device; 0.4% for osteochondral; 0.2% for superficial soft tissue, and 0.1% for vascular. Most AEs had severity grades I (160 [49%]) and II (117 [36%]).

CONCLUSIONS

Comprehensive local AE documentation according to the CES and severity grading was possible and showed that about one-fifth of ARCRs were affected, mostly by one AE of low severity. Shoulder stiffness was the most frequent event.

LEVEL OF EVIDENCE

Level IV, case series.

Detection of Cutibacterium acnes in arthroscopic rotator cuff and bankart repair

BACKGROUND

We evaluated the detection rate for Cutibacterium acnes (C. acnes) in patients who underwent arthroscopic cuff repair and Bankart repair.

METHODS

Arthroscopic cuff repair was performed in 105 patients (R group) and arthroscopic Bankart repair was performed in 29 patients (B group). Skin swabs prior to antisepsis, intraoperative synovial swabs of the glenohumeral joint (immediately after incision and prior to wound closure), suture of suture anchor, and postoperative swabs from the tip of arthroscope were cultured. Evaluation criteria were compared between groups and included the presence or absence of diabetes mellitus, operation time, frequency of preoperative injections, deep infections, and detection rate of C. acnes in multiple regions of the body.

RESULTS

There were 14 patients (12.2%) in the R group and one patient in the B group (3.6%) with diabetes mellitus, and no significant difference was found between the two groups. The frequency of injections to the shoulder was significantly greater in the R group at 3.6 ± 4.2 times compared to the B group at 1.6 ± 2.0 times. There were no deep infections in either groups. The detection rate for C. acnes was significantly greater in the synovial swabs alone (skin swabs for R and B groups, 42.3% and 47.6%, respectively; synovial swabs, 10.4% and 1.8%; suture, 8.7% and 0%; tip of arthroscope, 4.3% and 0%).

CONCLUSIONS

A significantly greater number of C. acnes samples were detected from synovial swabs of cuff tears, suggesting that its presence may be due to preoperative injections to the shoulder.

Mid- to Long-Term Outcomes After Deep Infections After Arthroscopic Rotator Cuff Repair

Purpose

To review clinical and subjective outcomes in patients with deep infections after arthroscopic rotator cuff repair.

Methods

All patients in whom deep infections developed after arthroscopic rotator cuff repair at a single center between 2002 and 2016 were retrospectively reviewed. Demographic data, clinical and microbiological findings, and treatment were analyzed. Clinical and subjective outcomes included the Constant score, visual analog scale score for pain, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score.

Results

Thirty patients could be identified and included in the study. The most commonly isolated pathogens were Staphylococcus epidermidis (36.7%) and Cutibacterium acnes (30.0%). In 26 of 30 patients (86.7%), the infection was treated initially with an open surgical approach, whereas 4 patients (13.3%) underwent arthroscopic revision. A transosseous rotator cuff repair could be performed in 20.0% of patients. A single reoperation was sufficient in 80% of patients, whereas 13.3% required 2 revisions and 6.7% required 3. At the final follow-up of 8.3 years (range, 4-14 years), 26 patients (1 woman and 25 men) were available for outcome evaluation. Significant improvement from the initial surgical procedure to final follow-up was detected in the Constant score (25.7 vs 65.7, P < .001), visual analog scale score for pain (7.0 vs 1.7, P < .001), American Shoulder and Elbow Surgeons score (38.0 vs 76.7, P < .001), and Simple Shoulder Test score (4.0 vs 8.3, P < .001).

Conclusions

Patients with deep infections after arthroscopic rotator cuff repair showed moderate mid- to long-term outcomes.

Level of Evidence

Level IV, therapeutic case series.

Prevention of Cutibacterium acnes infection in arthroscopic shoulder surgery: a systematic review

BACKGROUND

Cutibacterium acnes is a gram-positive anaerobe that can lead to postoperative shoulder infections. The purpose of this study was to determine the incidence of C acnes infections following shoulder arthroscopy and evaluate the efficacy of perioperative antibiotic prophylaxis in the prevention of these infections.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that evaluated the prevalence and clinical indications of C acnes infections after various arthroscopic shoulder surgical procedures. Patients were assessed based on positive culture rates, the contraction of infection, and antibiotic regimens used to prevent infection.

RESULTS

A total of 9 studies (1 level I, 5 level II, 1 level III, and 2 level IV) met the inclusion criteria, including a total of 3758 patients with a mean age of 59.9 years (range, 17-87 years) at the time of surgery. The mean follow-up time was 1.6 months (range, 1.0-12.0 months). Overall, 37.3% of patients (173 of 464) had positive C acnes skin and/or joint culture results, and in 0.22% of patients (8 of 3586), a C acnes infection was diagnosed postoperatively. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery significantly reduced the positive culture rate from 41.6% to 9.6% (P < .001).

CONCLUSIONS

C acnes infections occur at a very low rate (0.22%) following shoulder arthroscopy. The application of a topical benzoyl peroxide antibiotic in the days leading up to surgery in combination with preoperative antibiotic prophylaxis significantly reduces the prevalence of C acnes in shoulder arthroscopy patients.

Successful Revision Arthroscopic Rotator Cuff Repair Is Possible in the Setting of Prior Deep Infection

Purpose

To report on clinical outcomes of revision arthroscopic rotator cuff (RC) repair in the setting of prior deep infection.

Methods

A retrospective review was conducted of a single surgeon’s experience treating patients with deep infection after RC repair. Pain by visual analog scale (VAS), American Shoulder Elbow Society (ASES), Simple Shoulder Test (SST), and Single Assessment Numeric Evaluation (SANE) scores, as well as active range of motion, were collected preoperatively and at final follow-up.

Results

Three patients age 54.0 ± 7.5 years, mean ± standard error of the mean) with mean follow-up of 62 months (range 24 to 83) were treated for deep infection after RC repair. Improvements were observed in all subjective and objective outcomes; VAS pain (5.0 ± 0.6 vs 0.3 ± 0.3, P = .005), ASES score (37.2 ± 4.0 vs 93.9 ± 6.1, P = .003), and active forward elevation (68.3° ± 28.5° vs 173.3° ± 6.7°, P = .06.) Excellent outcomes in SST (mean 11.3 ± 0.7) and SANE (95.0 ± 5.0) scores were also observed. No recurrent infections were noted at final follow-up.

Conclusion

Arthroscopic reconstruction of the RC is a feasible goal in the setting of prior deep infection. When a thorough arthroscopic debridement can be achieved, it is possible to address residual RC tears with either revision repair or allograft reconstruction with the possibility of excellent short-term clinical outcomes.

Level of Evidence

Level IV, retrospective case series

Little benefit of surgical anchor and suture removal and of antibiotic therapy beyond 6 weeks in infected rotator cuff repair

BACKGROUND

The purpose of this study was to investigate the benefit of surgical anchor and/or suture removal and prolonged antibiotic therapy in acute and chronic infections of rotator cuff repair (RCIs).

METHODS

A single-center cohort and case-control study (Cox regression) was performed. Outcome variables were remission of infection and postinfection reoperations due to failed tendon healing for mechanical causes. All analyses were performed with an emphasis on anchor and suture retention or removal.

RESULTS

We identified 54 primary RCIs (44 men; median age 54 years) that were surgically revised (10 by open débridement and 44 by arthroscopy). Twenty-eight (52%) were not intact on revision surgery (débridement) - 10 were partially and 18 totally re-ruptured. The median number of surgical revisions was 1 (range, 1-3), and the median duration of postsurgical antibiotic therapy was 75 days. After a minimal follow-up of 2 years, 8 infections (8/54, 15%) recurred. Twenty patients needed a revision surgery; in all of those 20 patients, intraoperative samples were negative for infection. By multivariate analysis, anchor removal at the first revision influenced neither remission (hazard ratio [HR] 0.9, 95% confidence interval [CI] 0.4-2.0) nor the need for later revision surgery due to mechanical sequelae (HR 0.6, 95% CI 0.1-1.4). The corresponding HRs for suture removal were 0.9 (95% CI 0.4-1.7) and 0.4 (95% CI 0.1-1.2). Likewise, the numbers of revision surgery (HR 0.5, 95% CI 0.2-1.3) and antibiotics beyond 6 weeks failed to influence remission (HR 1.1, 95% CI 0.4-3.1).

CONCLUSIONS

In our RCI cohort, the removal of anchors or sutures, repeated revision surgery, or an antibiotic therapy beyond 6 weeks failed to improve remission or to reduce sequelae.

Incidence of Cutibacterium acnes in arthroscopic Bankart repair for traumatic anterior shoulder instability

Background

We evaluated the detection rate of Cutibacterium acnes (C. acnes) for patients who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability.

Methods

Study subjects included 36 patients who underwent arthroscopic Bankart repair. Skin swabs prior to antisepsis, intraoperative synovial swabs of the glenohumeral joint (immediately after incision and prior to wound closure), and the suture of the suture anchor were cultured. Evaluation criteria included the detection rate of C. acnes in multiple regions of the body.

Results

Using a skin swab culture test, C. acnes was detected in 63 of 108 samples (58.3%). The bacterium was detected in 2 of 36 samples (5.5%) and 4 of 36 (11.1%) in the synovial swab culture of the glenohumeral joint immediately after surgical incision and immediately before wound closure, respectively. In the suture culture of the suture used in the arthroscopic Bankart repair, C. acnes was detected in 1 of 36 samples (2.8%).

Conclusions

C. acnes was detected in patients undergoing surgeries for shoulder instability. The relationship between C. acnes and the pathological condition of shoulder instability remains unknown.

Incidence of Propionibacterium acnes in arthroscopic rotator cuff repair

BACKGROUND

Recently, Propionibacterium acnes was reported to be involved in postsurgical outcomes. We investigated the detection rate of P. acnes and clinical features of P. acnes infection following arthroscopic rotator cuff repair.

METHODS

Samples were collected from skin swabs before preparation, swabs of the synovium, sutures, and swabs from the arthroscope tip. We evaluated age, sex, presence of diabetes mellitus, preoperative contracture, operation time, blood test, Japanese Orthopaedic Association (JOA) scores, cuff integrity, deep infection, and positive inoculation rate.

RESULTS

We studied 90 patients (59 men and 31 women). Mean age was 60.6 years. Cultures of P. acnes showed a 65.5% positive superficial colonization rate (78.0%, male; 41.9%, female). Among the synovium swabs, P. acnes was detected in 13.6% and 0% of patients positive and negative for skin colonization with P. acnes, respectively. Positive culture was not correlated with age, sex, presence of diabetes mellitus, preoperative contracture, blood test, JOA score, cuff integrity, deep infection, operation time, and blood test date.

CONCLUSIONS

P. acnes was detected at a higher rate in the skin of male patients. Patients with P. acnes detected on the skin showed higher rates of detection in the synovium. These findings suggest that the route of infection is via contamination.

LEVEL OF EVIDENCE

Diagnostic level III; Case-control study.

Repair of Lafosse I subscapularis lesions brings no benefit in anterosuperior rotator cuff reconstruction

PURPOSE

Optimal management of partial anterosuperior rotator cuff tears is unknown. Our aim was to compare clinical and subjective outcomes of supraspinatus (SSP) repair patients treated with or without repair of an associated superior subscapularis (SSC) partial tear.

METHODS

SSP repair patients with an associated partial (Lafosse I) tear of the superior SSC tendon were retrospectively examined. Baseline and operative data and the outcomes of shoulder range of motion (ROM), pain level, strength, Constant-Murley Score, complications at 6 months as well as patient-reported Oxford Shoulder Score, Subjective Shoulder Value, and satisfaction at 6- and 24-month post-surgery were compared between patients with and without a repaired SSC tear. Mixed models and propensity-score matching were used to adjust baseline group differences.

RESULTS

Of 75 eligible patients, 34 had an SSC repair and were younger with better baseline function. Non-repair surgeries were significantly shorter by 34 min (95% CI 23-45; p < 0.001). There were no group differences in the clinical and patient-rated outcome scores at both follow-ups (n.s.) as well as in pain, muscle strength in abduction, ROM, the 6-month complication risk (risk difference - 1.9%), and satisfaction with postoperative shoulder condition (n.s.).

CONCLUSION

We could not show a functional or subjective benefit of repairing cranial partial tears of the SSC tendon over debridement only in the setting of an SSP reconstruction with 24 months of follow-up. A longer operative duration is expected if a partial SSC tear repair is performed.

LEVEL OF EVIDENCE

III.

Orthopaedic Shoulder Surgery in the Ambulatory Surgical Center: Safety and Outcomes

PURPOSE

To determine whether the risk of adverse events and readmission after non-arthroplasty shoulder surgery is influenced by the outpatient setting of surgical care and to identify risk factors associated with these adverse events.

METHODS

The Humana Claims Database was queried for all patients undergoing arthroscopic shoulder surgery and related open procedures in the hospital-based outpatient department (HOPD) or ambulatory surgical center (ASC) setting, using the PearlDiver supercomputer. Arthroplasty procedures were excluded because they carry a risk profile different from that of other outpatient surgical procedures. Outcome variables included unanticipated admission after surgery, readmission, deep vein thrombosis, pulmonary embolism, and wound infection within 90 days of surgery. The ASC and HOPD cohorts were propensity score matched, and outcomes were compared between them. Finally, logistic regression models were created to identify risk factors associated with unplanned admission after surgery.

RESULTS

A total of 84,658 patients met the inclusion criteria for the study: 28,730 in the ASC cohort and 56,819 in the HOPD cohort. The rates of all queried outcomes were greater in the HOPD cohort and achieved statistical significance. Sex, region, race, insurance status, comorbidity burden, anesthesia type, and procedural type were included in the regression analysis of unplanned admission. Factors associated with unplanned admission included increasing Charlson Comorbidity Index (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.12-1.17; P < .001); HOPD service location (OR, 2.37; 95% CI, 2.18-2.58; P < .001); general anesthesia (OR, 1.34; 95% CI, 1.08-1.59; P = .008); male sex (OR, 2.58; 95% CI, 2.17-3.15; P = .007); and open surgery (OR, 2.35; 95% CI, 1.90-2.61; P < .001).

CONCLUSIONS

The lower rates of perioperative morbidity in the ASC cohort suggest that proper patient selection is taking place and lends reassurance to surgeons who are practicing or are considering practicing in an ASC. Patients to whom some or all the risk factors for unplanned admission apply (male sex, higher comorbidity burden, open surgery) may be more suitable for HOPDs because admission from an ASC can be difficult and potentially unsafe.

LEVEL OF EVIDENCE

Level III, comparative study.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair

Background:

Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.

Purpose:

To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.

Study Design:

Descriptive epidemiology study.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.

Results:

A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m². Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).

Conclusion:

Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.

Cutibacterium Acnes (Formerly Propionibacterium Acnes) Contamination of the Surgical Field During Shoulder Arthroscopy

PURPOSE

To evaluate the prevalence of Cutibacterium acnes in the shoulder region and to analyze changes in C acnes contamination during shoulder arthroscopy, as well as to investigate the influence of sex and type of arthroscopic surgery on those parameters.

METHODS

Forty-eight consecutive patients undergoing reconstructive or non-reconstructive shoulder arthroscopy, after hair removal with a medical clipper, routine antibiotic prophylaxis, and skin preparation with an alcohol-based skin disinfectant, were prospectively enrolled in this study. The shoulder was divided into 4 regions of interest (anterior, medial, posterior, and axilla). Skin swabs were taken from each region at 3 time points (preoperatively before and after skin preparation, and at the conclusion of surgery), cultured for 21 days, and analyzed for the prevalence of C acnes.

RESULTS

The rate of C acnes-positive skin cultures was significantly increased at the end of surgery compared with preoperatively before (44.3% vs 27.6%, P < .001) and after (44.3% vs 31.3%, P = .001) skin preparation. No reduction in C acnes was observed with preoperative skin preparation (27.6% vs 31.3%, P = .401). At the end of shoulder arthroscopy, 64.6% of patients showed at least 1 culture positive for C acnes. The C acnes prevalence was significantly higher in male patients (48.3%) than female patients (20.1%, P < .001), at all time points (P < .016), and in all regions of interest (P < .001) except the axilla. No differences in the prevalence of C acnes were found between non-reconstructive and reconstructive procedures.

CONCLUSIONS

Skin contamination with C acnes around the shoulder increased significantly from before and after skin preparation to the conclusion of surgery in patients undergoing shoulder arthroscopy despite perioperative preventive measures.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Imaging of Usual and Unusual Complication of Rotator Cuff Repair

Several complications may be encountered after rotator cuff (RC) repair. A thorough knowledge of surgical interventions, normal postoperative findings, and postoperative complications is crucial to provide a timely diagnosis, improving the clinical outcome of patients. Postoperative complications may involve RC, implanted device, osteochondral tissue, surgical-site infection, peripheral nerves, soft tissues, and vascular structures. In this review, we discuss the usual and unusual complications detectable after RC repair.

Failed rotator cuff repair

After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated with better outcomes. Failure of rotator cuff repair is perceived differently by the patient, by the surgeon, and in terms of social and occupational abilities. The work-up of failed cuff repair differs little from the standard work-up of cuff tears. Information must be obtained about the circumstances of the first repair procedure, a possible diagnostic inadequacy and/or technical error, and early or delayed trauma such as an aggressive rehabilitation programme. Most cuff retears do not require surgery, given their good clinical tolerance and stable outcomes over time. Repeat cuff repair, when indicated by pain and/or functional impairment, can improve pain and function. The quality of the tissues and time from initial to repeat surgery will influence the outcomes. The ideal candidate for repeat repair is a male, younger than 70 years of age, who is not seeking compensation, shows more than 90̊ of forwards elevation, and in whom the first repair consisted only in tendon suturing or reattachment. In addition to patient-related factors, the local conditions are of paramount importance in the decision to perform repeat surgery, notably repeat suturing. The most favourable scenario is a small retear with good-quality muscles and tendons and no osteoarthritis. When these criteria are not all present, several options deserve consideration as potentially capable of relieving the pain and, to a lesser extent, the functional impairments. They include the implantation of material (autograft, allograft, or substitute), a muscle transfer procedure, or reverse shoulder arthroplasty. However, the outcomes are poorer than when these options are used as the primary procedure. Prevention is the best treatment of cuff repair failure and involves careful patient selection and a routine analysis of the treatments that may be required by concomitant lesions. Biceps tenotomy should be considered on a case-by-case basis. Smoking cessation should be strongly encouraged and any metabolic disorders associated with repair failure should be brought under control.

The effect of deep shoulder infections on patient outcomes after arthroscopic rotator cuff repair: a retrospective comparative study

Introduction

The purpose of this study was to evaluate the effects of deep shoulder infections after RCR on patient outcomes.

Methods

A retrospective chart review was conducted involving all patients with deep shoulder infections after arthroscopic RCR (study group). Another group of patients who were matched with the study group by age, gender and rotator cuff tear size, and did not develop deep shoulder infections after arthroscopic RCR were randomly identified (control group). The two groups were compared in terms of time to start physiotherapy, shoulder function, and delay in return to work.

Results

There were 10 patients in each group. The mean time to start physiotherapy after surgery was 145.3 (SD=158.8) days for the study group and 40.0 (SD=13.7) days for the control group (p=.051). The average forward elevation of the operated shoulder was 133 (SD=33.4) degrees for the study group, and 172 (SD=12.0) degrees for the control group (p=0.003). The average time to return to work at preoperative level was 5.6 months for the study group and 3 months for the control group.

Conclusion

Deep shoulder infections after RCR significantly impedes time to start physiotherapy, shoulder function, and patients' ability to return to work.

Level of evidence

III b [retrospective comparative (case-control) study].

Are Prophylactic Intravenous Antibiotics Required in Routine Shoulder Arthroscopic Surgery? A Systematic Review of the Literature

Purpose  The purpose of this study was to find out from the literature the difference in infection rates between patients who did and patients who did not receive prophylactic antibiotics in arthroscopic shoulder surgery.

Methods  We conducted a comprehensive search of the literature using Medline Ovid for prospective studies that looked at infection as the primary outcome following shoulder arthroscopy. The articles were then assessed for study design, outcome, and relevance to the specific question as part of the critical appraisal.

Results  Eight partially relevant articles were obtained from the search, but there were no prospective studies comparing infection in patients who had prophylactic antibiotics versus those who did not in shoulder arthroscopy.

Conclusion  No compelling evidence exists on the role of prophylactic antibiotics in preventing infections in shoulder arthroscopy.

Level of Evidence  Level IV, systematic review of level IV studies.

Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population

BACKGROUND

Shoulder arthroscopy is well established as a highly effective and safe procedure for the treatment for several shoulder disorders and is associated with an exceedingly low risk of infectious complications. Few data exist regarding risk factors for infection after shoulder arthroscopy, as previous studies were not adequately powered to evaluate for infection.

PURPOSE

To determine patient-related risk factors for infection after shoulder arthroscopy by using a large insurance database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files from 2005 to 2014 for patients undergoing shoulder arthroscopy. Patients undergoing shoulder arthroscopy for a diagnosis of infection or with a history of prior infection were excluded. Postoperative infection within 90 days postoperatively was then assessed with International Classification of Diseases, Ninth Revision codes for a diagnosis of postoperative infection or septic shoulder arthritis or a procedure for these indications. A multivariate binomial logistic regression analysis was then utilized to evaluate the use of an intraoperative steroid injection, as well as numerous patient-related risk factors for postoperative infection. Adjusted odds ratios (ORs) and 95% CIs were calculated for each risk factor, with P < .05 considered statistically significant.

RESULTS

A total of 530,754 patients met all inclusion and exclusion criteria. There were 1409 infections within 90 days postoperatively (0.26%). Revision shoulder arthroscopy was the most significant risk factor for infection (OR, 3.25; 95% CI, 2.7-4.0; P < .0001). Intraoperative steroid injection was also an independent risk factor for postoperative infection (OR, 1.46; 95% CI, 1.2-1.9; P = .002). There were also numerous independent patient-related risk factors for infection, the most significant of which were chronic anemia (OR, 1.58; 95% CI, 1.4-1.8; P < .0001), malnutrition (OR, 1.42; 95% CI, 1.2-1.7; P = .001), male sex (OR, 2.71; 95% CI, 2.4-3.1; P < .0001), morbid obesity (OR, 1.41; 95% CI, 1.2-1.6; P < .0001), and depression (OR, 1.36; 95% CI, 1.2-1.5; P < .0001).

CONCLUSION

Intraoperative steroid injection was a significant independent risk factor for postoperative infection after shoulder arthroscopy. There were also numerous significant patient-related risk factors for postoperative infection, including revision surgery, obesity, male sex, chronic anemia, malnutrition, depression, and alcohol use, among others.

Targeted intervention of acute postoperative infection after rotator cuff repair results in good functional outcomes

PURPOSE

The primary goal of this retrospective review of a prospective database was to document the functional results after acute postoperative deep infection following rotator cuff repair in a single orthopaedic unit over a period of 5 years. Secondary goals were to document the effect of infection on healing of the cuff repair and to describe its incidence, diagnostic challenges, pathogens and management.

METHODS

Patients undergoing arthroscopic rotator cuff repair were prospectively registered from 2010 to 2014. Eleven out of 1072 repairs developed an acute postoperative infection. The patients were examined with an MRI scan, Constant-Murley (CM) score and the Western Ontario Rotator Cuff Index (WORC) at final follow-up (median of 22 months).

RESULTS

All 11 patients who developed acute postoperative deep infections were males. Median age was 56 years (range 41-68). All patients underwent arthroscopic debridement and biopsies were collected at a median of 26 days (range 14-50) after primary surgery. In ten patients, Propionibacterium acnes was cultured, six of these patients also had positive cultures for coagulase-negative staphylococci. In the remaining patient, only coagulase-negative staphylococcus was cultured. Five patients were treated with one arthroscopic debridement, five had two arthroscopic debridements and one required arthroscopic debridement four times before the infection was eradicated. Two patients had their implants removed due to loosening of the suture anchors. All patients were treated with parenteral antibiotics for 1-4 weeks, followed by oral treatment for 1-5 weeks. At median 22 months (range 11-28) follow-up the median CM score was 84 and median WORC index was 81%. Ten patients had a postoperative MRI scan after a median of 23 months (range 3-49), with eight presenting a healed cuff repair.

CONCLUSION

The findings of this study support the rapid, targeted intervention of acute postoperative infection after RC repair with immediate arthroscopic debridement, irrigation and biopsies for bacteriological diagnostics followed by parenteral antibiotics. Furthermore, repeated arthroscopic debridement and irrigation are recommended if signs of infection persist. Removal of the implant is rarely needed. Despite the postoperative acute infection, these patients presented good functional results at final follow-up.

LEVEL OF EVIDENCE

Level III.