Serum C-reactive protein in patients undergoing elective shoulder arthroplasty. Prospective study

Factors Associated With Elevated Inflammatory Markers Prior to Shoulder Arthroplasty

Background: Preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) ranges for several shoulder arthroplasty indications are not well understood. Purpose: We sought to compare preoperative ESR and CRP values for a variety of shoulder arthroplasty indications and evaluate risk factors for elevated preoperative ESR and CRP values. Methods: We conducted a retrospective cohort study of shoulder arthroplasty cases performed at a single academic medical institution from 2013 to 2018. Preoperative ESR and CRP values for 235 shoulder arthroplasties with various indications were recorded. Independent risk factors for elevated values (CRP > 10.0 mg/L and ESR > 30.0 mm/h) were determined via multiple variable logistic regression. Results: Patients undergoing shoulder arthroplasty for osteoarthritis had an ESR (mean ± SD) of 22.6 ± 17.8, with 29.8% of patients elevated, and a CRP of 6.5 ± 6.4, with 25.5% of patients elevated. Arthroplasty for acute fracture and prosthetic joint infection (PJI) had higher preoperative ESR and CRP values. Multivariate analysis identified several predictors of elevated ESR, including infection, acute fracture, diabetes, and female sex. It also identified predictors of elevated CRP, including infection, acute fracture, and younger age. Conclusions: Preoperative ESR and CRP values may be elevated in 25% to 30% of patients undergoing primary shoulder arthroplasty. Arthroplasty for both acute fracture and PJI, along with several other patient factors, was associated with elevated preoperative ESR and CRP. Thus, routine collection of ESR and CRP preoperatively may not be of benefit, as elevated values are common. Further study is warranted.

Editorial Commentary: Are Serum Inflammatory Markers Useful Diagnostic Tools in the Shoulder?

Serum inflammatory markers are commonly used to evaluate for the presence of surgical-site infection or periprosthetic joint infections following orthopaedic surgery. However, data on the utility of these tests following shoulder surgery are more limited. Worse diagnostic performance is seen in the shoulder when compared with use of these tests in the evaluation of hip and knee infections, likely due to the low virulence of the commonly cultured shoulder organisms, and the normalization of these serum markers following shoulder surgery is less well defined when compared with the hip and knee literature. A better understanding of the behavior of these serum inflammatory markers in the shoulder may enhance the utility of these tests in the diagnosis and management of infection following elective shoulder surgery.

Hematologic Expression After Shoulder Surgery: Normalization Curve of Serum Inflammatory Markers

PURPOSE

To determine the normalization curves of the serologic markers including white blood cell (WBC) count, WBC differential for segmented neutrophil (WBC seg.), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) after elective shoulder surgery and to investigate the hematologic differences among different shoulder surgeries.

METHODS

Seventy-seven patients underwent arthroscopic rotator cuff repair (RCR, group A), 44 patients had open rotator cuff repair (group B), and 84 patients had shoulder arthroplasty (group C). Peak and normalization times of markers were determined at preoperatively, postoperative day (POD) 1 and 2 days, 1 and 2 weeks, 1, 2, 3, 6 months, and 1 year after surgery. The normal ranges of serologic markers were set to WBC 4000 to10,000/μL, WBC seg. 40% to 60%, ESR 0 to 20 mm/h, and CRP 0 to 0.8 mg/dL.

RESULTS

Groups reached peak mean WBC count and WBC seg. on POD 1; mean WBC count started decreasing on POD 2 but was within normal value afterwards. Mean WBC seg. decreased to normal value at 1 month postoperatively in group A and B and at 2 months postoperatively in group C. Mean ESR peaked at 2 weeks postoperatively and normalized after 1 month in groups A and B and 3 months in group C. Mean CRP levels peaked on POD 2 in all groups and normalized within 2 weeks postoperatively in groups A and B and 1 month postoperatively in Group C. Normalized values of WBC count, WBC seg., and ESR varied widely. In contrast, CRP showed a consistent undetectable median, upper and lower quartile values less than 0.5 after normalization. Mean serum ESR and CRP values at peak time were significantly greater in group C than in the other groups (P = .001).

CONCLUSIONS

The mean CRP levels were normalized at 2 weeks after rotator cuff repair and at 1 month after arthroplasties. Unlike the other serologic markers, CRP had consistent normalized values of median, upper and lower quartile afterwards. The peak levels of the inflammatory markers were greater and therefore normalized slower following more invasive surgery.

LEVEL OF EVIDENCE

Level III, case control study.

Postoperative Trends of Serum C-Reactive Protein Levels after Primary Shoulder Arthroplasty-Normal Trajectory and Influencing Factors

Background-Postoperative serum C-reactive protein (CRP) is an important diagnostic parameter for systemic inflammation and reflects surgical trauma. While trends and normal trajectories after total knee (TKA) or hip arthroplasty (THA) are established, there is no reference standard for shoulder arthroplasty (SA). Therefore, the aim of this study was to research CRP trends and influencing factors following SA. Methods-This retrospective study analyzed postoperative serum CRP levels and trajectories in 280 patients following SA. Influence of prosthesis design, sex, operating time, BMI, and humeral augmentation with bone cement were analyzed using descriptive statistics and (non-) parametric testing. Results-There is a CRP trend with a peak on day two or three, with a subsequent decrease until day seven. Reverse and stemmed prostheses show a statistically higher CRP peak than stemless prostheses or hemiarthroplasties (HA). There was no influence of gender, body mass index (BMI), operating time, or bone cement. Conclusion-The presented findings may contribute to a better understanding of the postoperative CRP course after SA. The results of this retrospective study should be validated by a prospective study design in the future.

Safety and Effectiveness of Shoulder Arthroplasties in Spain: A Systematic Review

The effectiveness and safety of shoulder arthroplasties in the general context of a Spanish patient population remains unclear. The aim of this study was to ascertain both the effectiveness and safety of primary shoulder arthroplasties and the prosthesis types used in Spain. A systematic review of all the available literature evaluating the effectiveness and safety of primary shoulder arthroplasties in Spain was performed. A narrative synthesis was performed, and evidence tables were created in four dimensions: study design, arthroplasty characteristics, safety, and effectiveness. Orthopaedic Data Evaluation Panel (ODEP) scores were used to evaluate prosthesis types. Twenty-one studies were selected that included a total of 1293 arthroplasties. The most common indication was fractures, while the prosthesis most frequently used was the Delta Xtend (ODEP 10A). The most common complication was scapular notching. Prosthesis revision rate was approximately 6% for follow-ups between 12 and 79 months. In addition, significant improvements were observed in the Constant-Murley test score after the intervention. Currently in Spain, shoulder arthroplasty can be considered a safe and effective procedure with functional recovery and pain reduction for eligible patients with humeral fracture, rotator cuff arthropathy, fracture sequelae and malunion of the proximal humerus, and degenerative disease. Future longitudinal research and population-based studies could serve to confirm these results and identify points of improvement.

Results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection

Background

The objective of this study is to present the results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection and to determine the rate of positive cultures in the second-stage surgery in shoulder arthroplasty and its meaning.

Methods

Twenty-one patients (22 cement spacers) treated with two-stage surgery because of a shoulder arthroplasty infection were included. In the second stage, the cement spacer was sent for sonication and at least four tissue cultures were obtained. Epidemiological data, comorbidities, sensitivity of the microorganisms to the antibiotic loaded in the cement spacer in the first revision surgery, time elapsed since an antibiotic was last administered until second revision procedure, functional shoulder status at last follow-up, and any complication were recorded.

Results

Three out of the 22 cases (13.6%) presented positive cultures at the second-stage surgery. Periprosthetic tissue culturing detected the three positive culture cases in the second stage while the cement spacer sonication detected two and missed one. Considering periprosthetic tissue culturing as the standard procedure, the cement spacer sonication showed sensitivity at 66.6%. Recurrent infection over time was considered present in 3 patients; two of them had been previously diagnosed with a positive culture at the second stage (66.6%).

Conclusions

A good number of patients (13.6%) present a positive culture at the second stage of the two-stage surgical procedure for infected shoulder arthroplasty, and those patients seem to be at high risk for recurrent infection. Periprosthetic tissue cultures have a higher sensitivity to detecting a positive culture at the second stage than cement spacer sonication.