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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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El Amiri L, Clavert P, Gaudias J, Klein S, Rondé Oustau C, Antoni M. High infection control rate after systematic one-stage procedure for shoulder arthroplasty chronic infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:2809-2826. [PMID: 37612523 DOI: 10.1007/s00264-023-05927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE The two stage revision procedure is the gold standard surgical technique in chronic shoulder periprosthetic joint infection (PJI). Series of one stage revision have been published with similar outcomes but with preoperative selection of patients. The aim of this work was to report the outcomes (infection eradication, functional, and radiographic) after systematic one stage revision, without preoperative selection of patients, in chronic shoulder PJI. METHODS This was a retrospective monocentric study including 40 patients (14 women and 26 men) with a diagnosis of periprosthetic joint infection after a shoulder arthroplasty. A one stage shoulder prosthesis revision was performed in all patients, for a PJI evolving for more than three weeks, without preoperative patient selection. The primary endpoint was the absence of signs of persistent infection at a minimum follow-up of two years. Secondary endpoints were clinical and radiological outcomes. RESULTS At the last follow-up, 36/40 patients had no recurrence of infection after the one stage revision, i.e., 90% of our series. In 45% (18/40) of the cases, the microbial organism was not known at the time of the one stage revision. Cutibacterium acnes was the most frequent pathogen, found in 67.5% (27/40) of the patients. The infection was polymicrobial in 40% (16/40) of the cases. At last follow-up, mean absolute Constant score was 48.4% (16-93) and weighted score was 65.5% (22-100), and satisfaction was evaluated by the patients as excellent or good in 75% (30/40). About 20% (8/40) of the patients had a postoperative complication. CONCLUSION A one stage revision procedure, combined with appropriate antibiotic therapy, made it possible to eradicate the PJI in 90% of the shoulders in our series with satisfactory functional outcomes.
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Affiliation(s)
- Laëla El Amiri
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France
| | - Philippe Clavert
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France
| | - Jeannot Gaudias
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Stéphane Klein
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Cécile Rondé Oustau
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Maxime Antoni
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France.
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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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Two-stage shoulder arthroplasty after deep infection of the shoulder caused by arthroplasty, osteosynthesis or other surgical procedures: microbial spectrum, complications and functional outcome after at least 1 year follow-up. Arch Orthop Trauma Surg 2023; 143:707-715. [PMID: 34432098 DOI: 10.1007/s00402-021-04129-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Infection represents probably the most challenging complication in shoulder arthroplasty and all other surgical procedures of the shoulder. A deep infection of the shoulder is often combined with a destruction of the joint and a loss of function. In many cases the arthroplasty is the last resort for these patients to obtain a satisfactory function. The objective of this study was to determine outcome data on microbiota and clinical results of a two-stage shoulder arthroplasty procedure after deep infection of the shoulder. METHODS Twenty-six patients with a deep shoulder infection after arthroplasty, osteosynthesis, or rotator-cuff repair were included, while two patients had an empyema without prior surgery. All underwent initial surgical debridement with implantation of an antibiotic-loaded spacer, followed by postoperative systemic antibiotics. The patients obtained definitive shoulder arthroplasty in a second surgery. None of the patients had to undergo more than two surgeries before the arthroplasty. The follow-up analysis including microbiota results, complication rates, and functional outcomes could be determined after at least 1 year in 60% of patients (n = 16). RESULTS The most frequently detected microorganisms were S. epidermidis (31%, n = 10) and Cutibacterium acnes (19%, n = 6). In 28% (n = 9) of cases multi-drug resistant bacteria were detected and in 35% (n = 8) of cases more than one microorganism was found. The overall revision rate was 42%, 11 of 26 patients, in the first 8 weeks after arthroplasty. Reasons for revision were joint dislocations in 23% (n = 6), 15% (n = 4) postoperative hematomas, one (4%) re-infection and one (4%) periprosthetic fracture. At follow-up after 19.3 ± 5.5 months postoperatively, a mean abduction of 113.4°, anteversion of 122.8° and external rotation of 14° was found, with an average age and gender-adjusted Constant Score of the affected shoulder of 63. The subjects' pain and impairment in normal life measured by a questionnaire with school grades were significantly reduced (p < 0.05) as compared to prior shoulder arthroplasty. CONCLUSION The most relevant bacteria in the study cohort were Staphylococcus subspecies and to a lower extent Cutibacterium acnes. A high number of multi-drug resistant and mixed microbiota spectra were detected, defining a need to adapt therapeutic regimen targeting these microbiotas. The two-stage shoulder arthroplasty after a deep infection resulted in excellent infection control with however high early postoperative rates for joint dislocation (23%) and hematomas (15%). At follow-up a stable joint was achieved with a sufficient functional outcome and satisfying outcome for activities of daily living and pain. CLINICAL TRIAL Trial registration number: DRKS00016927, date of registration: 2019/03/19.
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Reddy AK, Checketts JX, Stephens BJ, Anderson JM, Cooper CM, Hunt T, Fishbeck K, Boose M, Detweiler B, Chalkin B, Norris BL. Complication and revision rates after reverse total shoulder revision from hemiarthroplasty: a systematic review. Shoulder Elbow 2022; 14:481-490. [PMID: 36199509 PMCID: PMC9527483 DOI: 10.1177/17585732211019390] [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: 01/22/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 01/17/2023]
Abstract
Background Thus, the purpose of the present study was to (1) characterize common postoperative complications and (2) quantify the rates of revision in patients undergoing hemiarthroplasty to reverse total shoulder arthroplasty revisional surgery. We hypothesize that hardware loosenings will be the most common complication to occur in the sample, with the humeral component being the most common loosening. Methods This systematic review adhered to PRISMA reporting guideline. For our inclusion criteria, we included any study that contained intraoperative and/or postoperative complication data, and revision rates on patients who had undergone revision reverse total shoulder arthroplasty due to a failed hemiarthroplasty. Complications include neurologic injury, deep surgical site infections, hardware loosening/prosthetic instability, and postoperative fractures (acromion, glenoid, and humeral fractures). Results The study contained 22 studies that assessed complications from shoulders that had revision reverse total shoulder arthroplasty from a hemiarthroplasty, with a total sample of 925 shoulders. We found that the most common complication to occur was hardware loosenings (5.3%), and of the hardware loosenings, humeral loosenings (3.8%) were the most common. The revision rate was found to be 10.7%. Conclusion This systematic review found that revision reverse total shoulder arthroplasty for failed hemiarthroplasty has a high overall complication and reintervention rates, specifically for hardware loosening and revision rates.
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Affiliation(s)
- Arjun K Reddy
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Jake X Checketts
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | | | - J Michael Anderson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Craig M Cooper
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, USA
| | - Tyler Hunt
- Lake Erie College of Osteopathic Medicine, Erie, PA, USA
| | - Keith Fishbeck
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Marshall Boose
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Byron Detweiler
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Brian Chalkin
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
| | - Brent L Norris
- Department of Orthopedic Surgery, Oklahoma State University Medical Center, Tulsa, OK, USA
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Ponraj DS, Falstie-Jensen T, Jørgensen NP, Ravn C, Brüggemann H, Lange J. Diagnosis of orthopaedic-implant-associated infections caused by slow-growing Gram-positive anaerobic bacteria - a clinical perspective. J Bone Jt Infect 2021; 6:367-378. [PMID: 34660180 PMCID: PMC8515996 DOI: 10.5194/jbji-6-367-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/13/2021] [Indexed: 12/21/2022] Open
Abstract
Slow-growing Gram-positive anaerobic bacteria (SGAB) such as
Cutibacterium acnes are increasingly recognized as causative agents of implant-associated infections (IAIs) in orthopaedic surgeries. SGAB IAIs are difficult to diagnose because of their non-specific clinical and laboratory findings as well as the fastidious growth conditions required by these bacteria. A high degree of clinical suspicion and awareness of the various available diagnostic methods is therefore important. This review gives an overview of the current knowledge regarding SGAB IAI, providing details about clinical features and available diagnostic methodologies. In recent years, new methods for the diagnosis of IAI were developed, but there is limited knowledge about their usefulness in SGAB IAI. Further studies are required to determine the ideal diagnostic methodology to identify these infections so that they are not overlooked and mistakenly classified as aseptic failure.
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Affiliation(s)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, 8200, Denmark
| | | | - Christen Ravn
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Kolding, 6000, Denmark
| | | | - Jeppe Lange
- Department of Clinical Medicine, Aarhus University, Aarhus, 8000, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, 8700, Denmark
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Henry TW, Entezari V, Ghoraishian M, Williams GR, Namdari S. Complications Associated With Intravenous Antibiotic Treatment for Cutibacterium acnes Periprosthetic Shoulder Infection. Orthopedics 2021; 44:e422-e426. [PMID: 34039208 DOI: 10.3928/01477447-20210414-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Whether positive Cutibacterium acnes cultures during revision shoulder arthroplasty represent true periprosthetic joint infection (PJI), deep tissue inoculant, or laboratory contaminant is a point of substantial controversy. The purpose of this study was to review complications of intravenous antibiotics used for treatment of presumed C acnes shoulder PJI. A study population of 26 patients treated for C acnes PJI with a minimum follow-up of 2 years after operative treatment was established. Complication occurrence and severity were obtained through chart review and phone survey. Sixteen (61.5%) patients experienced a therapeutic complication. Twelve (46.2%) patients experienced a total of 47 antibiotic-associated adverse effects and 10 (38.5%) patients experienced 11 total peripherally inserted central catheter line-associated complications. Female sex carried an increased risk for severe complications (relative risk, 3.3; 95% CI, 1.2-9.5; P=.024). Treatment duration of greater than 6 weeks was a significant predictor for the total number of complications experienced [F(1,23)=5.361; P=.030; adjusted R2=0.189]. Age older than 65 years, treatment duration greater than 6 weeks, and female sex were significant predictors for the number of severe complications [F(3,21)=3.249; P=.042; adjusted R2=0.219]. Treating C acnes infection with intravenous antibiotics carries a substantial risk of adverse events, highlighting the importance of accurate diagnosis of shoulder PJI. Further investigations into the efficacy and safety profile of oral antibiotics for shoulder PJI are necessary. [Orthopedics. 2021;44(3):e422-e426.].
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Kusejko K, Auñón Á, Jost B, Natividad B, Strahm C, Thurnheer C, Pablo-Marcos D, Slama D, Scanferla G, Uckay I, Waldmann I, Esteban J, Lora-Tamayo J, Clauss M, Fernandez-Sampedro M, Wouthuyzen-Bakker M, Ferrari MC, Gassmann N, Sendi P, Jent P, Morand PC, Vijayvargiya P, Trebše R, Patel R, Kouyos RD, Corvec S, Kramer TS, Stadelmann VA, Achermann Y. The Impact of Surgical Strategy and Rifampin on Treatment Outcome in Cutibacterium Periprosthetic Joint Infections. Clin Infect Dis 2021; 72:e1064-e1073. [PMID: 33300545 DOI: 10.1093/cid/ciaa1839] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cutibacterium species are common pathogens in periprosthetic joint infections (PJI). These infections are often treated with β-lactams or clindamycin as monotherapy, or in combination with rifampin. Clinical evidence supporting the value of adding rifampin for treatment of Cutibacterium PJI is lacking. METHODS In this multicenter retrospective study, we evaluated patients with Cutibacterium PJI and a minimal follow-up of 12 months. The primary endpoint was clinical success, defined by the absence of infection relapse or new infection. We used Fisher's exact tests and Cox proportional hazards models to analyze the effect of rifampin and other factors on clinical success after PJI. RESULTS We included 187 patients (72.2% male, median age 67 years) with a median follow-up of 36 months. The surgical intervention was a 2-stage exchange in 95 (50.8%), 1-stage exchange in 51 (27.3%), debridement and implant retention (DAIR) in 34 (18.2%), and explantation without reimplantation in 7 (3.7%) patients. Rifampin was included in the antibiotic regimen in 81 (43.3%) cases. Infection relapse occurred in 28 (15.0%), and new infection in 13 (7.0%) cases. In the time-to-event analysis, DAIR (adjusted hazard ratio [HR] = 2.15, P = .03) and antibiotic treatment over 6 weeks (adjusted HR = 0.29, P = .0002) significantly influenced treatment failure. We observed a tentative evidence for a beneficial effect of adding rifampin to the antibiotic treatment-though not statistically significant for treatment failure (adjusted HR = 0.5, P = .07) and not for relapses (adjusted HR = 0.5, P = .10). CONCLUSIONS We conclude that a rifampin combination is not markedly superior in Cutibacterium PJI, but a dedicated prospective multicenter study is needed.
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Affiliation(s)
- Katharina Kusejko
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Bernhard Jost
- Department of Orthopaedics and Traumatology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Benito Natividad
- Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Departament of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carol Strahm
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Christine Thurnheer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Giulia Scanferla
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ilker Uckay
- University Hospital Zurich, Orthopedic University Hospital Balgrist, Zurich, Switzerland
| | - Isabelle Waldmann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | | | - Martin Clauss
- Center for Musculoskeletal Infections, Department for Orthopedics and Trauma Surgery, University Hospital Basel, University of Basel, Basel, and Kantonsspital Baselland, Liestal, Switzerland
| | | | - Marjan Wouthuyzen-Bakker
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Matteo Carlo Ferrari
- Humanitas Clinical and Research Center -IRCCS and Humanitas University, Department of Biomedical Sciences, Milan, Italy
| | - Natalie Gassmann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Parham Sendi
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philipp Jent
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Rihard Trebše
- Medical Faculty University of Ljubljana, Valdoltra Orthopedic Hospital, Ankaran, Slovenia
| | | | - Roger D Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | - Stéphane Corvec
- Service de Bactériologie- Hygiène hospitalière, CRCINA, Université de Nantes, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Tobias Siegfried Kramer
- Charité Universitätsmedizin Berlin, Berlin, Germany; Evangelisches Waldkrankenhaus Spandau, Berlin, Germany LADR Zentrallabor Dr. Kramer und Kollegen, Geesthacht, Germany
| | | | - Yvonne Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Foster AL, Cutbush K, Ezure Y, Schuetz MA, Crawford R, Paterson DL. Cutibacterium acnes in shoulder surgery: a scoping review of strategies for prevention, diagnosis, and treatment. J Shoulder Elbow Surg 2021; 30:1410-1422. [PMID: 33373684 DOI: 10.1016/j.jse.2020.11.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/02/2020] [Accepted: 11/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutibacterium acnes is a commensal, gram-positive, facultatively anaerobic bacillus that resides in the dermis. Historically thought to be a contaminant when identified on cultured specimens, recent advances in diagnostic technology have now implicated it as the most common organism responsible for postoperative shoulder infections. Despite a recognition of the role of this organism and a significant research interest in recent years, there is clear lack of consensus guideline on strategies to prevent, diagnose, and treat postoperative shoulder infection. METHOD The electronic databases PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched in March 2020. All experimental and nonexperimental studies that investigate C acnes in shoulder surgery were included. Inclusion was limited to articles published after 2000 and written in English; reviews, gray literature, or abstracts were excluded. A total of 70 studies were included in this review. This scoping review was performed in accordance with the Extended Preferred Reporting Items of Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). RESULTS Standard surgical prophylactic regimens such as intravenous antibiotics and topical chlorhexidine are ineffective at removing C acnes from the deep layer of the dermis, and there is a shift toward using topical benzoyl peroxide with significantly improved efficacy. An improved understanding of the bacteria has demonstrated that a prolonged culture time of up to 14 days is needed, especially in cases of established infection. Advances in diagnostics such as sonication and molecular-based testing are promising. Although usually thought to be susceptible to a broad range of antibiotics, resistance is emerging to clindamycin. An improved understanding of its ability to form a biofilm highlights the difficulty in treating an established infection. CONCLUSION The role of C acnes causing postoperative infection following shoulder surgery is being increasingly recognized. Strategies for prevention, diagnosis, and treatment have been outlined from both an antimicrobial and surgical perspective. A number of these strategies are emerging and require further research to demonstrate efficacy before implementation into clinical guidelines.
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Affiliation(s)
- Andrew L Foster
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kenneth Cutbush
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Surgery, School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Yukiko Ezure
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia
| | - Michael A Schuetz
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Department of Orthopaedic Surgery, Royal Brisbane and Women's Hospital, Herston, QLD, Australia; Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Ross Crawford
- Faculty of Science and Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, RBWH Campus, Brisbane, QLD, Australia.
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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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Falstie-Jensen T, Lange J, Daugaard H, Sørensen AKB, Ovesen J, Søballe K. Unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome? J Shoulder Elbow Surg 2021; 30:1299-1308. [PMID: 33548396 DOI: 10.1016/j.jse.2020.12.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several studies have confirmed a high rate of unexpected positive cultures (UPCs) after presumably aseptic revisions of shoulder arthroplasties; however, the impact on the outcome is still unclear. The purpose of this prospective study is to compare the patient-reported outcomes of standard revisions with and without the emergence of UPCs. METHODS During a 3-year period, we included all patients who were revised for reasons other than suspicion of infection from 2 orthopedic centers. Five biopsies were obtained from every revision, and only cultures with the same bacteria in at least 3 biopsy specimens were classified as UPCs. All patients were assessed using the Oxford Shoulder Score (OSS) and range of motion preoperatively and after at least a 2-year follow-up. RESULTS In this study, 124 patients were included, with a median follow-up of 29 months (range 29-32), and UPCs emerged after 27 revisions (22%), with Cutibacterium acnes accounting for 67% (18/27). At baseline, the OSS was 22 in both the culture-negative and UPC groups (P = .46). Then, at follow-up, the OSS was 37 in the culture-negative group and 35 in the UPC group (P = .91). The forward elevation increased significantly by 44° and 41°, respectively, in the 2 groups, but no statistically significant difference between the culture-negative group and the UPC group was found (P = .66). In contrast, the external rotation was unchanged after the revision, and again, no difference in the change between the culture-negative and UPC groups (P = .54) was observed. Subgroup analyses stratified by different implant designs revealed equal patterns with no statistical differences in outcome. CONCLUSION We did not find a difference in outcome after a presumed aseptic revision regardless of the emergence of UPCs. Similarly, we could not demonstrate that patients with UPCs presented with poorer function at baseline compared with culture-negative patients. The clinical relevance of UPCs thus requires further evaluation, especially in the case of C acnes as a potential pathogenic versus a merely colonizing microbe.
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Affiliation(s)
| | - Jeppe Lange
- Orthopedic Department, Horsens Regional Hospital, Horsens, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Daugaard
- Orthopedic Department, Herlev-Gentofte Hospital, Herlev, Denmark
| | | | - Janne Ovesen
- Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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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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Factors predictive of Cutibacterium periprosthetic shoulder infections: a retrospective study of 342 prosthetic revisions. J Shoulder Elbow Surg 2020; 29:1177-1187. [PMID: 31668686 DOI: 10.1016/j.jse.2019.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/26/2019] [Accepted: 08/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cutibacterium are the most common cause of periprosthetic shoulder infections, as defined by ≥2 deep cultures. Established Cutibacterium periprosthetic infections cannot be resolved without prosthesis removal. However, the decision for implant removal must be made from an assessment of infection risk before the results of intraoperative cultures are finalized. We hypothesized that the risk for a Cutibacterium infection is associated with characteristics that are available at the time of revision arthroplasty. METHODS In a retrospective review of 342 patients having prosthetic revisions between 2006 and 2018 for whom definitive deep culture results were available, we used univariate and multivariate analyses to compare the preoperative and intraoperative characteristics of 101 revisions with Cutibacterium periprosthetic infections to the characteristics of 241 concurrent revisions not meeting the definition of infection. RESULTS Patients with definite Cutibacterium periprosthetic infections were younger (59 ± 10 vs. 64 ± 12, P < .001), were more likely to be male (91% vs. 44%, P < .001), were more likely to have had their index procedure performed for primary osteoarthritis (54% vs. 39%, P = .007), were more likely to be taking testosterone supplements (8% vs. 2%, P = .02), had lower American Society of Anesthesiologists scores (1.9 ± 0.7 vs. 2.3 ± 0.7, P < .001), and had lower body mass indices (29 ± 5 vs. 31 ± 7, P = .005). Patients with definite Cutibacterium periprosthetic infections also had significantly higher preoperative loads of Cutibacterium on their unprepared skin surface (1.7 ± 0.9 vs. 0.4 ± 0.8, P < .001) and were more likely to have the surgical finding of synovitis (41% vs. 16%, P < .001). CONCLUSIONS The risk of definite Cutibacterium periprosthetic infections is associated with observations that can be made before or at the time of revision arthroplasty.
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Goldman BH, Halpern AL, Deal MJ, Richey BP, Mason EM, Gupta HO, Callegari J, Bravo CJ. Management of Revision Reverse Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2020. [DOI: 10.1177/2471549220902296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Brian H Goldman
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - Abby L Halpern
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - Matthew J Deal
- University of Central Florida, College of Medicine, Orlando, Florida
| | - Bradley P Richey
- University of Central Florida, College of Medicine, Orlando, Florida
| | - Eric M Mason
- University of Central Florida, College of Medicine, Orlando, Florida
| | - Hari O Gupta
- Department of Orthopaedic Surgery, Larkin Community Hospital, South Miami, Florida
| | - Jonathan Callegari
- Department of Orthopaedic Surgery, Millcreek Community Hospital, Erie, Pennsylvania
| | - Cesar J Bravo
- Virginia Tech-Carilion School of Medicine, Carilion Clinic, Department of Orthopaedics, Roanoke, Virginia
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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: 13] [Impact Index Per Article: 3.3] [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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Akgün D, Maziak N, Plachel F, Minkus M, Scheibel M, Perka C, Moroder P. Diagnostic Arthroscopy for Detection of Periprosthetic Infection in Painful Shoulder Arthroplasty. Arthroscopy 2019; 35:2571-2577. [PMID: 31351811 DOI: 10.1016/j.arthro.2019.03.058] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/24/2019] [Accepted: 03/29/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the utility of arthroscopic biopsies for detection of periprosthetic infection in painful shoulder arthroplasty without objective signs of infection. METHODS A retrospective analysis of all patients who underwent a diagnostic arthroscopy for painful shoulder arthroplasty from June 2012 through July 2018 was performed. Patients with a subsequent revision shoulder arthroplasty after diagnostic arthroscopy were included. Arthroscopic tissue culture results were compared with the culture results of intraoperative tissue samples obtained at the time of open revision surgery. A minimum of 3 tissue samples from synovia and bone-prosthesis interface with signs of synovitis or abnormal appearance was routinely collected. Cases with 2 or more positive cultures for the same microorganism obtained at open revision surgery were considered as true presence of infection. The study protocol was reviewed and approved by the institutional ethics committee. RESULTS Twenty-three cases in 22 patients were included in this study. Five of these 23 cases were classified as true infection based on the samples obtained during open revision surgery, and 16 cases had a positive culture in diagnostic arthroscopy. Cutibacterium acnes was isolated in each case. Classifying any microbiologic growth in the arthroscopic biopsies as positive resulted in a sensitivity and negative predictive value of 100%, specificity of 39%, and positive predictive value of 31.3% for the detection of a periprosthetic shoulder infection (PPSI). If at least 2 positive samples with the same microbiologic growth in the arthroscopic biopsies were considered as positive, sensitivity and negative predictive value dropped to 80% and 94.4%, respectively, but the specificity and positive predictive value increased to 94.4% and 80%, respectively. CONCLUSIONS Diagnostic arthroscopy is a useful diagnostic tool in patients with suspicion but no clear evidence of PPSI. Arthroscopically obtained tissue biopsies for culture offer a high sensitivity and specificity in the diagnosis of PPSI if at least 2 cultures positive for the same microorganism are considered as infection. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Doruk Akgün
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany.
| | - Nina Maziak
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Fabian Plachel
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Marvin Minkus
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Markus Scheibel
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Philipp Moroder
- Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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