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Bdeir M, Lerchl A, Hetjens S, Schilder A, Gravius S, Baumgärtner T, Darwich A. One- vs. Two-Stage Revision for Periprosthetic Shoulder Infections: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2024; 13:440. [PMID: 38786168 PMCID: PMC11117334 DOI: 10.3390/antibiotics13050440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/28/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Periprosthetic shoulder infection (PSI) remains a challenging complication after shoulder arthroplasty. Therapeutic options include one- or two-stage revision, irrigation and debridement, and resection arthroplasty. With our systematic review and meta-analysis, we aimed to compare one- and two-stage revisions for periprosthetic shoulder joint infections and determine the most appropriate therapeutic procedure. We performed an extensive literature search in PubMed, Ovid Medline, Cochrane Library, Web of Science, and CINAHL and filtered out all relevant studies. The meta-analysis was performed using the random-effects model, heterogeneity was analyzed using I2, and publication bias was assessed using the Egger's test. A total of 8 studies with one-stage revisions, 36 studies with two-stage revisions, and 12 studies with both one-stage and two-stage revisions were included. According to the random-effects model, the reinfection rate for the entirety of the studies was 12.3% (95% Cl: 9.6-15.3), with a low-to-moderate heterogeneity of I2 = 47.72%. The reinfection rate of the one-stage revisions was 10.9%, which was significantly lower than the reinfection rate of the two-stage revisions, which was 12.93% (p = 0.0062). The one-stage revision rate was significantly lower with 1.16 vs. 2.25 revisions in the two-stage revision group (p < 0.0001). The postoperative functional outcome in one-stage-revised patients was comparable but not statistically significant (p = 0.1523). In one- and two-stage revisions, most infections were caused by Cutibacterium acnes. In summary, our systematic review and meta-analysis show the superiority of single-stage revision regarding reinfection and revision rates in periprosthetic shoulder joint infection.
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Affiliation(s)
- Mohamad Bdeir
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; (A.L.); (A.S.); (S.G.); (T.B.); (A.D.)
| | - Aimée Lerchl
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; (A.L.); (A.S.); (S.G.); (T.B.); (A.D.)
| | - Svetlana Hetjens
- Institute of Medical Statistics and Biomathematics, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany;
| | - Andreas Schilder
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; (A.L.); (A.S.); (S.G.); (T.B.); (A.D.)
| | - Sascha Gravius
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; (A.L.); (A.S.); (S.G.); (T.B.); (A.D.)
| | - Tobias Baumgärtner
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; (A.L.); (A.S.); (S.G.); (T.B.); (A.D.)
| | - Ali Darwich
- Department of Orthopaedic and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167 Mannheim, Germany; (A.L.); (A.S.); (S.G.); (T.B.); (A.D.)
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Hollier-Larousse B, Hardy A, El Sayed F, Roux AL, Ménigaux C, Bauer T, Werthel JD. Single-stage revision for total shoulder arthroplasty infection. Results at a minimum 2 years follow-up. Orthop Traumatol Surg Res 2024:103881. [PMID: 38582223 DOI: 10.1016/j.otsr.2024.103881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 10/10/2023] [Accepted: 12/22/2023] [Indexed: 04/08/2024]
Abstract
INTRODUCTION Similar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment. HYPOTHESIS Single-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results. METHODS This single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported. RESULTS The average follow-up was 40.4 months (24-102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42-57±21.83). DISCUSSION Single-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
| | - Alexandre Hardy
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
| | - Faten El Sayed
- Infection et Inflammation, université Paris-Saclay, UVSQ, Inserm, Montigny-Le-Bretonneux, France; Microbiology Department, GHU Paris-Saclay, hôpital Ambroise-Paré, AP-HP, Boulogne Billancourt, France
| | - Anne-Laure Roux
- Infection et Inflammation, université Paris-Saclay, UVSQ, Inserm, Montigny-Le-Bretonneux, France
| | - Christophe Ménigaux
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
| | - Thomas Bauer
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
| | - Jean-David Werthel
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
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Rodrigues-Lopes R, Silva F, Torres J. Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis. J Shoulder Elbow Surg 2024; 33:722-737. [PMID: 37839627 DOI: 10.1016/j.jse.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/29/2023] [Accepted: 09/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty. METHODS Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model. RESULTS After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03). CONCLUSIONS This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.
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Affiliation(s)
| | - Fábia Silva
- Department of Orthopaedics and Traumatology, University Hospital Center of São João, Porto, Portugal
| | - João Torres
- Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Orthopaedics and Traumatology, University Hospital Center of São João, Porto, Portugal
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Barret H, Boileau P. Can Pyrocarbon be used as a functional spacer for the treatment of recalcitrant shoulder infections? JSES Int 2024; 8:167-175. [PMID: 38312269 PMCID: PMC10837719 DOI: 10.1016/j.jseint.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background The most common treatment approach in periprosthetic joint infection (PJI) and chronic shoulder joint infection (SJI) is a two-stage revision involving interval placement of an antibiotic cement spacer or a resection arthroplasty. Knowing that Pyrocarbon has a smooth surface that prevents pathogen adhesion, the question arises whether it could be used as a temporary or permanent functional spacer? Purpose The primary objective of the present study was to assess the rate of infection eradication after temporary or definitive implantation of Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in patients with recalcitrant PJI or SJI. Our secondary objective was to assess mid-term clinical and radiographic outcomes. Methods Fifteen patients (mean age: 52 ± 19 years) with chronic shoulder infection underwent, after joint débridement, implantation of PISA (InSpyre; Tornier-Stryker, Kalamazoo, MI, USA) with tailored perioperative antibiotics. In 7 cases, PJI occurred after hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 2), hemireverse (n = 2), and resurfacing arthroplasty (n = 1). In 8 cases, SJI occurred in the context of failed surgery after fracture sequelae (n = 4), instability (n = 2), and cuff arthropathy (n = 2). Preoperatively, patients had a mean of 3 previous failed surgeries before PISA implantation. Patients were evaluated with clinical, laboratory, and radiographic assessment at a minimum of 2 years after surgery. Results At a mean follow-up of 55 ± 18 months, no patient experienced reinfection after temporary (3 cases) or definitive (12 cases) PISA implantation. The adjusted Constant score increased from 33% ± 20 preoperatively to 65% ± 28 at last follow-up and SSV from 22% ± 19 to 63% ± 23 (P < .001). Active forward elevation increased from 27° ± 19 to 113° ± 30, external rotation from 7° ± 21 to 25° ± 25, and internal rotation level 3 ± 2 to level 5 ± 2 points (P < . 001). On final radiographs of definitive PISA, complete humeral densification, or a neocortex, formed around the implant in 64% (7/11). Conclusion Our data suggest that, after washout, débridement and tailored antibiotics, PISA can be used as a temporary or definitive functional spacer for the treatment of recalcitrant shoulder infections and presents the following advantages: (1) PISA does not seem to be a risk for recurrent infection thanks to the antibacterial property of Pyrocarbon; (2) PISA can be used as a temporary or a definitive spacer without causing bone erosion, thanks to the low modulus of elasticity of Pyrocarbon; (3) PISA can be used as a salvage procedure in case of complete glenoid or humeral destruction, thanks to the sphericity of the implant needing no implant anchorage.
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Affiliation(s)
- Hugo Barret
- ICR-Institut de Chirurgie Réparatrice, Groupe Kantys, Nice, France
| | - Pascal Boileau
- ICR-Institut de Chirurgie Réparatrice, Groupe Kantys, Nice, France
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Jacquot A, Samargandi R, Peduzzi L, Mole D, Berhouet J. Infected Shoulder Arthroplasty in Patients Younger than 60 Years: Results of a Multicenter Study. Microorganisms 2023; 11:2770. [PMID: 38004781 PMCID: PMC10673608 DOI: 10.3390/microorganisms11112770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Background: Periprosthetic joint infection (PJI) after shoulder arthroplasty remains a significant complication. This study aimed to explore the epidemiology and risk factors of shoulder PJI in patients aged 60 and younger, analyze treatment options, and evaluate outcomes after 1-year follow-up. Methods: In this retrospective multicentric observational study, data from 1404 shoulders in patients under 60 who underwent primary shoulder arthroplasty were analyzed. Patients with PJI and at least 1-year follow-up after infection treatment were included. Results: The study identified 55 shoulders with PJI, resulting in a 2.35% infection rate after primary shoulder arthroplasty in the young population. Male gender and reverse shoulder arthroplasty were risk factors for infection, while previous surgeries did not significantly contribute. The most common causative agents were Cutibacterium acnes and Staphylococcus epidermidis. Open washout had a 52.9% success rate for acute infections, while one-stage and two-stage revisions achieved infection control rates of 91.3% and 85.7%, respectively. Resection arthroplasty had an 81.8% success rate but poorer functional outcomes. Conclusions: PJI following shoulder arthroplasty in young patients is a significant concern. Preoperative planning should be carefully considered to minimize infection risk. Treatment options such as open washout and one-stage and two-stage revisions offer effective infection control and improved functional outcomes. Resection arthroplasty should be reserved for complex cases where reimplantation is not a viable option.
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Affiliation(s)
- Adrien Jacquot
- Centre for Chirurgie des Articulations et du Sport (ARTICS), 24 rue du XXIème Régiment d’Aviation, 54000 Nancy, France; (A.J.); (D.M.)
| | - Ramy Samargandi
- Service de Chirurgie Orthopédique et Traumatologique, CHRU Trousseau, Faculté de Médecine de Tours, Université de Tours, 1C Avenue de la République, 37170 Chambray-les-Tours, France;
- Department of Orthopedic Surgery, Faculty of Medicine, University of Jeddah, Jeddah 23218, Saudi Arabia
| | - Lisa Peduzzi
- Service de Chirurgie Orthopédique, Centre Hospitalo-Universitaire Nancy-Emile Galle, 49, rue Hermite CS 5211, 54052 Nancy, France;
| | - Daniel Mole
- Centre for Chirurgie des Articulations et du Sport (ARTICS), 24 rue du XXIème Régiment d’Aviation, 54000 Nancy, France; (A.J.); (D.M.)
| | - Julien Berhouet
- Service de Chirurgie Orthopédique et Traumatologique, CHRU Trousseau, Faculté de Médecine de Tours, Université de Tours, 1C Avenue de la République, 37170 Chambray-les-Tours, France;
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Tonotsuka H, Sugiyama H, Funasaki H, Yoshida M, Kato S, Tanaka K, Saito M. Chronological changes in the rate of surgical field contamination in the shoulder joint. J Orthop Sci 2023:S0949-2658(23)00267-1. [PMID: 37838595 DOI: 10.1016/j.jos.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/04/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND In shoulder surgery, low-virulence bacteria such as Cutibacterium acnes and coagulase-negative staphylococci can cause postoperative infection. However, the degree of sterility during surgery after disinfection is not known, and the efficacy of double skin preparation for such bacteria is unclear. This study aimed to evaluate chronological changes in the surgical field contamination rate in the shoulder joint and to compare single and double skin preparation. METHODS In total, 126 shoulders in 121 patients undergoing shoulder surgery (64 men, 62 women; mean age 64 years) were enrolled. Patients were divided into two groups: single skin preparation, where the site was painted with 10% povidone iodine, and double skin preparation, where the site was treated with 1% chlorhexidine gluconate/83% isopropyl alcohol and painted 10% povidone iodine. Swab samples from the axillary and proximal areas in the surgical field were collected chronologically before starting surgery and at 30, 60, and 120 min after starting surgery (MAS). The contamination rate of each sample was compared and detected species were evaluated. RESULTS The contamination rate for the axillary area was 48.4%, 85.9%, 95.3%, and 97.1% in the single-preparation group and 32.3%, 72.6%, 87.1%, and 91.2% in the double-preparation group before starting surgery and 30, 60, and 120 MAS, respectively, and that the proximal area was 12.5%, 26.6%, 29.7%, and 35.3% in the single-preparation group and 16.1%, 19.4%, 27.4%, and 38.2% in the double-preparation group, respectively. Significant differences were not seen between the groups by area or time point. Most detected species were Cutibacterium acnes and coagulase-negative staphylococci. CONCLUSIONS The incidence of surgical field contamination in shoulder joint was high from immediately after starting surgery. In the axillary area, the contamination rates exceeded 70% from 30 MAS in both groups. Measures against infection should be instituted considering these findings when performing shoulder surgery.
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Affiliation(s)
- Hisahiro Tonotsuka
- Department of Orthopaedic Surgery, Kanagawa Rehabilitation Hospital, Japan; Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan.
| | - Hajime Sugiyama
- Department of Orthopaedic Surgery, Kanagawa Rehabilitation Hospital, Japan; Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan
| | - Hiroki Funasaki
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan
| | - Mamoru Yoshida
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan
| | - Soki Kato
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan
| | - Kota Tanaka
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan
| | - Mitsuru Saito
- Department of Orthopaedic Surgery, The Jikei University School of Medicine, Japan
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Fiore M, Ferra L, Giannini C, Sambri A, Filippini M, Tedeschi S, Zamparini E, Viale P, De Paolis M, Guerra E. Management of periprosthetic joint infection of shoulder arthroplasty: Single-stage versus two-stage protocols. A systematic review and meta-analysis of the literature. Shoulder Elbow 2023; 15:25-40. [PMID: 37692869 PMCID: PMC10492529 DOI: 10.1177/17585732221116839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 09/12/2023]
Abstract
Background The treatment of shoulder prosthetic joint infections (PJIs) requiring removal of the prosthesis is not well defined. This article aims to systematically review and compare the results of the literature in single-stage and two-stage protocols in the treatment of shoulder PJI. Methods An in-depth search on PubMed/Scopus/Web of Science databases and cross-referencing search was carried out concerning the articles reporting detailed data on the topic. Results A total of 486 shoulder PJIs were included: 137 treated with single-stage and 349 with two-stage procedure. A similar distribution between early and not-early infections (19.1% vs 80.9%) was found between the two groups. The overall rate of success in terms of PJI eradication was significantly higher in the single-stage group (95.6% vs 85.7%, p < 0.001). The non-infection-related complications rate was 13.8% in the single-stage group and 37.6% in the two-stage group (p < 0.001), the non-infection-related revision rate was 8% and 18.9%, respectively (p = 0.005). Discussion The single-phase protocol showed a higher success rate in eradicating the infection and a lower complication rate. However, the low number of patients included, the low quality of the articles, the lack of data on clinical severity and bacteriological virulence suggest caution in conclusions.
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Affiliation(s)
- Michele Fiore
- Alma Mater Studiorum – University of Bologna, Bologna, Italy
| | - Lorenzo Ferra
- Alma Mater Studiorum – University of Bologna, Bologna, Italy
| | | | - Andrea Sambri
- Alma Mater Studiorum – University of Bologna, Bologna, Italy
- Orthopedics and Traumatology Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Sara Tedeschi
- Infectious Disease Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Eleonora Zamparini
- Infectious Disease Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pierluigi Viale
- Infectious Disease Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Massimiliano De Paolis
- Orthopedics and Traumatology Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Guerra
- Shoulder & Elbow Surgery Department, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Changes in microbiological spectrum and antibiotic susceptibility in two-stage exchange for periprosthetic shoulder infections. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04635-7. [PMID: 36175674 DOI: 10.1007/s00402-022-04635-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/18/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Periprosthetic joint infections (PJI) are a major concern in shoulder arthroplasty, which in some cases require two-stage exchange. While it was shown that low-virulence bacteria are the most isolated pathogens in shoulder PJI, little is known about changes in microbiological spectrum and resistance patterns during two-stage revision. METHODS This retrospective study included all patients (n = 25) who received a two-stage revision from January 2011 to December 2020 for shoulder PJI in one institution. Microbiological spectrum, antimicrobial resistance patterns, and re-revision rates of culture positive first- and second-stage procedures were analyzed. The mean follow-up time was 29.7 months (range 8; 115 months). At final follow-up, subjective shoulder value (SSV) and visual analog scale (VAS) score for pain and satisfaction with the surgery were assessed. RESULTS In 25 patients, a total of 54 2-stage exchange procedures were performed and positive cultures were obtained in 36 of these surgeries (66.7%). A total of 7 out of 25 patients (28.0%) showed a positive microbiological culture at first and second stages. In those patients, the mean time between first and second stages was 30.9 weeks (range 6; 70). Three out of those seven patients (42.9%) had a polymicrobial spectrum with one microorganism persistent at stage two, including Cutibacterium acnes (n = 1) and Staphylococcus epidermidis (MRSE) (n = 2). In all these cases, antimicrobial resistance patterns changed. All cultures with monomicrobial spectrum (n = 4) at first stage showed a changed spectrum. Patients with positive first- and second-stage revisions showed a mean SSV of 49.3% ± 23.5 versus 52.9% ± 29.5 in single positive patients (p = 0.76). Re-revision was performed in five cases, two of those in patients with positive first- and second-stage cultures. CONCLUSION There is a high rate of changes in microbiological spectrum and resistance patterns between culture positive first- and second-stage procedures as well as subsequent re-revisions. Intraoperative samples during reimplantation should be taken and resistance reconsidered in case of re-revision.
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Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis. J Shoulder Elbow Surg 2022; 31:668-679. [PMID: 34774777 DOI: 10.1016/j.jse.2021.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/29/2021] [Accepted: 10/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs. METHODS A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of .05 was set as significant. RESULTS The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001). CONCLUSION When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.
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Lemmens L, Geelen H, Depypere M, De Munter P, Verhaegen F, Zimmerli W, Nijs S, Debeer P, Metsemakers WJ. Management of periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2514-2522. [PMID: 33895302 DOI: 10.1016/j.jse.2021.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic shoulder infection (PSI) remains a devastating complication after reverse shoulder arthroplasty (RSA). Currently, scientific data related to the management of PSI are limited, and the optimal strategy and related clinical outcomes remain unclear. Guidelines from the Infectious Diseases Society of America for the management of periprosthetic joint infection are mainly based on data from patients after hip and knee arthroplasty. The aim of this study was to evaluate whether these guidelines are also valid for patients with PSI after RSA. In addition, the functional outcome according to the surgical intervention was assessed. METHODS An RSA database was retrospectively reviewed to identify infections after primary and revision RSAs, diagnosed between 2004 and 2018. Data collected included age, sex, indication for RSA, causative pathogen, surgical and antimicrobial treatment, functional outcome, and recurrence. RESULTS Thirty-six patients with a PSI were identified. Surgical treatment was subdivided into débridement and implant retention (DAIR) (n = 6, 17%); 1-stage revision (n = 1, 3%); 2-stage revision (n = 16, 44%); multiple-stage revision (>2 stages) (n = 7, 19%); definitive spacer implantation (n = 2, 6%); and resection arthroplasty (n = 4, 11%). The most common causative pathogens were Staphylococcus epidermidis (n = 11, 31%) and Cutibacterium acnes (n = 9, 25%). Recurrence was diagnosed in 4 patients (11%), all of whom were initially treated with a DAIR approach. The median follow-up period was 36 months (range, 24-132 months). CONCLUSION PSI is typically caused by low-virulence pathogens, which often are diagnosed with a delay, resulting in chronic infection at the time of surgery. Our results indicate that treatment of patients with chronic PSI with DAIR has a high recurrence rate. In addition, implant exchange (ie, 1- and 2-stage exchange) does not compromise the functional result as compared with implant retention. Thus, patients with chronic PSI should be treated with implant exchange. Future research should further clarify which surgical strategy (ie, 1-stage vs. 2-stage exchange) has a better outcome overall.
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Affiliation(s)
- Laura Lemmens
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Hans Geelen
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Clinical Biology, University Hospitals Leuven, Leuven, Belgium
| | - Paul De Munter
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Filip Verhaegen
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Werner Zimmerli
- Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital Baselland, Liestal, Switzerland
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Philippe Debeer
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium.
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Bordure P, Marc C, Hubert L, Rony L. Does the retention of osseointegrated prosthetic implants during the surgical management of chronic infections following reverse total shoulder arthroplasty (RTSA) influence functional outcomes without impacting the efficacy of the infection treatment? Orthop Traumatol Surg Res 2021; 107:102906. [PMID: 33789197 DOI: 10.1016/j.otsr.2021.102906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The gold standard (GS) for treating chronic infections following reverse total shoulder arthroplasty (RTSA) is a complete exchange of the prosthesis carried out in one or two stages. This surgical procedure, which may damage the bone stock, can result in poor functional outcomes due to intraoperative complications. The purpose of this study was to compare the GS to a surgical technique that retained osseointegrated implants: the partial one-stage exchange. HYPOTHESIS Partial one-stage exchange was effective in treating chronic infections after RTSA (no recurrent infection) and resulted in better functional outcomes than the GS. MATERIALS AND METHODS This retrospective single-center study included 18 patients with chronic infection after a primary RTSA. Two treatments were compared in a non-randomized fashion. The first included 11 patients who underwent a partial one-stage exchange with implant retention in case of macroscopic osseointegration. The second included seven patients who were treated with the GS: six patients with a complete one-stage exchange and one patient with a two-stage surgical approach. The absence of recurrent infection and functional outcomes were assessed after a minimum of two years. RESULTS There were no statistically significant differences in treatment efficacy between the two strategies: 91% vs. 100%, respectively. The partial one-stage exchange resulted in a significantly improved shoulder function compared to the GS with postoperative Constant scores of 55±14.58 vs. 44±14.45, respectively (p=.03). In the partial one-stage exchange group, there was a significantly improved shoulder function with a preoperative Constant score of 40 [28-55]±9.04 preoperatively vs. 55 [25-75]±14.58 postoperatively (p=.01). The GS treatment did not significantly improve the postoperative function (p=.09). DISCUSSION Partial one-stage exchange does not compromise treatment efficacy of chronic infections after RTSA. This technique resulted in better shoulder function than a conventional GS-type management. A study with greater statistical power is required. LEVEL OF EVIDENCE III; clinical series, retrospective, single-center.
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Affiliation(s)
- Pierre Bordure
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France.
| | - Clément Marc
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France
| | - Laurent Hubert
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France
| | - Louis Rony
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France
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12
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Kim SC, Kim IS, Jang MC, Yoo JC. Complications of reverse shoulder arthroplasty: a concise review. Clin Shoulder Elb 2021; 24:42-52. [PMID: 33652512 PMCID: PMC7943379 DOI: 10.5397/cise.2021.00066] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/14/2021] [Indexed: 11/25/2022] Open
Abstract
Reverse shoulder arthroplasty is an ideal treatment for glenohumeral dysfunction due to cuff tear arthropathy. As the number of patients treated with reverse shoulder arthroplasty is increasing, the incidence of complications after this procedure also is increasing. The rate of complications in reverse shoulder arthroplasty was reported to be 15%-24%. Recently, the following complications have been reported in order of frequency: periprosthetic infection, dislocation, periprosthetic fracture, neurologic injury, scapular notching, acromion or scapular spine fracture, and aseptic loosening of prosthesis. However, the overall complication rate has varied across studies because of different prosthesis used, improvement of implant and surgical skills, and different definitions of complications. Some authors included complications that affect the clinical outcomes of the surgery, while others reported minor complications that do not affect the clinical outcomes such as minor reversible neurologic deficit or minimal scapular notching. This review article summarizes the processes related to diagnosis and treatment of complications after reverse shoulder arthroplasty with the aim of helping clinicians reduce complications and perform appropriate procedures if/when complications occur.
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Affiliation(s)
- Su Cheol Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Il Su Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Chang Jang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Chul Yoo
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Clinical Outcome of Two-Stage Revision after Periprosthetic Shoulder Infection. J Clin Med 2021; 10:jcm10020218. [PMID: 33435442 PMCID: PMC7826686 DOI: 10.3390/jcm10020218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Periprosthetic shoulder infections are devastating complications after shoulder arthroplasty. A potential treatment concept is a two-stage prosthesis exchange. Data are sparse in terms of clinical outcome, including infection-free survival and patient satisfaction after this procedure. In the present study, we investigated recurrence of infection, revision-free survivorship and clinical outcome following two-stage revision due to periprosthetic shoulder infection. Furthermore, reasons for poor outcome were analyzed. Methods: Sixteen patients undergoing two-stage revision after shoulder joint infection were retrospectively identified. Recurrence of infection was analyzed by Kaplan–Meier survival curve. Clinical outcome was quantified with subjective shoulder value (SSV), “quick” Disabilities of the Arm, Shoulder and Hand (qDASH) and Rowe score. Range of motion (ROM) was measured pre- and postoperatively. Postoperative scores and ROM were compared in a subgroup analysis according to different reimplanted prosthesis types. Results: The reinfection-free implant survival was 81% after one year and at final follow-up (FU; mean of 33.2 months). The overall revision-free survival amounted to 56% after one year and at final FU. Patients who received reverse shoulder arthroplasty (RSA) as part of reimplantation had less disability and long-term complications. This group demonstrated better subjective stability and function compared to patients revised to megaprostheses or large-head hemiarthroplasties. Conclusions: Two-stage revision following periprosthetic joint infection of the shoulder allows appropriate infection control in the majority of patients. However, the overall complications and revision rates due to mechanical failure or reinfection are high. Reimplantation of RSA seem superior to alternative prosthesis models in terms of function and patient satisfaction. Therefore, bone-saving surgery and reconstruction of the glenoid may increase the likelihood of reimplantation of RSA and potentially improve outcome in the case of infection-related two-stage revision of the shoulder.
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14
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Brown M, Eseonu K, Rudge W, Warren S, Majed A, Bayley I, Higgs D, Falworth M. The management of infected shoulder arthroplasty by two-stage revision. Shoulder Elbow 2020; 12:70-80. [PMID: 33343718 PMCID: PMC7726183 DOI: 10.1177/1758573219841057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 12/24/2018] [Accepted: 03/11/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND There remains no gold standard management for deep shoulder periprosthetic joint infection (PJI). This case series aims to present our experience of two-stage revision arthroplasty, including eradication of infection and reoperation rates. METHODS We retrospectively reviewed patients undergoing revision arthroplasty for shoulder PJI between 2006 and 2015. Cases were confirmed using Musculoskeletal Infection Society (MSIS) and American Academy of Orthopaedic Surgeons (AAOS) guidelines. TSA removal, debridement and irrigation preceded antibiotic-loaded cement spacer insertion and a minimum of six weeks intravenous antibiotics. Reimplantation was performed as a second stage following a negative aspirate. RESULTS Twenty-eight patients underwent a first stage procedure (mean age 69 years; 16 male, 12 female). Propionibacterium acnes, Methicillin-sensitive Staphylococcus aureus, Coagulase-negative Staphylococcus and Staphylococcus epidermidis were the commonest microorganisms cultured. Five cases had mixed growths and six cases provided no growth. Three patients did not proceed to a second stage. Twenty-five patients underwent reimplantation (mean interval 6.7 months), with 80% remaining infection-free (mean follow-up 38.3 months). DISCUSSION Managing complex and late presentation shoulder PJI with two-stage revision is associated with high rates of infection eradication (80%). In the absence of a management consensus, our experience supports two-stage revision arthroplasty for eradicating infection in this complex patient group.
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Affiliation(s)
- Matthew Brown
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK,Matthew Brown, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.
| | - Kelechi Eseonu
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Will Rudge
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Simon Warren
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK,Department of Microbiology, Royal Free Hospital, Hampstead, London, UK,Department of Microbiology, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Addie Majed
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Ian Bayley
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Deborah Higgs
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mark Falworth
- Department of Shoulder & Elbow Surgery, Royal National Orthopaedic Hospital, Stanmore, UK
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15
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Belay ES, Danilkowicz R, Bullock G, Wall K, Garrigues GE. Single-stage versus two-stage revision for shoulder periprosthetic joint infection: a systematic review and meta-analysis. J Shoulder Elbow Surg 2020; 29:2476-2486. [PMID: 32565412 DOI: 10.1016/j.jse.2020.05.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder periprosthetic joint infection (PJI) is a significant complication after arthroplasty with high morbidity. An evidence-based algorithm for the treatment of shoulder PJI is lacking in current practice. The purpose of this systematic review and meta-analysis was to understand and compare the role of single- and 2-stage shoulder arthroplasty revision for PJI. METHODS A comprehensive literature review was performed to identify all studies related to shoulder arthroplasty for PJI in PubMed, Scopus, and EMBASE. Inclusion criteria for this systematic review were studies that reported on single- or 2-stage revision, with infection eradication and a minimum follow-up of 12 months and a minimum of 5 patients for analysis. A random-effects meta-analysis was performed, and heterogeneity was assessed with Cochrane Q and I2. RESULTS A total of 13 studies reporting on single-stage revision and 30 studies reporting on 2-stage revision were included in final analysis. The majority of positive cultures from single-stage revision for PJI resulted in Cutibacterium acnes with 113 of 232 (48.7%) reported cases compared with 190 of 566 (33.7%) reported cases for 2-stage revision. However, there was a lower percentage of methicillin-resistant Staphylococcus aureus positive cultures, with 2.5% for single-stage compared with 9.7% for 2-stage revision. The overall pooled random-effect reinfection incidence was 0.05 (95% confidence interval: 0.02-0.08), with moderate heterogeneity (I2 = 34%, P = .02). The reinfection rate was 6.3% for single-stage and 10.1% for 2-stage revision, but this was not significant (Q = 0.9 and P = .40). CONCLUSION Based on a systematic review with meta-analysis, single-stage revision for shoulder PJI is an effective treatment. Indeed, our analysis showed single-stage to be more effective than 2-stage, but this is likely confounded by a treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with 2-stage in the published literature. This implies that shoulder surgeons treating PJI can be reassured of a low recurrence rate (6.3%) when using single-stage treatment for C acnes or other sensitive, low-virulence organisms.
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Affiliation(s)
- Elshaday S Belay
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Richard Danilkowicz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Garrett Bullock
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Kevin Wall
- Department of Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
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16
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Arenas-Miquelez A, Arbeloa-Gutierrez L, Familiari F, de Pablos J. Salvage Procedures of the Shoulder: Glenohumeral Arthrodesis and Resection Arthroplasty. Indian J Orthop 2020; 55:27-37. [PMID: 34122752 PMCID: PMC8149774 DOI: 10.1007/s43465-020-00279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND With the advances of modern medicine and technology there has been an increase of indications of shoulder reconstruction techniques and shoulder arthroplasty. Consequently, the number of complications and failures have increased in parallel. Not negligible number of cases are driven to an end-stage situation where salvage procedures, such as glenohumeral arthrodesis (GHA) and shoulder resection arthroplasty (SRA), are the only remaining solution. METHODS The current literature on glenohumeral arthrodesis and shoulder resection arthroplasty was reviewed to determine the indications, surgical technique, complications and outcomes. The electronic search was conducted using the MEDLINE and EMBASE databases and the strategies used were "glenohumeral arthrodesis", "glenohumeral fusion", "shoulder arthrodesis" and "shoulder resection arthroplasty". RESULTS Indications for glenohumeral arthrodesis (GHA) include brachial plexus injury, tumor resections, chronic infection, failed prosthetic arthroplasty, persistent refractory instability or pseudoparalysis of the shoulder with combined irreparable rotator cuff and deltoid injuries. GHA provides good stability, pain resolution, although function is markedly compromised and relying mostly on scapulothoracic joint. The gold standard surgical technique continues to be open shoulder arthrodesis and still has a high complication rate. Shoulder resection arthroplasty (SRA) indications have evolved through the years, being nowadays a salvage procedure for recalcitrant infection of shoulder arthroplasty the main indication. Shoulder function after SRA is often severely compromised, but has a high infection rate resolution. SRA is not technically demanding and complications are rare, being the persistence of infection the most common one. DISCUSSION Despite GHA and SRA having negative connotations, in selected patients, these procedures can diminish pain, resolve persistent infections and provide an acceptable shoulder function. Hence, they should be retained as part of the treatment algorithm for complex shoulder pathology.
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Affiliation(s)
- Antonio Arenas-Miquelez
- grid.1004.50000 0001 2158 5405Shoulder and Elbow, Orthopaedics, Macquarie University Hospital, Suite 303, 2 Technology Place, Sydney, NSW 2109 Australia
| | | | - Filippo Familiari
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro, Italy
| | - Julio de Pablos
- Advanced Reconstructive Osseous Surgery, San Juan de Dios Hospital, Pamplona, Spain
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17
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Cooper ME, Trivedi NN, Sivasundaram L, Karns MR, Voos JE, Gillespie RJ. Diagnosis and Management of Periprosthetic Joint Infection After Shoulder Arthroplasty. JBJS Rev 2020; 7:e3. [PMID: 31291202 DOI: 10.2106/jbjs.rvw.18.00152] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Maxwell E Cooper
- Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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18
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Alessio-Mazzola M, Repetto I, Russo A, Clemente A, Ventura N, Formica M, Burastero G, Felli L. Permanent Spacers Are a Reliable Solution for Peri-prosthetic Shoulder Infection: A Systematic Review. HSS J 2020; 16:272-279. [PMID: 33082722 PMCID: PMC7534885 DOI: 10.1007/s11420-020-09755-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 02/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peri-prosthetic shoulder infection (PSI), a highly disabling complication of shoulder arthroplasty, often requires additional surgery and prolonged antibiotic therapy. Of strategies proposed to manage this devastating condition, the use of cement spacers, perhaps even as a definitive treatment, is debated. QUESTIONS/PURPOSES We sought to systematically review the literature on antibiotic-loaded cement spacers as a viable, perhaps definitive, treatment for PSI, evaluating the eradication rates, mechanical reliability, and functional results related to its use. METHODS We conducted a systematic review of studies published from January 1, 1980, through September 1, 2019. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Review and Meta-analysis, we searched for studies reporting functional and clinical outcomes in patients with PSI treated with a permanent spacer of the shoulder. Two independent reviewers searched eight databases, as well as reference lists of the retrieved articles. RESULTS After exclusion criteria were applied, 12 studies were included, involving a total of 143 patients. The mean age was 65.8 years; the mean follow-up was 37.4 months. A total of 133 patients (93%) were free from infection at latest follow-up. The mean post-operative active elevation of the shoulder ranged from 48.6 to 90°, the mean abduction ranged from 51 to 75°, and external rotation ranged from 3.6 to 29°. The mean Constant-Murley score ranged from 20.6 to 42 points (out of 100, from worst to best). CONCLUSION The use of a permanent cement spacer is a reliable solution to PSI in low-demand, older patients with comorbidities, a population in whom it is desirable to avoid additional surgery. Our review found a high rate of infection eradication and moderate-to-good objective and subjective results. However, the overall level of evidence of included studies was very low, and higher-quality studies are needed to clarify the role of permanent spacers in the treatment of PSI.
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Affiliation(s)
- Mattia Alessio-Mazzola
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Ilaria Repetto
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Russo
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Clemente
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Niccolò Ventura
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Formica
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Giorgio Burastero
- Joint Replacement Unit, Azienda Ospedaliera Santa Corona, Pietra Ligure, Italy
| | - Lamberto Felli
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
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Aïm F, Marion B, Kerroumi Y, Meyssonnier V, Marmor S. Reply to the letter by Christophe Nich. Orthop Traumatol Surg Res 2020; 106:987-989. [PMID: 32665202 DOI: 10.1016/j.otsr.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/12/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Florence Aïm
- Centre de référence des infections ostéo-articulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France; Service de chirurgie orthopédique, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France.
| | - Blandine Marion
- Centre de référence des infections ostéo-articulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France; Service de chirurgie orthopédique, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - Younes Kerroumi
- Centre de référence des infections ostéo-articulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - Vanina Meyssonnier
- Centre de référence des infections ostéo-articulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France
| | - Simon Marmor
- Centre de référence des infections ostéo-articulaires, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France; Service de chirurgie orthopédique, groupe hospitalier Diaconnesses Croix Saint-Simon, 125, rue d'Avron, 75020 Paris, France
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Sheppard WL, Mosich GM, Smith RA, Hamad CD, Park HY, Zoller SD, Trikha R, McCoy TK, Borthwell R, Hoang J, Truong N, Cevallos N, Clarkson S, Hori KR, van Dijl JM, Francis KP, Petrigliano FA, Bernthal NM. Novel in vivo mouse model of shoulder implant infection. J Shoulder Elbow Surg 2020; 29:1412-1424. [PMID: 32014357 PMCID: PMC11037115 DOI: 10.1016/j.jse.2019.10.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/30/2019] [Accepted: 10/02/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Animal models are used to guide management of periprosthetic implant infections. No adequate model exists for periprosthetic shoulder infections, and clinicians thus have no preclinical tools to assess potential therapeutics. We hypothesize that it is possible to establish a mouse model of shoulder implant infection (SII) that allows noninvasive, longitudinal tracking of biofilm and host response through in vivo optical imaging. The model may then be employed to validate a targeting probe (1D9-680) with clinical translation potential for diagnosing infection and image-guided débridement. METHODS A surgical implant was press-fit into the proximal humerus of c57BL/6J mice and inoculated with 2 μL of 1 × 103 (e3), or 1 × 104 (e4), colony-forming units (CFUs) of bioluminescent Staphylococcus aureus Xen-36. The control group received 2 μL sterile saline. Bacterial activity was monitored in vivo over 42 days, directly (bioluminescence) and indirectly (targeting probe). Weekly radiographs assessed implant loosening. CFU harvests, confocal microscopy, and histology were performed. RESULTS Both inoculated groups established chronic infections. CFUs on postoperative day (POD) 42 were increased in the infected groups compared with the sterile group (P < .001). By POD 14, osteolysis was visualized in both infected groups. The e4 group developed catastrophic bone destruction by POD 42. The e3 group maintained a congruent shoulder joint. Targeting probes helped to visualize low-grade infections via fluorescence. DISCUSSION Given bone destruction in the e4 group, a longitudinal, noninvasive mouse model of SII and chronic osteolysis was produced using e3 of S aureus Xen-36, mimicking clinical presentations of chronic SII. CONCLUSION The development of this model provides a foundation to study new therapeutics, interventions, and host modifications.
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Affiliation(s)
- William L Sheppard
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Gina M Mosich
- Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Ryan A Smith
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Christopher D Hamad
- Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Howard Y Park
- Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Stephen D Zoller
- Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Rishi Trikha
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Tatiana K McCoy
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Rachel Borthwell
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - John Hoang
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicole Truong
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Nicolas Cevallos
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Samuel Clarkson
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Kellyn R Hori
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jan Maarten van Dijl
- Department of Medical Microbiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kevin P Francis
- Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA; PerkinElmer, Hopkinton, MA, USA
| | - Frank A Petrigliano
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA
| | - Nicholas M Bernthal
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA; Department of Orthopedic Surgery, University of California, Los Angeles, Santa Monica, CA, USA.
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One- or two-stage exchange for periprosthetic shoulder infection: Systematic review and meta-analysis. Orthop Traumatol Surg Res 2020; 106:5-15. [PMID: 31862323 DOI: 10.1016/j.otsr.2019.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/07/2019] [Accepted: 10/21/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One-stage exchange is the gold-standard for management of periprosthetic shoulder infection. The present review compares efficacy between 1- and 2-stage exchange in this indication. MATERIAL AND METHODS We performed a systematic literature review and meta-analysis following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) criteria. The literature search used the Medline, Embase and Central data-bases. The studies included assessed 1- and 2-stage exchange in periprosthetic shoulder infection. The main outcome was reinfection rate, and the secondary outcome postoperative complications rate. RESULTS Twenty-one studies, for 501 patients, were included: 5 assessing 1-stage exchange, 11 2-stage, and 5 both. Mean follow-up was 4.3 years (range, 2-6.1 years). Mean reinfection rates ranged between 0 and 50% in 1-stage exchange and between 0 and 36.8% in 2-stage exchange. The combined rate was 7% (95% CI, 3.8-12.5%) in 1-stage and 21.3% (95% CI, 16-27.9%) in 2-stage exchange. Mean complications rates ranged between 0 and 50% in 1-stage exchange and between 5.7% and 73%% in 2-stage exchange. The combined rate was 17% (95% CI, 11.9-23.9%) in 1-stage and 32.8% (95% CI, 25.8-40.6%) in 2-stage exchange. DISCUSSION To our knowledge, the present meta-analysis is the first to assess results in 1- and 2-stage exchange for chronic periprosthetic shoulder infection. CONCLUSION One-stage exchange seemed to provide better results, with less reinfection and fewer complications than 2-stage exchange. LEVEL OF EVIDENCE I, meta-analysis.
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Goetti P, Gallusser N, Antoniadis A, Wernly D, Vauclair F, Borens O. Advanced septic arthritis of the shoulder treated by a two-stage arthroplasty. World J Orthop 2019; 10:356-363. [PMID: 31754606 PMCID: PMC6854056 DOI: 10.5312/wjo.v10.i10.356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/03/2019] [Accepted: 09/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited.
AIM To evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.
METHODS We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.
RESULTS Mean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively.
CONCLUSION Short interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.
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Affiliation(s)
- Patrick Goetti
- Department of orthopedic surgery and traumatology, Lausanne University Hospital and University of Lausanne, Lausanne 1010, Switzerland
| | - Nicolas Gallusser
- Department of orthopedic surgery and traumatology, Lausanne University Hospital and University of Lausanne, Lausanne 1010, Switzerland
| | - Alexander Antoniadis
- Department of orthopedic surgery and traumatology, Lausanne University Hospital and University of Lausanne, Lausanne 1010, Switzerland
| | - Diane Wernly
- Department of orthopedic surgery and traumatology, Lausanne University Hospital and University of Lausanne, Lausanne 1010, Switzerland
| | - Frédéric Vauclair
- Department of orthopedic surgery and traumatology, Lausanne University Hospital and University of Lausanne, Lausanne 1010, Switzerland
| | - Olivier Borens
- Department of orthopedic surgery and traumatology, Lausanne University Hospital and University of Lausanne, Lausanne 1010, Switzerland
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Aibinder WR, Lee J, Shukla DR, Cofield RH, Sanchez-Sotelo J, Sperling JW. An Anatomic Intraoperatively Prepared Antibiotic Spacer in Two-Stage Shoulder Reimplantation for Deep Infection: The Potential for Early Rehabilitation. Orthopedics 2019; 42:211-218. [PMID: 31323104 DOI: 10.3928/01477447-20190701-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/03/2019] [Indexed: 02/03/2023]
Abstract
Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211-218.].
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Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: evaluation of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S32-S66. [PMID: 31196514 DOI: 10.1016/j.jse.2019.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/20/2019] [Indexed: 02/01/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.
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25
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Egglestone A, Ingoe H, Rees J, Thomas M, Jeavons R, Rangan A. Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty. Shoulder Elbow 2019; 11:167-181. [PMID: 31210788 PMCID: PMC6555110 DOI: 10.1177/1758573218779076] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this scoping review is to assess the current evidence regarding periprosthetic shoulder infection to inform development of evidence and consensus-based guidelines. METHODS A search of Medline, Embase and PubMed was performed; two authors screened the results independently for inclusion. RESULTS Totally 88 studies were included. Incidence of periprosthetic shoulder infection ranged from 0.7% to 7%. The most common organisms to cause periprosthetic shoulder infection were Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and coagulase-negative Staphylococcus. Male gender and younger age are the most reported risk factors. Erythrocyte sedimentation rate, C-reactive protein and serum/synovial biomarkers had limited diagnostic accuracy. Thirty-nine studies reported the outcome of surgical management of periprosthetic shoulder infection. Eradication rates vary from 54% to 100% for debridement procedures; 66-100% for permanent spacers; 50-100% following single-stage revision; 60-100% following two-stage revision; and 66-100% following resection arthroplasty. CONCLUSION There is wide heterogeneity in study designs and outcomes of studies are often contradictory and due to issues with methodology and small sample sizes the optimal pathways for diagnosis and management cannot be determined from this review. Future research should be based on larger cohorts and randomised trials where feasible to provide more valid research for guiding future treatment of periprosthetic shoulder infection.
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Affiliation(s)
- Anthony Egglestone
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
| | - Helen Ingoe
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford, UK
| | - Michael Thomas
- Heatherwood and Wexham Park Hospitals Trust, Berkshire, UK
| | - Richard Jeavons
- North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK
| | - Amar Rangan
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
- Faculty of Medical Sciences & NDORMS, University of Oxford, Oxford, UK
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Mercurio M, Castioni D, Iannò B, Gasparini G, Galasso O. Outcomes of revision surgery after periprosthetic shoulder infection: a systematic review. J Shoulder Elbow Surg 2019; 28:1193-1203. [PMID: 31003887 DOI: 10.1016/j.jse.2019.02.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/04/2019] [Accepted: 02/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic shoulder infection (PSI) is one of the most challenging complications after shoulder arthroplasty. Different treatments have been proposed, but the best surgical procedure remains disputed in the current literature. This systematic review investigated the outcomes of revision surgery after PSI. METHODS The PubMed and Scopus databases were used to search keywords in April 2018. Of 2157 titles, 34 studies were finally analyzed. Demographics, laboratory and microbiological data, types of implants, surgical techniques with complications and reoperations, eradication rates, and clinical and functional outcomes were reported. RESULTS A total of 754 patients were identified. Cutibacterium acnes (C. acnes) was the most common microorganism found both in PSI (33%) and persistent infections (40%). Preoperatively, C-reactive protein was elevated in 70% of patients with PSI. Reverse shoulder arthroplasty had a lower prevalence of infection (P < .001). The eradication rate was 96% with 1 stage, 93% with permanent spacers, 86% with 2 stages, 85% with resection arthroplasty, and 65% with irrigation and débridement. One-stage revision was the best treatment, considering postoperative flexion and abduction, compared with resection arthroplasty, permanent spacers, and 2-stage revision. One-stage revision showed fewer postoperative complications than irrigation and débridement, resection arthroplasty, and 2-stage surgery. Two-stage surgery was the most common treatment, and the functional score demonstrated no differences between 2-stage and 1-stage procedures. CONCLUSIONS Our review suggests that a 1-stage procedure should be recommended to treat PSI. Two-stage revision could be reserved for select cases in which the bacterium involved is unknown.
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Affiliation(s)
- Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Davide Castioni
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy.
| | - Bruno Iannò
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
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Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S67-S99. [PMID: 31196516 DOI: 10.1016/j.jse.2019.04.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 04/20/2019] [Indexed: 02/05/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.
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Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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28
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Somerson JS, Boylan MR, Hug KT, Naziri Q, Paulino CB, Huang JI. Risk factors associated with periprosthetic joint infection after total elbow arthroplasty. Shoulder Elbow 2019; 11:116-120. [PMID: 30936951 PMCID: PMC6434963 DOI: 10.1177/1758573217741318] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 10/10/2017] [Accepted: 10/15/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND For patients undergoing total elbow arthroplasty (TEA), the present study aimed to investigate: (i) what risk factors are associated with periprosthetic elbow infection; (ii) what is the incidence of infection after TEA; and (iii) what is the acuity with which these infections present? METHODS The Statewide Planning and Research Cooperative System database was used to identify all patients who underwent TEA between 2003 and 2012 in New York State. Admissions for prosthetic joint infection (PJI) were identified using ICD-9 (International Classification of Diseases, Ninth Revision, Clinical Modification) diagnosis code 996.66. Multivariate analysis was used to determine risk factors that were independently prognostic for PJI. RESULTS Significant risk factors for PJI included hypothyroidism [odds ratio (OR) = 2.04; p = 0.045], tobacco use disorder (OR = 3.39; p = 0.003) and rheumatoid arthritis (OR = 3.31; p < 0.001). Among the 1452 patients in the study period who underwent TEA, 3.7% (n = 54) were admitted postoperatively for PJI. There were 30 (56%) early infections, 17 (31%) delayed infections and seven (13%) late infections. CONCLUSIONS Pre-operative optimization of thyroid function, smoking cessation and management of rheumatoid disease may be considered in surgical candidates for TEA. The results of the present study add prognostic data to the literature that may be helpful with patient selection and risk profile analysis. LEVEL OF EVIDENCE Level III: prognostic study.
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Affiliation(s)
- Jeremy S. Somerson
- University of Texas Medical Branch, Galveston, TX, USA,Jeremy S. Somerson, Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA.
| | | | - Kevin T. Hug
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA, USA
| | - Qais Naziri
- SUNY Downstate Medical Center, Brooklyn, NY, USA
| | | | - Jerry I. Huang
- University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, WA, USA
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Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections. Orthop Traumatol Surg Res 2019; 105:237-240. [PMID: 30497888 DOI: 10.1016/j.otsr.2018.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/21/2018] [Accepted: 10/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Periprosthetic shoulder infections (PSIs) represent a serious complication following shoulder arthroplasty. No consensus exists regarding the optimal option. We conducted a retrospective case-control study to compare the outcomes of 2-stage revision shoulder arthroplasty and those of definitive articulating antibiotic spacer implantation with regards to eradication of the infection, improvement of pain and shoulder function. MATERIALS AND METHODS Thirty patients treated for an infected shoulder arthroplasty were retrospectively reviewed after a mean follow-up of 8 years (range, 2-10 years). Nineteen underwent definitive articulating antibiotic spacer implantation and 11 underwent 2-stage revision arthroplasty. Mean age at surgery was 68.8 years. Assessment included Constant-Murley score, visual analog scale pain score, objective examination, patient subjective satisfaction score as well as standard radiographs. RESULTS At the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to preoperative values (p<0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. No statistically significant differences were reported between the two groups concerning Constant-Murley and VAS scores, while average forward flexion and abduction were significantly higher in patients undergoing 2-stage revision surgery. CONCLUSIONS Both surgical procedures provided infection eradication and satisfying subjective functional outcomes. Functional results were superior in patients treated with revision shoulder prosthesis, although a higher rate of complication was reported in this cohort of patients, thus suggesting the use of permanent spacer in high-risk or low-demanding elderly patients. LEVEL OF EVIDENCE III, Retrospective case-control study.
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30
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Outcomes of revision arthroplasty for shoulder periprosthetic joint infection: a three-stage revision protocol. J Shoulder Elbow Surg 2019; 28:268-275. [PMID: 30293858 DOI: 10.1016/j.jse.2018.07.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/08/2018] [Accepted: 07/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study evaluated outcomes after treatment of shoulder periprosthetic joint infection (PJI) with a 3-stage revision protocol consisting of (1) débridement, explantation, and cement spacer placement, followed by parenteral antibiotics; (2) open biopsy and débridement; and (3) reimplantation if cultures were negative. We hypothesized this protocol would eradicate persistent infection while producing excellent functional and subjective outcomes, and there would be no difference in these parameters for patients with shoulder PJI compared with patients with revision for aseptic indications. METHODS We retrospectively analyzed a prospectively collected revision shoulder arthroplasty cohort to identify shoulder PJI patients treated with a 3-stage protocol. Demographics, culture data, range of motion, and patient-reported outcomes were collected. Outcomes for patients with shoulder PJI and revision to RTSA were compared with patients revised to RTSA for noninfectious indications. Significance was defined as P < .05. RESULTS There were 28 cases of shoulder PJI in 27 patients (age, 66.4 ± 11.2 years,); of these, 21 shoulders were revised to RTSA, and 7 shoulders were revised to hemiarthroplasty. There was no recurrent infection at a mean 32-month follow-up. One year after surgery, mean forward flexion was 110° ± 41° and abduction was 106° ± 42°. Mean final American Shoulder and Elbow Surgeons subjective score was 66.5 ± 23.3. The 21 shoulders with PJI revised to RTSA had no differences for functional and subjective outcomes compared with revised patients without shoulder PJI. CONCLUSIONS A 3-stage revision protocol for shoulder PJI reliably eradicated infection. Patients with PJI revised to RTSA can have similar outcomes as patients with noninfectious revision to RTSA.
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Kunutsor SK, Wylde V, Beswick AD, Whitehouse MR, Blom AW. One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis. Sci Rep 2019; 9:232. [PMID: 30659227 PMCID: PMC6338765 DOI: 10.1038/s41598-018-36313-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023] Open
Abstract
Periprosthetic joint infection (PJI) is a catastrophic complication of shoulder arthroplasty. Commonly used surgical treatments include one- or two-stage revision, but their effectiveness in controlling infection is uncertain. We aimed to compare re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and two-stage revision surgery for shoulder PJI using a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or two-stage revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation. The re-infection rate (95% CI) in pooled analysis of eight one-stage studies (147 participants) was 5.3% (1.4-10.6). The corresponding rate for 27 two-stage studies (351 participants) was 11.5% (6.0-18.1). Postoperative clinical measures of function and pain were not significantly different between the two revision strategies. The pooled noninfection complication rate (95% CI) for one-stage and two-stage revision was 12.1% (6.1-19.5) and 18.9% (8.4-31.9) respectively. New evidence suggests one-stage revision is at least equally as effective as the two-stage in controlling infection, maintaining joint function, and improving complications in shoulder PJI.
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Affiliation(s)
- Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Vikki Wylde
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew D Beswick
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Ashley W Blom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
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Marcheggiani Muccioli GM, Guerra E, Roberti di Sarsina T, Alesi D, Fratini S, Cammisa E, Rinaldi VG, Lullini G, Rotini R, Zaffagnini S. Diagnosis and Treatment of Infected Shoulder Arthroplasty: Current Concepts Review. JOINTS 2018; 6:173-176. [PMID: 30582106 PMCID: PMC6301844 DOI: 10.1055/s-0038-1675800] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 10/07/2018] [Indexed: 11/02/2022]
Abstract
Periprosthetic shoulder infection (PSI) is an emerging pathology which requires many improvements in diagnosis and treatment to obtain a satisfying success rate. Different approaches have been described. This article summarizes current concepts of diagnostic process and main treatments described in the literature.
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Affiliation(s)
| | - Enrico Guerra
- Shoulder and Elbow Unit, Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Domenico Alesi
- II Orthopaedic and Traumatologic Clinic, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Fratini
- II Orthopaedic and Traumatologic Clinic, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Eugenio Cammisa
- II Orthopaedic and Traumatologic Clinic, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Vito Gaetano Rinaldi
- II Orthopaedic and Traumatologic Clinic, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giada Lullini
- Laboratory of Movement Analysis and Functional-Clinical Evaluation of Prosthesis, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberto Rotini
- Shoulder and Elbow Unit, Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Stefano Zaffagnini
- II Orthopaedic and Traumatologic Clinic, Istituto Ortopedico Rizzoli, Bologna, Italy
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Sevelda F, Fink B. One-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm. J Shoulder Elbow Surg 2018; 27:2175-2182. [PMID: 30104101 DOI: 10.1016/j.jse.2018.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/31/2018] [Accepted: 06/02/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Studies on 1-stage exchange in septic shoulder arthroplasty are limited and show a wide variation of treatment strategies. This retrospective study investigated infection-free survival and function of 1-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm. METHODS The requirement for 1-stage exchange was an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile prior to revision surgery. If no microorganism was isolated or the underlying pathogen was a difficult-to-treat microorganism (not accessible for biofilm-active antibiotics, enterococci, and fungi), 2-stage exchange was performed. Function was assessed by the Constant score. RESULTS Fourteen patients were included, with a mean follow-up period of 5.8 years. The most and second most commonly detected microorganisms were Cutibacterium acnes (formerly Propionibacterium acnes), and Staphylococcus epidermidis, respectively. At 1-stage exchange, patients received local and systemic antibiotics based on the susceptibility profile of the microorganism. Twelve patients with insufficient rotator cuffs received reverse shoulder arthroplasty, whereas 2 patients with intact rotator cuffs underwent anatomic total shoulder arthroplasty. The infection-free survival rate at 1 and 5 years was 100% and 93% (95% confidence interval [CI], 59%-99%), respectively, with 1 recurrence of infection 22 months after 1-stage exchange. Another patient with limited range of motion underwent revision 6 months postoperatively, leading to a revision-free survival rate of 93% (95% CI, 59%-99%) and 86% (95% CI, 54%-96%) at 1 and 5 years, respectively. The mean Constant score was 65 (range, 44-95). CONCLUSION One-stage exchange with prior detection of the underlying microorganism provides satisfactory infection-free survival and function.
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Affiliation(s)
- Florian Sevelda
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany; Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany; Orthopaedic Department, University-Hospital Hamburg-Eppendorf, Hamburg, Germany
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Implant Removal and Spacer Placement for Infected Shoulder Arthroplasty: Risk Factors for Repeat Procedures, Spacer Retention, and Mortality. HSS J 2018; 14:228-232. [PMID: 30258325 PMCID: PMC6148586 DOI: 10.1007/s11420-017-9586-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current studies reporting on patients following prosthesis removal and spacer placement for periprosthetic joint infection (PJI) of the shoulder have largely been descriptive and insufficiently powered to determine risk factors for outcomes other than reimplantation. PURPOSE The objective of the present study is to provide a national perspective on the 1-year outcomes following prosthesis removal and spacer placement and risk factors for outcomes other than reimplantation for treatment of PJI following shoulder arthroplasty. METHODS A national database was queried for Medicare patients who underwent prosthesis removal and spacer placement for PJI between 2005 and 2012. These patients were then evaluated for 5 major study endpoints including: (1) replantation of a shoulder prosthesis within 1 year postoperatively, (2) a repeat irrigation and debridement with second antibiotic spacer placement procedure within 1 year postoperatively, (3) in-hospital death within 1 year postoperatively, (4) a shoulder Girdlestone-type procedure within 1 year postoperatively, and (5) the remaining patients, who were considered to have a retained spacer. Patients with a study endpoint within 1 year postoperatively were included in the study: (1) mortality, (2) repeat debridement, (3) resection arthroplasty, and (4) reimplantation. While it is possible that some patients were not captured due to errors in coding, it is unlikely that patients were lost to follow-up due to change in location of services, given that the database captures all episodes of care that are coded throughout the USA. Independent risk factors were evaluated using logistic regression analysis. RESULTS Nine hundred seventy-five patients who underwent prosthesis removal and spacer placement were included. Within 1 year postoperatively, 21 patients died (2.2%), 70 patients had a repeat debridement procedure (7.2%), 55 patients had a resection arthroplasty procedure (5.6%), 349 patients retained their spacers (35.8%), and the remaining 480 patients had a shoulder arthroplasty reimplanted (49.2%). Numerous independent risk factors exist for all outcomes studied. CONCLUSION The fate of antibiotic spacers placed for PJI of the shoulder at 1 year is variable, with numerous independent risk factors for outcomes other than reimplantation. Patients with PJI following total shoulder arthroplasty should be counseled on the risk factors that influence the outcomes of staged revision for shoulder PJI.
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Wahl P, Sprecher CM, Brüning C, Meier C, Milz S, Gautier E, Fintan Moriarty T. Successful bony integration of a porous tantalum implant despite longlasting and ongoing infection: Histologic workup of an explanted shoulder prosthesis. J Biomed Mater Res B Appl Biomater 2018; 106:2924-2931. [PMID: 30199602 DOI: 10.1002/jbm.b.34174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/25/2018] [Accepted: 05/13/2018] [Indexed: 01/30/2023]
Abstract
Infection associated with an implant is a complication feared in surgery, as it leads to loosening and dysfunction. This report documents an unexpected good bony integration of a porous tantalum shoulder prosthesis despite infection. A shoulder prosthesis with a porous tantalum glenoidal base plate was retrieved after 3 years of ongoing infection with Staphylococcus spp. Methyl-methacrylate embedded sections of the retrieved glenoidal component were analyzed by optical and scanning electron beam microscopy (SEM). Bone ongrowth and ingrowth were quantified. Bone had formed at the implant surface and within the open cell structure of the porous tantalum. The bone implant contact index was 32%. The bone ingrowth or relative bone area within the open structure was 8.2%, respectively 11.9% in the outer 50% of the thickness. Due to the section thickness, bone ongrowth could best be documented in SEM. Despite long-lasting and ongoing infection, the glenoidal base plate of the prosthesis showed good bony integration upon removal. The bone ingrowth into the porous tantalum was comparable to the values previously reported for the undersurface of retrieved proximal humerus resurfacing implants. Good integration of the implant however did not solve the problem of infection, and related morbidity. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2924-2931, 2018.
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Affiliation(s)
- Peter Wahl
- Division of Orthopaedic and Trauma Surgery, Cantonal Hospital, Winterthur, Switzerland.,Department of Septic Surgery, BG Trauma Centre, Frankfurt, Germany
| | | | | | - Christoph Meier
- Division of Orthopaedic and Trauma Surgery, Cantonal Hospital, Winterthur, Switzerland
| | - Stefan Milz
- Institute of Anatomy, Ludwig-Maximilians-University, Munich, Germany
| | - Emanuel Gautier
- Department of Orthopaedic Surgery, HFR Fribourg-Cantonal Hospital, Fribourg, Switzerland
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Pellegrini A, Legnani C, Macchi V, Meani E. Management of periprosthetic shoulder infections with the use of a permanent articulating antibiotic spacer. Arch Orthop Trauma Surg 2018; 138:605-609. [PMID: 29335894 DOI: 10.1007/s00402-018-2870-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Management of periprosthetic shoulder infections (PSIs) still remains challenging. We conducted a retrospective case study to assess the outcomes of definitive articulating antibiotic spacer implantation in a cohort of elderly, low-demanding patients. We hypothesized that in patients with low functional demands seeking pain relief with chronic PSIs, treatment with a definitive articulating antibiotic spacer would lead to satisfying results concerning eradication of the infection, improvement of pain, and improving shoulder function. MATERIALS AND METHODS 19 patients underwent definitive articulating antibiotic spacer implantation for the treatment of an infected shoulder arthroplasty. Mean age at surgery was 70.2 years. Patients were assessed pre-operatively with functional assessment including Constant-Murley score, and objective examination comprehending ROM, visual analog scale pain score, and patient subjective satisfaction (excellent, good, satisfied, or unsatisfied) score. Radiographs were taken to examine signs of loosening, and change in implant positioning. RESULTS At the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to pre-operative values (p < 0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. In one case, glenoid osteolysis was reported, which did not affect the clinical outcome. CONCLUSIONS In selected elderly patients with low functional demands seeking pain relief with infected shoulder arthroplasty, definitive management with a cement spacer is a viable treatment option that helps in eradicating shoulder infection and brings satisfying subjective and objective outcomes. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Antonio Pellegrini
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Galeazzi Orthopaedic Institute, San Siro Clinical Institute Site, Milan, Italy
| | | | - Vittorio Macchi
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Galeazzi Orthopaedic Institute, San Siro Clinical Institute Site, Milan, Italy
| | - Enzo Meani
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Galeazzi Orthopaedic Institute, San Siro Clinical Institute Site, Milan, Italy
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Staged Revision With Antibiotic Spacers for Shoulder Prosthetic Joint Infections Yields High Infection Control. Clin Orthop Relat Res 2018; 476:146-152. [PMID: 29389759 PMCID: PMC5919231 DOI: 10.1007/s11999.0000000000000049] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of periprosthetic joint infection (PJI) of the shoulder with two-stage revision arthroplasty using an antibiotic-loaded cement spacer is established strategy, but there is sparse information regarding the likelihood of infection control and restoration of shoulder. QUESTIONS/PURPOSE (1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder? (2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions? PATIENTS AND METHODS Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 ± 34 months). Ten patients (21%) were excluded because they were deceased (n = 3), moved abroad (n = 4), or refused followup (n = 3), leaving 38 for analysis in this retrospective study. During the first stage, removal of the prosthesis, débridement, and implantation of a gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral). For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons. The primary outcome included the proportion of patients achieving infection control 2 years after the second-stage procedure after implantation of the cement spacer. Infection control was determined as the absence of the Musculoskeletal Infection Society PJI criteria. The clinical outcome assessed with the Constant and Murley scores served as the secondary outcome parameter. A subgroup (RTSA; HA, spacer retention) analysis of the Constant and Murley scores was performed. RESULTS Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores at latest followup compared with their pretreatment scores (mean ± SD, 27 ± 19 versus 43 ± 20; mean difference, 17; 95% CI, 10-24; p = 0.001). For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased (mean ± SD, 31 ± 20 versus 51 ± 20; mean difference, 20; 95% CI, 11-30; p = 0.001). The Constant and Murley scores did not improve in patients who underwent HA (mean ± SD, 22 ±15 versus 24 ± 90; mean difference, 3; 95% CI, -10 to 16; p = 0.509) or who retained the spacer (mean ± SD, 18 ±12 versus 35 ±10; mean difference, 19; 95% CI, -5 to 44; p = 0.093). CONCLUSION Revision arthroplasty using an antibiotic-loaded cement spacer provided successful infection control in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement spacer; however, baseline differences among patient groups very likely contributed to these differences, and they should not be attributed to implant selection alone. LEVEL OF EVIDENCE Level III, therapeutic study.
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Periprosthetic Joint Infection of Shoulder Arthroplasties: Diagnostic and Treatment Options. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4582756. [PMID: 29423407 PMCID: PMC5750516 DOI: 10.1155/2017/4582756] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/05/2017] [Accepted: 11/26/2017] [Indexed: 12/21/2022]
Abstract
Periprosthetic joint infection (PJI) is one of the most frequent reasons for painful shoulder arthroplasties and revision surgery of shoulder arthroplasties. Cutibacterium acnes (Propionibacterium acnes) is one of the microorganisms that most often causes the infection. However, this slow growing microorganism is difficult to detect. This paper presents an overview of different diagnostic test to detect a periprosthetic shoulder infection. This includes nonspecific diagnostic tests and specific tests (with identifying the responsible microorganism). The aspiration can combine different specific and nonspecific tests. In dry aspiration and suspected joint infection, we recommend a biopsy. Several therapeutic options exist for the treatment of PJI of shoulder arthroplasties. In acute infections, the options include leaving the implant in place with open debridement, septic irrigation with antibacterial fluids like octenidine or polyhexanide solution, and exchange of all removable components. In late infections (more than four weeks after implantation) the therapeutic options are a permanent spacer, single-stage revision, and two-stage revision with a temporary spacer. The functional results are best after single-stage revisions with a success rate similar to two-stage revisions. For single-stage revisions, the microorganism should be known preoperatively so that specific antibiotics can be mixed into the cement for implantation of the new prosthesis and specific systemic antibiotic therapy can be applied to support the surgery.
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Assenmacher AT, Alentorn-Geli E, Dennison T, Baghdadi YMK, Cofield RH, Sánchez-Sotelo J, Sperling JW. Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26:1978-1983. [PMID: 28751093 DOI: 10.1016/j.jse.2017.05.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 05/01/2017] [Accepted: 05/08/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Two-stage reimplantation is the most common treatment modality considered for periprosthetic shoulder infection (PSI). Most studies to date have reported on a relatively small number of shoulders. The purpose of this study was to determine the outcome of 2-stage reimplantation for PSI in terms of both eradication of infection and restoration of function. METHODS Between 1980 and 2010, 40 shoulders (39 patients) underwent a 2-stage reimplantation for PSI; 35 shoulders (34 patients) met inclusion criteria (10 hemiarthroplasties, 24 anatomic total shoulder arthroplasties, 1 reverse total shoulder arthroplasty). Outcome data included pain, motion, Neer rating, and complications. RESULTS At most recent follow-up (4.1 years), 2-stage reimplantation had resulted in significant improvements in pain (from 4.4 to 2 on a 5-point scale; P < .0001), mean forward elevation (64°-118°; P < .0001), and mean external rotation (14°-41°; P < .0001). Preoperative testing showed leukocytosis in 1 patient, elevated C-reactive protein concentration in 67%, elevated erythrocyte sedimentation rate in 61%, and positive preoperative aspiration in 69%. Persistent infection, defined as positive cultures in samples obtained at the time of reimplantation, was identified in 5 shoulders (15%); 50% of persistent infections grew Propionibacterium acnes. Reoperations for infection included irrigation and débridement (1), a second 2-stage reimplantation (2), and resection arthroplasty (1); 2 additional patients were treated with chronic suppression. Reoperation for aseptic glenoid loosening was performed in 2 additional shoulders. Results were graded excellent in 10 (28%), satisfactory in 12 (33%), and unsatisfactory in 13 (39%) shoulders. CONCLUSION Two-stage reimplantation eradicated PSI in 85% of the shoulders. Pain relief and good arcs of motion were achieved in many patients, but there was an overall rate of unsatisfactory results approaching 40%. Preoperative testing was not always reliable for the diagnosis of PSI.
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Affiliation(s)
| | | | - Taylor Dennison
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Robert H Cofield
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
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Bonnevialle N, Dauzères F, Toulemonde J, Elia F, Laffosse JM, Mansat P. Periprosthetic shoulder infection: an overview. EFORT Open Rev 2017; 2:104-109. [PMID: 28507783 PMCID: PMC5420823 DOI: 10.1302/2058-5241.2.160023] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Periprosthetic shoulder infection (PSI) is rare but potentially devastating. The rate of PSI is increased in cases of revision procedures, reverse shoulder implants and co-morbidities. One specific type of PSI is the occurrence of low-grade infections caused by non-suppurative bacteria such as Propionibacterium acnes or Staphylococcus epidemermidis. Success of treatment depends on micro-organism identification, appropriate surgical procedures and antibiotic administration efficiency. Post-operative early PSI can be treated with simple debridement, while chronic PSI requires a one- or two-stage revision procedure. Indication for one-time exchange is based on pre-operative identification of a causative agent. Resection arthroplasty remains an option for low-demand patients or recalcitrant infection.
Cite this article: EFORT Open Rev 2017;2:104-109. DOI: 10.1302/2058-5241.2.160023
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Affiliation(s)
- Nicolas Bonnevialle
- Orthopaedic Department and Biomechanics Department, IMFT CNRS URM 5502, Riquet Hospital, University Centre, Place Baylac, 31059 Toulouse, France
| | - Florence Dauzères
- Orthopaedic Department, Riquet Hospital, University Centre, Place Baylac, 31059 Toulouse, France
| | - Julien Toulemonde
- Orthopaedic Department, Riquet Hospital, University Centre, Place Baylac, 31059 Toulouse, France
| | - Fanny Elia
- Orthopaedic Department, Riquet Hospital, University Centre, Place Baylac, 31059 Toulouse, France
| | - Jean-Michel Laffosse
- Orthopaedic Department, CRIOAC and Biomechanics Department, IMFT CNRS, Riquet Hospital, University Centre, Place Baylac, 31059 Toulouse, France
| | - Pierre Mansat
- Orthopaedic Department and Biomechanics Department, IMFT CNRS URM 5502, Riquet Hospital, University Centre, Place Baylac, 31059 Toulouse, France
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Hsu JE, Somerson JS, Vo KV, Matsen FA. What is a “periprosthetic shoulder infection”? A systematic review of two decades of publications. INTERNATIONAL ORTHOPAEDICS 2017; 41:813-822. [DOI: 10.1007/s00264-017-3421-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 01/27/2017] [Indexed: 02/02/2023]
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Nelson GN, Davis DE, Namdari S. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2016; 25:1337-45. [PMID: 27012542 DOI: 10.1016/j.jse.2015.11.064] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 11/15/2015] [Accepted: 11/22/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although many case series have been published on the treatment of shoulder periprosthetic joint infection (PJI), few provide direct comparison of outcomes. This systematic review synthesizes the available English literature on shoulder PJI to quantify treatment effectiveness. METHODS The PubMed and Embase databases were searched in April 2014. Keywords included "shoulder replacement infection" and "shoulder arthroplasty infection." Of 663 titles, 55 manuscripts underwent full-text review after application of exclusion criteria. Thirty articles were finally included. RESULTS Propionibacterium acnes was most commonly reported, representing 38.9% of infections, followed by Staphylococcus species. Risk factors for shoulder PJI include previous surgery, increased age, male gender, increased body mass index, and diabetes mellitus. The average white blood cell count in 13 studies was 7472 cells/µL. Ten studies reported a mean erythrocyte sedimentation rate of 27.6 mm/h, whereas 14 studies reported a mean C-reactive protein level of 2.6 mg/dL. P. acnes in intraoperative culture specimens was an independent risk factor for failed treatment for shoulder PJI. When outcomes were pooled, no statistical difference was found in the success rates of 1-stage, 2-stage, or resection arthroplasty revision; each displayed a success rate >90%. However, single-stage revision produced the highest mean Constant score; implant retention resulted in the best range of motion. CONCLUSIONS Our data suggest that single-stage revision can be as effective as 2-stage or resection treatments; however, the retrospective nature of these data precluded our ability to control for confounding variables. Future studies on shoulder PJI should involve direct comparisons of 1-stage vs. 2-stage treatment while comparing cost, morbidity, and functional outcomes.
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Affiliation(s)
- Gregory N Nelson
- Shoulder and Elbow Surgery, The Center for Orthopedic Research and Education, Phoenix, AZ, USA.
| | - Daniel E Davis
- Rothman Institute for Orthopedic Surgery, Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Institute for Orthopedic Surgery, Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
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Pinder EM, Ong JCY, Bale RS, Trail IA. Ten questions on prosthetic shoulder infection. Shoulder Elbow 2016; 8:151-7. [PMID: 27583013 PMCID: PMC4950280 DOI: 10.1177/1758573216632464] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 01/18/2016] [Indexed: 01/02/2023]
Abstract
Prosthetic shoulder infection can cause significant morbidity secondary to pain and stiffness. Symptoms may be present for years before diagnosis because clinical signs are often absent and inflammatory markers may be normal. An emerging common culprit, Propionibacterium acnes, is hard to culture and so prolonged incubation is necessary. A negative culture result does not always exclude infection and new synovial fluid biochemical markers such as α defensin are less sensitive than for lower limb arthroplasty. A structured approach is necessary when assessing patients for prosthetic shoulder joint infection. This includes history, examination, serum inflammatory markers, plain radiology and aspiration and/or biopsy. A classification for the likelihood of prosthetic shoulder infection has been described based on culture, pre-operative and intra-operative findings. Treatment options include antibiotic suppression, debridement with component retention, one-stage revision, two-stage revision and excision arthroplasty. Revision arthroplasty is associated with the best outcomes.
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Affiliation(s)
| | | | | | - Ian A Trail
- Professor Ian A Trail, Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP, UK.
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Moroder P, Gerhardt C, Renz N, Trampuz A, Scheibel M. Diagnostik und Management des Endoprotheseninfekts am Schultergelenk. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s11678-016-0361-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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George DA, Volpin A, Scarponi S, Haddad FS, Romanò CL. Does exchange arthroplasty of an infected shoulder prosthesis provide better eradication rate and better functional outcome, compared to a permanent spacer or resection arthroplasty? a systematic review. BMC Musculoskelet Disord 2016; 17:52. [PMID: 26832360 PMCID: PMC4735952 DOI: 10.1186/s12891-016-0901-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 01/26/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The best surgical modality for treating chronic periprosthetic shoulder infections has not been established, with a lack of randomised comparative studies. This systematic review compares the infection eradication rate and functional outcomes after single- or two-stage shoulder exchange arthroplasty, to permanent spacer implant or resection arthroplasty. METHODS Full-text papers and those with an abstract in English published from January 2000 to June 2014, identified through international databases, such as EMBASE and PubMed, were reviewed. Those reporting the success rate of infection eradication after a single-stage exchange, two-stage exchange, resection arthroplasty or permanent spacer implant, with a minimum follow-up of 6 months and sample size of 5 patients were included. RESULTS Eight original articles reporting the results after resection arthroplasty (n = 83), 6 on single-stage exchange (n = 75), 13 on two-stage exchange (n = 142) and 8 papers on permanent spacer (n = 68) were included. The average infection eradication rate was 86.7 % at a mean follow-up of 39.8 months (SD 20.8) after resection arthroplasty, 94.7 % at 46.8 months (SD 17.6) after a single-stage exchange, 90.8 % at 37.9 months (SD 12.8) after two-stage exchange, and 95.6 % at 31.0 months (SD 9.8) following a permanent spacer implant. The difference was not statistically significant (p = 0.650). Regarding functional outcome, patients treated with single-stage exchange had statistically significant better postoperative Constant scores (mean 51, SD 13) than patients undergoing a two-stage exchange (mean 44, SD 9), resection arthroplasty (mean 32, SD 7) or a permanent spacer implant (mean 31, SD 9) (p = 0.029). However, when considering studies comparing pre- and post-operative Constant scores, the difference was not statistically significant. CONCLUSION This systematic review failed to demonstrate a clear difference in infection eradication and functional improvement between all four treatment modalities for established periprosthetic shoulder infection. The relatively low number of patients and the methodological limitations of the studies available point out the need for well designed multi-center trials to further assess the best treatment option of peri-prosthetic shoulder infection.
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Affiliation(s)
- D. A. George
- />Department of Trauma and Orthopaedics, University College London Hospitals, 235 Euston Road, London, NW1 2BU UK
| | - A. Volpin
- />Department of Trauma and Orthopaedics, University College London Hospitals, 235 Euston Road, London, NW1 2BU UK
| | - S. Scarponi
- />Centre for Reconstructive Surgery and Osteoarticular Infections, Orthopaedic Research Institute Galeazzi, Milan, Italy
| | - F. S. Haddad
- />Department of Trauma and Orthopaedics, University College London Hospitals, 235 Euston Road, London, NW1 2BU UK
| | - C. L. Romanò
- />Centre for Reconstructive Surgery and Osteoarticular Infections, Orthopaedic Research Institute Galeazzi, Milan, Italy
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Nelson GN, Paxton ES, Narzikul A, Williams G, Lazarus MD, Abboud JA. Leukocyte esterase in the diagnosis of shoulder periprosthetic joint infection. J Shoulder Elbow Surg 2015; 24:1421-6. [PMID: 26279499 DOI: 10.1016/j.jse.2015.05.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/26/2015] [Accepted: 05/04/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder periprosthetic joint infection (PJI) is difficult to diagnose with traditional methods. Leukocyte esterase (LE) has recently proven to be reliable in knee arthroplasty; however, its value in the shoulder has not been explored. We hypothesized that LE would display high sensitivity and specificity in shoulder PJI. METHODS Two groups were prospectively evaluated: 45 primary and 40 revision shoulder arthroplasties. Synovial fluid and soft tissue cultures were obtained at surgery. Synovial fluid was evaluated with LE test strips. Any aspiration that contained erythrocytes was centrifuged and retested. Shoulder PJI was defined by modified Musculoskeletal Infection Society (MSIS) criteria. RESULTS Of 5 primaries with positive tissue cultures (11%), only 1 was positive for LE. Of 16 revisions with positive cultures (40%), 4 had positive LE results. Among all patients with bacterial isolates, 6 aspirates were not interpretable (29%), despite centrifugation. LE had sensitivity of 25% and specificity of 75% to predict positive cultures in revisions. Ten revision patients met modified MSIS criteria for PJI. The sensitivity of LE in these patients was 30%, and the specificity was 67% (positive predictive value, 43%; negative predictive value, 83%). If bloody aspirates were considered positive, LE sensitivity in MSIS PJI increased to 60%, but the positive predictive value fell to 37.5%. CONCLUSION LE is an unreliable diagnostic measure in shoulder PJI. The presence of erythrocytes within aspirates further decreased its accuracy. We conclude that LE should not be used for the routine identification of shoulder PJI.
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Affiliation(s)
- Gregory N Nelson
- Shoulder and Elbow Surgery, The Center for Orthopedic Research and Education, Phoenix, AZ, USA.
| | - E Scott Paxton
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alexa Narzikul
- Rothman Institute for Orthopedic Surgery, Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gerald Williams
- Rothman Institute for Orthopedic Surgery, Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark D Lazarus
- Rothman Institute for Orthopedic Surgery, Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Rothman Institute for Orthopedic Surgery, Sidney Kimmel School of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
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Zhang AL, Feeley BT, Schwartz BS, Chung TT, Ma CB. Management of deep postoperative shoulder infections: is there a role for open biopsy during staged treatment? J Shoulder Elbow Surg 2015; 24:e15-20. [PMID: 24972813 DOI: 10.1016/j.jse.2014.04.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/30/2014] [Accepted: 04/08/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite the gold standard treatment of 2-stage exchange arthroplasty, reinfection after periprosthetic shoulder infections and periarticular osteomyelitis can be as high as 37%. This study describes a protocol to detect persistent deep shoulder infection before revision arthroplasty. METHODS Patients who presented with periprosthetic shoulder infections and osteomyelitis after previous surgery were treated with a standardized protocol of irrigation and debridement (I&D), removal of implants, antibiotic cement spacer placement, and pathogen-directed antibiotic therapy for 6 weeks. After completion of antibiotics and resolution of clinical symptoms, specimens were obtained from an open biopsy performed in the operating room, followed by revision arthroplasty at a later date if final cultures were without evidence of infection. If evidence of infection persisted, then another course of I&D and antibiotic treatment was performed. American Shoulder and Elbow Surgeon scores were used to evaluate clinical outcomes. RESULTS Eighteen patients were included between 2005 and 2012. The most common pathogens isolated were Propionibacterium acnes (44%), Staphylococcus epidermidis (39%), and S aureus (22%). Four patients (22%) had evidence of persistent infection on specimens from open biopsy and required subsequent rounds of I&D before replantation. The infecting pathogen in 75% of patients with persistent infection was P acnes, and 38% of patients with P acnes infection had recurrence. Mean follow-up of 24 months showed no signs of recurrent infection in any patient and an average American Shoulder and Elbow Surgeon score of 71. CONCLUSION Despite prior staged treatment for deep postoperative shoulder infections, specimens obtained from open biopsy before replantation detected a persistent infection rate of 22% in all patients and 38% in patients with P acnes infection, which may indicate a role for this procedure in the prevention of recurrent infections.
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Affiliation(s)
- Alan L Zhang
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Brian S Schwartz
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Teddy T Chung
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA.
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Achermann Y, Stasch P, Preiss S, Lucke K, Vogt M. Characteristics and treatment outcomes of 69 cases with early prosthetic joint infections of the hip and knee. Infection 2014; 42:511-9. [DOI: 10.1007/s15010-014-0584-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 01/03/2014] [Indexed: 01/27/2023]
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Franceschini V, Chillemi C. Periprosthetic shoulder infection. Open Orthop J 2013; 7:243-9. [PMID: 23919098 PMCID: PMC3731811 DOI: 10.2174/1874325001307010243] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 04/21/2013] [Accepted: 04/23/2013] [Indexed: 02/07/2023] Open
Abstract
Shoulder arthroplasty is considered the most effective surgical procedure for endstage shoulder pain from different causes including osteoarthritis, cuff-tear arthropathy, trauma, and tumors. Although uncommon and less frequent than knee or hip periprosthetic infection, periprosthetic shoulder infection represents a devastating complication and, despite treatment, is associated with unsatisfactory results. The most commonly identified microorganisms in periprosthetic shoulder infections are Staphylococcus aureus, coagulase-negative Staphylococci and Propionibacterium acnes. Diagnosis is not always easy and mainly derives from the integration of clinical symptoms, laboratory exams, radiological studies and microbiological swabs. Different options are available for treatment, including antibiotic therapy, lavage and debridement with retention of the prosthesis, one-stage reimplantation, two-stage reimplantation with antibiotic-impregnated cement spacer and resection arthroplasty. The aim of this review is to describe the current knowledge regarding risk factors, etiology, diagnosis and treatment of periprosthetic shoulder infection.
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Affiliation(s)
- Vincenzo Franceschini
- Department of Orthopaedics and Traumatology, Sapienza University of Rome, ICOT, via Faggiana 1668, 04100
Latina, Italy
| | - Claudio Chillemi
- Department of Orthopaedics and Traumatology, Istituto Chirurgico Ortopedico Traumatologico (ICOT), via Faggiana
1668, 04100 Latina, Italy
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50
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Klatte TO, Junghans K, Al-Khateeb H, Rueger JM, Gehrke T, Kendoff D, Neumann J. Single-stage revision for peri-prosthetic shoulder infection. Bone Joint J 2013; 95-B:391-5. [DOI: 10.1302/0301-620x.95b3.30134] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There have been only a few small studies of patients with an infected shoulder replacement treated with a single-stage exchange procedure. We retrospectively reviewed 35 patients (19 men and 16 women) with a peri-prosthetic infection of the shoulder who were treated in this way. A total of 26 were available for clinical examination; three had died, two were lost to follow-up and four patients had undergone revision surgery. The mean follow-up time was 4.7 years (1.1 to 13.25), with an infection-free survival of 94%. The organisms most commonly isolated intra-operatively were Staphylococcus epidermidis and Propionibacterium acnes; two patients developed a recurrent infection. Three different types of prosthesis were used: a hemiarthroplasty, a hemiarthroplasty with a bipolar head and reverse prosthesis. The mean Constant-Murley score at final follow-up was 43.3 (14 to 90) for patients with a hemiarthroplasty, 56 (40 to 88) for those with a hemiarthroplasty with a bipolar head and 61 (7 to 90) for those with a reverse prosthesis. The mean hospital stay was 10.6 days (5 to 29). Single-stage exchange is a successful and practical treatment for patients with peri-prosthetic infection of the shoulder. Cite this article: Bone Joint J 2013;95-B:391–5.
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Affiliation(s)
- T. O. Klatte
- HELIOS ENDO-Klinik Hamburg and University
Medical Centre Hamburg-Eppendorf, Orthopaedic
Surgery, Holstenstr. 2, 22767 Hamburg, Germany
| | - K. Junghans
- HELIOS ENDO-Klinik Hamburg, Orthopaedic
Surgery, Holstenstr. 2, 22767
Hamburg, Germany
| | - H. Al-Khateeb
- Royal National Orthopaedic Hospital, Brockley
Hill, Stanmore, Middlesex
HA7 4LP, UK
| | - J. M. Rueger
- University Medical Center Hamburg-Eppendorf, Department
of Trauma-, Hand- and Reconstructive Surgery, Martinistr.
52, 20246 Hamburg, Germany
| | - T. Gehrke
- HELIOS ENDO-Klinik Hamburg, Orthopaedic
Surgery, Holstenstr. 2, 22767
Hamburg, Germany
| | - D. Kendoff
- HELIOS ENDO-Klinik Hamburg, Orthopaedic
Surgery, Holstenstr. 2, 22767
Hamburg, Germany
| | - J. Neumann
- HELIOS ENDO-Klinik Hamburg, Orthopaedic
Surgery, Holstenstr. 2, 22767
Hamburg, Germany
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