1
|
Mizels J, Lewis DC, Tashjian RZ, Chalmers PN. Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial. J Am Acad Orthop Surg 2024:00124635-990000000-00990. [PMID: 38759230 DOI: 10.5435/jaaos-d-23-00376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 10/04/2023] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up. METHODS This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up. RESULTS Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168). CONCLUSION The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Joshua Mizels
- From the Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | | | | | | |
Collapse
|
2
|
Karimi A, Jalalpour P, Reddy RP, Sabzevari S, Keeling LE, Lin A. Diagnostic arthroscopy for periprosthetic shoulder arthroplasty infections: a systematic review and meta-analysis. JSES Int 2023; 7:835-841. [PMID: 37719814 PMCID: PMC10499863 DOI: 10.1016/j.jseint.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Periprosthetic joint infection of the shoulder (PJI) is a devastating complication with a reported incidence of 1%-15.4% and is often difficult to diagnose with current diagnostic tools including serologic tests and arthrocentesis. This systematic review evaluates the reliability and validity of arthroscopic biopsy in the current literature for the diagnosis of shoulder PJI. Methods MEDLINE, Scopus, Web of Sciences, Google Scholar, and Cochrane databases were queried electronically from inception to June 2022 for publications reporting diagnostic accuracy of shoulder arthroscopic biopsy for detecting infection after anatomic total shoulder arthroplasty, shoulder hemiarthroplasty, or reverse total shoulder arthroplasty. This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results After exclusion, our meta-analysis consisted of 7 articles with a total of 112 patients. The estimated pooled sensitivity and specificity of arthroscopic biopsy for confirmation of shoulder periprosthetic infection were 0.87 (95% confidence interval [CI]: 0.73-0.95) and 0.79 (95% CI: 0.67-0.88), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 4.15 (95% CI: 2.57, 6.70) and 0.17 (95% CI: 0.08, 0.36), respectively. The aggregate positive predictive value was 73.58% (95% CI: 63.29%-81.82%), and aggregate negative predictive value was 89.83% (95% CI: 80.59%-94.95%). The diagnostic odds ratio of arthroscopic biopsy was 19.92 (95% CI: 4.96-79.99). Conclusion Arthroscopic biopsy in patients suspected of shoulder PJI has good diagnostic accuracy, with high sensitivity and specificity. Given the various biopsy protocols (such as devices, numbers, locations, etc.), further prospective studies are necessary to define the future role of arthroscopic biopsy in diagnosis and treatment.
Collapse
Affiliation(s)
- Amin Karimi
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
- Research Development Unit, Department of Orthopedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooyan Jalalpour
- Research Development Unit, Department of Orthopedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rajiv P Reddy
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Soheil Sabzevari
- Memorial Sloan Kettering Cancer Center, Weill Cornell University, New York City, NY, USA
| | - Laura E Keeling
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, PA, USA
| |
Collapse
|
3
|
Role of pre-revision tissue biopsy in evaluation of painful shoulder arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg 2021; 30:1445-1457. [PMID: 33220414 DOI: 10.1016/j.jse.2020.10.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pre-revision tissue biopsy (PTB) for culture has been used as a diagnostic tool in the evaluation for periprosthetic joint infection among patients with a painful shoulder arthroplasty. The purpose of this study was to (1) determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of PTB culture results compared with results of "gold-standard" tissue biopsy for culture taken at the time of subsequent revision surgery (TBR), and (2) report the current indications and protocols described for use of PTB. The hypothesis was that PTB culture results would correlate highly with results of TBR and that protocols for PTB would vary by institution. METHODS By use of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis of English-language literature were performed using the Embase, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases from inception through March 2020. Methodological Index for Non-randomized Studies (MINORS) validated grading criteria were used to summarize the quality and bias of included studies. Studies were included if an arthroscopic or open tissue biopsy was performed in patients who had previously undergone anatomic total shoulder arthroplasty, shoulder hemiarthroplasty, or reverse total shoulder arthroplasty as a separate procedure prior to revision of components, if applicable. Meta-analysis to identify the sensitivity, specificity, NPV, and PPV of PTB was performed. Analysis was performed by first defining 1 positive PTB culture result as infection and then defining 2 positive culture results as infection. RESULTS A total of 1751 titles were screened, and 66 full-text articles were reviewed for inclusion. Four total studies encompassing 72 cases met the inclusion criteria. All studies were small (N = 13 to N = 23), retrospective series, with all but 12 biopsies performed arthroscopically. Sixty-five patients (90.2%) underwent subsequent revision surgery and TBR. Of these patients, 23 (35.4%) had ≥1 positive culture result with PTB and TBR. By this definition, the sensitivity of PTB was 92.0% (95% confidence interval [CI], 72.5%-98.6%); specificity, 70.0% (95% CI, 53.3%-82.9%); PPV, 65.7% (95% CI, 47.7%-80.3%); and NPV, 93.3% (95% CI, 76.5%-98.8%). For 2 positive PTB results, the sensitivity of PTB was 100% (95% CI, 51.7%-100%); specificity, 50.0% (95% CI, 31.4%-68.6%); PPV, 33.3% (95% CI, 14.4%-58.8%); and NPV, 100% (95% CI, 69.9%-100%). No complications of PTB were reported. The mean Methodological Index for Non-randomized Studies (MINORS) grade was 11.4 (range, 8.5-14). CONCLUSION PTB is a sensitive diagnostic modality with a high NPV that may aid in the diagnosis of shoulder periprosthetic joint infection in patients with a painful shoulder arthroplasty. Given the disparate biopsy protocols, greater standardization of clinical best practices and broader prospective studies are necessary to define the future role of PTB in dictating treatment.
Collapse
|
4
|
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
| | | | | | | | | | | |
Collapse
|
5
|
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: 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: 02/21/2019] [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.
Collapse
|
6
|
Shoulder Joint Infections with Negative Culture Results: Clinical Characteristics and Treatment Outcomes. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3756939. [PMID: 30891455 PMCID: PMC6390271 DOI: 10.1155/2019/3756939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 12/26/2018] [Accepted: 01/29/2019] [Indexed: 11/17/2022]
Abstract
Background The incidence of septic arthritis of the shoulder joint is increasing as the population ages. The prevalence of shoulder infection is also increasing because of the growing use of arthroscopy and expansion of procedures in the shoulder. However, cultures do not always identify all microorganisms, even in symptomatic patients. The incidence of negative cultures ranges from 0% to 25%. Few studies have reported clinical features and treatment outcomes of culture-negative shoulder infections. This cohort study addresses culture-negative shoulder joint infections in nonarthroplasty patients. This study aimed to compare clinical characteristics and treatment outcomes of patients with culture-negative results to those with culture-positive results. Our hypothesis was that culture-negative infections would have more favorable outcomes than culture-positive infections. Methods We retrospectively reviewed data of 36 patients (17 culture-negative and 19 culture-positive) with shoulder infections between June 2004 and March 2015. The minimum follow-up duration was 1.2 years (mean, 5 ± 3.8 years; range, 1.2-11 years). We assessed preoperative demographic data and characteristics, laboratory markers, imaging and functional scores, intraoperative findings, and postoperative findings of both groups. Results Culture-negative patients (17/36, 47.2%) had a significantly lower occurrence of repeated surgical debridement (culture-negative vs. culture-positive: 1.2 ± 0.4 vs. 2.4 ± 1.7, p = 0.002) without osteomyelitis. In the multiple logistic regression analysis, the presence of osteomyelitis [odds ratio (OR) = 9.7, 95% confidence interval (CI): 1.0-91.8, p=0.04)] and the number of surgical debridements (OR = 5.3, 95% CI: 1.3-21.6, p=0.02) were significantly associated with culture-positive infections. Conclusions Culture-negative infections without osteomyelitis are less severe than culture-positive infections. Culture-negative infections can be controlled more easily and are not necessarily a negative prognostic factor for shoulder joint infections.
Collapse
|
7
|
Tashjian RZ, Granger EK, Zhang Y. Utility of prerevision tissue biopsy sample to predict revision shoulder arthroplasty culture results in at-risk patients. J Shoulder Elbow Surg 2017; 26:197-203. [PMID: 27727058 DOI: 10.1016/j.jse.2016.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 06/11/2016] [Accepted: 07/01/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The diagnosis of infection after shoulder arthroplasty can be challenging. The current study evaluated the utility of a prerevision biopsy sample in predicting positive cultures or a final diagnosis of infection in the setting of an "at-risk" failed shoulder arthroplasty. METHODS The study reviewed 77 patients with no history of infection undergoing revision shoulder arthroplasty by a single surgeon between June 2010 and July 2015. All patients with a C-reactive protein and erythrocyte sedimentation rate within normal reference ranges and no fluid on aspirate, or an abnormal value for the erythrocyte sedimentation rate or C-reactive protein, or both, and no growth on aspirate, underwent a prerevision biopsy because they were considered "at-risk" for infection. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to evaluate the utility of biopsy specimens to predict positive cultures as well as a final determination of infection. RESULTS A prerevision biopsy was performed in 17 patients with a failed arthroplasty. The sensitivity, specificity, PPV, and NPV, for a positive prerevision biopsy sample to predict a positive final culture were 0.75, 0.6, 0.82, and 0.5, respectively. The sensitivity, specificity, PPV, and NPV for an infection defined by a prerevision biopsy sample to predict an infection defined by the combined final revision and biopsy cultures were 0.9, 0.86, 0.9, and 0.86, respectively. CONCLUSIONS The ability for prerevision biopsy specimens of failed arthroplasties to predict the presence of bacteria at the time of revision surgery is high, although lower than previously reported. If biopsy results are used to define and predict a diagnosis of infection, the sensitivity, specificity, PPV, and NPV all significantly improve.
Collapse
Affiliation(s)
- Robert Z Tashjian
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Erin K Granger
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Yue Zhang
- Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, UT, USA
| |
Collapse
|
8
|
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.
Collapse
Affiliation(s)
| | | | | | - Ian A Trail
- Professor Ian A Trail, Upper Limb Unit, Wrightington Hospital, Hall Lane, Appley Bridge, Wigan, Lancashire WN6 9EP, UK.
| |
Collapse
|
9
|
Horner NS, de Sa D, Heaven S, Simunovic N, Bedi A, Athwal GS, Ayeni OR. Indications and outcomes of shoulder arthroscopy after shoulder arthroplasty. J Shoulder Elbow Surg 2016; 25:510-8. [PMID: 26652703 DOI: 10.1016/j.jse.2015.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/09/2015] [Accepted: 09/15/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Arthroscopy is a widely used intervention in the treatment of a variety of shoulder conditions. Arthroscopy has also been selectively used in symptomatic patients after shoulder arthroplasty. The purpose of this systematic review was to determine indications for shoulder arthroscopy in patients after shoulder arthroplasty and to report patient outcomes after these procedures. MATERIALS AND METHODS The electronic databases MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for studies involving shoulder arthroscopy in shoulder arthroplasty patients. A full-text review of eligible studies was conducted in duplicate, and references were searched using predetermined inclusion and exclusion criteria. RESULTS The review included 11 studies containing 84 patients. All were Level IV evidence. The most common indications for shoulder arthroscopy in the setting of shoulder arthroplasty were pain or loss of range of motion without a clear diagnosis, suspected periprosthetic infection, and rotator cuff assessment. Although 92% of patients were satisfied with the procedure and standardized shoulder scores increased in all studies that reported them, 44% of patients still went on to additional revision surgery after arthroscopy. CONCLUSIONS Shoulder arthroscopy in patients after arthroplasty is most frequently used as a diagnostic tool; however, it has utility in treating a number of predetermined pathologies. Despite the low sample size and quality of evidence in our review, patient satisfaction after arthroscopy is high because standardized outcome scores improve, and the risk of complications is low. However, a high percentage of patients who receive arthroscopy later require further surgery.
Collapse
Affiliation(s)
- Nolan S Horner
- Michael G. DeGroote School of Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sebastian Heaven
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Nicole Simunovic
- Centre for Evidence-Based Orthopaedics, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Asheesh Bedi
- Division of Orthopaedic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - George S Athwal
- Roth
- McFarlane Hand & Upper Limb Centre, St. Josephs Health Care, London, ON, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
10
|
Heaven S, de Sa D, Duong A, Simunovic N, Ayeni OR. Safety and efficacy of arthroscopy in the setting of shoulder arthroplasty. Curr Rev Musculoskelet Med 2016; 9:54-8. [PMID: 26810062 PMCID: PMC4762807 DOI: 10.1007/s12178-016-9318-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Shoulder arthroplasty has become a reliable and reproducible method of treating a range of shoulder pathologies including fractures, osteoarthritis, and rotator cuff arthropathy. Although most patients experience favorable outcomes from shoulder arthroplasty, some patients suffer from persistent symptoms post-arthroplasty and it is these patients who present a unique diagnostic and therapeutic challenge. The role of arthroscopy in assessing and treating patients with symptomatic prosthetic joints elsewhere in the body has been established in recent literature. However, the range of pathology that can affect a prosthetic shoulder is distinct from the knee or the hip and requires careful and considered assessment if an accurate diagnosis is to be made. When used alongside other investigations in a comprehensive assessment protocol, arthroscopy can play an important role in the diagnosis and treatment of the problematic shoulder arthroplasty.
Collapse
Affiliation(s)
- Sebastian Heaven
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main Street West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main Street West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Andrew Duong
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main Street West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Nicole Simunovic
- Centre for Evidence-Based Orthopaedics, Department of Clinical Epidemiology and Biostatistics, McMaster University, 293 Wellington Street North, Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main Street West, 4E15, Hamilton, ON, L8N 3Z5, Canada.
| |
Collapse
|
11
|
A clinical perspective on musculoskeletal infection treatment strategies and challenges. J Am Acad Orthop Surg 2015; 23 Suppl:S44-54. [PMID: 25808969 DOI: 10.5435/jaaos-d-14-00379] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Orthopaedic implants improve the quality of life of patients, but the risk of postoperative surgical site infection poses formidable challenges for clinicians. Future directions need to focus on prevention and treatment of infections associated with common arthroplasty procedures, such as the hip, knee, and shoulder, and nonarthroplasty procedures, including trauma, foot and ankle, and spine. Novel prevention methods, such as nanotechnology and the introduction of antibiotic-coated implants, may aid in the prevention and early treatment of periprosthetic joint infections with goals of improved eradication rates and maintaining patient mobility and satisfaction.
Collapse
|
12
|
Abstract
Periprosthetic joint infection remains a clinical challenge with no benchmark for diagnosis. The diagnosis is based on many different clinical variables that may be difficult to interpret, especially in the setting of chronic systemic disease. Synovial fluid aspiration, diagnostic imaging, traditional culture, peripheral serum inflammatory markers, and intraoperative frozen sections each have their limitations but continue to be the mainstay for diagnosis of periprosthetic joint infection. As molecular- and biomarker-based technologies improve, the way we interpret and diagnose periprosthetic joint infection will ultimately change and may even improve diagnostic accuracy and turnaround time. Future research on this topic should be focused on improving diagnostic criteria for low-virulence organisms, improving interpretation of intraoperative frozen sections, and establishing improved synovial fluid and peripheral serum biomarker profiles for periprosthetic joint infection.
Collapse
|
13
|
Dilisio MF, Miller LR, Warner JJP, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am 2014; 96:1952-8. [PMID: 25471909 DOI: 10.2106/jbjs.m.01512] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic shoulder infections can be difficult to diagnose. The purpose of this study was to investigate the utility of arthroscopic tissue culture for the diagnosis of infection following shoulder arthroplasty. Our hypothesis was that culture of arthroscopic biopsy tissue is a more reliable method than fluoroscopically guided shoulder aspiration for diagnosing such infection. METHODS A retrospective review identified patients who had undergone culture of arthroscopic biopsy tissue during the evaluation of a possible chronic periprosthetic shoulder infection. The culture results of the arthroscopic biopsies were compared with those of fluoroscopically guided glenohumeral aspiration and open tissue biopsy samples obtained at the time of revision surgery. RESULTS Nineteen patients had undergone arthroscopic biopsy to evaluate a painful shoulder arthroplasty for infection. All subsequently underwent revision surgery, and 41% of those with culture results at that time had a positive result, which included Propionibacterium acnes in each case. All arthroscopic biopsy culture results were consistent with the culture results obtained during the revision surgery, yielding 100% sensitivity, specificity, positive predictive value, and negative predictive value. In contrast, fluoroscopically guided glenohumeral aspiration yielded a sensitivity of 16.7%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 58.3%. CONCLUSIONS Arthroscopic tissue biopsy is a reliable method for diagnosing periprosthetic shoulder infection and identifying the causative organism. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Matthew F Dilisio
- Department of Orthopaedics, Brigham and Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115. E-mail address for L.D. Higgins:
| | - Lindsay R Miller
- Department of Orthopaedics, Brigham and Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115. E-mail address for L.D. Higgins:
| | - Jon J P Warner
- Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - Laurence D Higgins
- Department of Orthopaedics, Brigham and Women's Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115. E-mail address for L.D. Higgins:
| |
Collapse
|
14
|
Abstract
➤ The unique bacterial flora of the shoulder present diagnostic and treatment challenges that are distinct from those seen with failed hip and knee arthroplasties.➤ The presentation, diagnosis, and management of suppurative periprosthetic joint infections of the shoulder are similar to those of the hip and the knee.➤ Failed arthroplasties with positive cultures (FAPCs) are poorly performing shoulder reconstructions associated with low-virulence microorganisms that do not evoke a suppurative inflammatory response. Propionibacterium acnes is the predominant bacterium isolated from these cases.➤ With improved surgeon awareness and the addition of longer tissue-culture incubation times, detection of FAPCs has become more common. However, management is hampered by the lack of reliable, timely tests that can determine the presence of less virulent organisms in the preoperative or intraoperative settings.➤ The implications of positive culture results in FAPCs are unclear. Key test characteristics such as the false-positive rate and the prevalence of positive cultures in well-performing shoulders are unknown as there is no useful confirmatory test to validate the culture data and no reliable way to detect the presence of less virulent microorganisms without reoperation.➤ Soft-tissue and osseous deficits are frequently encountered when revising previously infected shoulders. The rate of complications in these scenarios is high, and the outcomes are the least favorable compared with revisions for any other indication.➤ The development of a consensus definition of a periprosthetic shoulder infection is critical to future investigations of these devastating complications.
Collapse
Affiliation(s)
- William R Mook
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710. E-mail address for W.R. Mook:
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Duke University Medical Center, Box 3000, Durham, NC 27710. E-mail address for W.R. Mook:
| |
Collapse
|
15
|
Li X, Eichinger JK, Higgins LD. Management of failed metal-backed glenoid component in patients with bilateral total shoulder arthroplasty. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2014; 7:143-8. [PMID: 24403762 PMCID: PMC3883189 DOI: 10.4103/0973-6042.123527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Total shoulder arthroplasty (TSA) is successful in providing pain relief and functional improvements for patients with shoulder arthritis. Outcomes are directly correlated with implant position and fixation, which ultimately affects wear and longevity. Metal-backed glenoid components were introduced as an alternative to the standard cemented glenoid fixation. Early loosening and cavitary glenoid bone loss has been reported as a major complication associated with these metal-backed glenoids, which presents the surgeon with a challenging revision situation. Furthermore, failure of bilateral TSA in patients with metal-backed glenoids is extremely rare. We present two patients with early failure of bilateral TSA secondary to loosening of the metal-backed glenoids. Both patients had significant glenoid bone loss and were treated with four different types of revision techniques. A description of treatments and outcomes of both patients are reported along with the simple shoulder test and American Shoulder and Elbow Surgeons scores. One patient underwent revision to bilateral reverse prosthesis and experienced a much-improved outcome in comparison to the patient revised to a hemiarthroplasty and resection arthroplasty, for each shoulder respectively. In patients who present with failed TSA, revision to a reverse prosthesis with or without staged glenoid bone graft should be considered as an option of treatment. It is also important to rule out infection with intraoperative tissue biopsy before proceeding to revision surgery. However, in patients with catastrophic glenoid bone loss, both hemiarthroplasty and resection arthroplasty can provide an alternative treatment option, but they are associated with a poorer functional outcome and pain relief.
Collapse
Affiliation(s)
- Xinning Li
- Assistant Professor, Sports Medicine and Shoulder and Elbow Surgery, Department of Orthopaedics, Boston University School of Medicine, 720 Harrison Avenue - Suite #808, Boston, MA 02118, USA
| | - Josef K Eichinger
- Assistant Professor of Surgery, Chief of Shoulder & Elbow Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Laurence D Higgins
- Assistant Professor, Chief of the Sports Medicine and Shoulder Service. Harvard Medical School. Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
16
|
Injection-induced low-grade infection of the shoulder joint: preliminary results. Arch Orthop Trauma Surg 2012; 132:1387-92. [PMID: 22707212 DOI: 10.1007/s00402-012-1562-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Indexed: 02/09/2023]
Abstract
BACKGROUND Purulent arthritis of the shoulder has been widely reported. Low-grade post-operative infections of the shoulder have also been observed. Low-grade infections of the shoulder without prior surgery have not been reported in the literature. The purpose of this study is to present our experience of seven patients with low-grade infections of the shoulder without a history of prior surgery. METHODS We retrospectively reviewed seven patients, mean age of 45 years that originally presented with diffuse shoulder pain, with or without stiffness. None had prior surgery but all had prior injections, average 5.6, into the shoulder. All patients were treated with various arthroscopic procedures. All had harvesting of four tissue probes identifying low-grade infection. Pre/post-operative pain score, pre/post-operative range of motion, intraoperative findings, post-operative Constant score, Subjective Shoulder Value and pre/post operative radiographs were analyzed. Post-operative antibiotic therapy was recorded. RESULTS All patients showed synovitis without pus or any other sign of infection. Propionibacterium acnes were identified in five, coagulase-negative Staphylococcus in two, and Staphylococcus saccharolyticus in one shoulder. One patient had a mixed infection (Propionibacterium acnes and coagulase-negative Staphylococcus). Therapy consisted of oral antibiotics for 1-6 months. Four patients had a satisfactory and three an unsatisfactory outcome. CONCLUSIONS Diffuse shoulder pain with or without stiffness in patients without prior surgical history can be caused by low-grade infection. Treatment using oral antibiotics has unpredictable outcomes. Further studies are necessary to analyze this pathology. LEVEL OF EVIDENCE Level IV, retrospective case series, treatment study.
Collapse
|