Arthroscopic debridement for septic arthritis of the shoulder joint: post-infectious arthritis is an inevitable consequence?

Re-operation rates of arthroscopic management versus arthrotomy in treatment of septic arthritis of native shoulder joint in adults. A systematic review and meta-analysis

AIMS

Previous studies have reported concern regarding high reoperation rates when septic arthritis of the native shoulder is treated arthroscopically, compared to open arthrotomy. We aimed to compare re-operation rate between the two strategies.

PATIENTS AND METHODS

The review was registered prospectively at PROSPERO, (CRD42021226518). We searched common databases and references lists (8 February 2021). The inclusion criteria included interventional or observational studies of adult patients with a confirmed diagnosis of native shoulder joint septic arthritis and had either arthroscopy or arthrotomy. The exclusion criteria included patients with periprosthetic or post-surgical infections, patients who had atypical infections, and studies that did not report re-operation rate. Cochrane Collaboration's tool for assessing risk of bias (ROBINS-I) was used.

RESULTS

Nine studies (retrospective cohort studies) were included that involved 5,643 patients (5,645 shoulders). Mean age ranged from 55.6 to 75.5 years, and follow-up time ranged from 1-41 months. Mean duration of symptoms prior to presentation ranged from 8.3-23.3 days. Metanalysis observed a higher re-operation rate for reinfection at any time point following initial arthroscopy in comparison to arthrotomy, odds ratio 2.61 (95% confidence interval 1.04, 6.56). There was marked heterogeneity (I2 = 78.8%) among studies including surgical techniques and missing data.

CONCLUSION

This metanalysis observed a higher reoperation rate in arthroscopy in comparison to arthrotomy for the treatment of native shoulder septic arthritis in adults. The quality of the included evidence is low and the heterogeneity among included studies is marked. Higher quality evidence is still needed that address limitations of previous studies.

Joint aspiration and serum markers - do they matter in the diagnosis of native shoulder sepsis? A systematic review

Background

Septic arthritis of the native shoulder is traditionally diagnosed with the same strategies as knee or hip septic arthritis. However, septic arthritis of the shoulder is frequently a missed or delayed diagnosis. Reliance on aspiration and serum markers has been called into question recently. The purpose of this study was to conduct a systematic review investigating the value of joint aspiration and serum markers in the diagnosis of native shoulder joint sepsis.

Methods

PubMed/MEDLINE, Scopus, and the Cochrane Library were used in the systematic literature search from January 1, 1960, through January 23, 2021. The primary outcome was to report on the synovial white cell count of patients with native shoulder sepsis. Descriptive statistics using percentages, means, and intraclass correlation coefficient (ICC) values were used to summarize the results.

Results

Thirty-one studies, including 25 case series, one case-control, and five cohort studies with a total of 7434 native shoulder joints, were included. There was no standardized approach to diagnosing septic arthritis of the shoulder. Only 10 studies (32%) reported on synovial white cell count with the majority yielding aspiration counts greater than 50,000 cells/mm³, although one study was as low as 30,000 cells/mm³.

Conclusions

The diagnosis of native shoulder joint sepsis lacks uniformity. Methods used to evaluate shoulder sepsis are heterogeneous and may lead to delays or misdiagnosis with devastating sequelae. Synovial white cell count is underutilized and may also present with a lower value than expected, which is likely related to the time interval between symptom onset and diagnosis.

Factors affecting the outcome of septic arthritis of the shoulder joint with arthroscopic management

BACKGROUND

Good results have been reported with arthroscopic therapy of septic arthritis of the shoulder; however, few studies have focused on the risk factors for failure of arthroscopic surgery. The purpose of this study was to identify the risk factors affecting the recurrence or death post-surgery in cases of septic arthritis of the shoulder.

METHODS

We retrospectively assessed the records of patients who underwent surgical treatment for septic arthritis of the shoulder between 2009 and 2019. Patients were divided into 2 groups based on complete recovery, recurrence, or death after a single arthroscopic surgery: the eradicated group and the recurred/death group. To identify risk factors for the failure of arthroscopic surgery for septic arthritis of the shoulder, the following parameters were considered: age, sex, presentation of a rotator cuff tear, the arthroscopic staging of the infection, diabetes mellitus, the causative organism, preoperative white blood cell count, and C-reactive protein level in blood. We compared two groups with respect to the presence of potential risk factors.

RESULTS

This study included 22 patients with a mean age of 67.9 years. Septic arthritis of the shoulder was eradicated completely with a single arthroscopic surgery in 17 patients (77.3%). However, failure of the surgery resulting in recurrence or death was observed in 5 patients (22.7%). No significant differences were observed in other parameters between the two groups except for the causative organism. Methicillin-resistant Staphylococcus aureus was found in 1 patient (5.9%) in the eradicated group. On the other hand, Methicillin-resistant S. aureus was found in 3 patients (60%) in the recurred/death group (p = 0.024).

CONCLUSION

Most patients with septic arthritis of the shoulder are effectively treated with a single arthroscopic surgery. This study suggests that Methicillin-resistant S. aureus as the causative organism may be the most important prognostic factor in these cases.