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Miley LK, Boyum JH, McDonald JS, Horst KK, Howe BM, Ringler MD. Predictive value of joint fluid volume on advanced pre-procedure imaging related to success of arthrocentesis and presence of septic arthritis. Emerg Radiol 2024; 31:491-497. [PMID: 38844659 DOI: 10.1007/s10140-024-02244-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/17/2024] [Indexed: 07/31/2024]
Abstract
PURPOSE Septic arthritis is a dangerous medical condition requiring prompt diagnosis, often via arthrocentesis. A "dry tap" occurs when no fluid is aspirated. We hypothesized that the absence of a joint effusion on pre-procedure advanced imaging would reliably predict a dry tap and exclude septic arthritis. METHODS A cohort of 217 arthrocentesis cases of large joints (hips, shoulders, knees) from our institution, with pre-procedure advanced imaging (CT, MR, US) of the same joint performed within the previous 48 h, was analyzed. Exclusion criteria included non-native joints or inadequate imaging of the affected joint. These cases underwent blinded review by 4 radiologists who measured the deepest pocket of joint fluid on the pre-procedure imaging. Wilcoxon rank-sum test was performed comparing joint fluid pocket size to outcomes of successful aspiration and final diagnosis. RESULTS A smaller average joint pocket fluid size was present on advanced imaging in both dry taps compared with successful arthrocenteses (p < .0001), and in uninfected joints compared with septic joints (p = .0001). However, the overlap of values was too great to allow for a perfectly predictive cutoff. 29% (5/17) of patients with no visible joint fluid on pre-aspiration imaging underwent successful arthrocentesis, one case representing septic arthritis. CONCLUSION Volume of joint fluid on advanced pre-arthrocentesis imaging cannot reliably predict subsequent dry tap nor exclude septic arthritis.
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Affiliation(s)
- Lindsey K Miley
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America.
| | - James H Boyum
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Jennifer S McDonald
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Kelly K Horst
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Benjamin M Howe
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Michael D Ringler
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States of America
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2
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Deirmengian C, Toler K, Sharma V, Miamidian JL, McLaren A. The False-Positive Rate of Synovial Fluid Culture at a Single Clinical Laboratory Using Culture Bottles. Cureus 2024; 16:e55641. [PMID: 38586694 PMCID: PMC10996834 DOI: 10.7759/cureus.55641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction Synovial fluid (SF) cultures can yield false-positive or negative results when diagnosing periprosthetic joint infection (PJI). False-positives may arise during sample collection or from laboratory contamination. Understanding false-positive SF culture rates is crucial for interpreting PJI laboratory data, yet clinical laboratories rarely report these rates. This study aimed to define the false-positive SF culture rate at a major specialized clinical laboratory. Methods This study retrospectively analyzed prospectively collected data at a single clinical laboratory that receives SF for clinical testing for PJI. A total of 180,317 periprosthetic SF samples from the hip, knee, and shoulder were identified from January 2016 to December 2023, which met the inclusion criteria for this study. Samples were classified by both a modified 2018 International Consensus Meeting (ICM) score and an inflammation score that combined the SF-C-reactive protein, alpha-defensin, SF-white blood cell count, and SF-polymorphonuclear% into one standardized metric. Logistic regression was utilized to evaluate the impact of various collection-based characteristics on culture positivity, including inflammation biomarkers, the source joint, quality control metrics, and days of specimen transport to the laboratory. SF culture false-positivity was calculated based on the ICM category of "not-infected" or low inflammation score. Results Overall, 13.3% (23,974/180,317) of the samples were associated with a positive culture result: 12.5% for knee samples, 20.3% for hip samples, and 14.7% for shoulder samples. The false-positive SF culture rate among 131,949 samples classified as "not-infected" by the modified 2018 ICM definition was 0.47% (95%CI: 0.43 to 0.51%). Stratification by joint revealed a false-positive rate of 0.34% (95%CI: 0.31 to 0.38%) for knee samples, 1.24% (95%CI: 1.05 to 1.45%) for hip samples, and 3.02% (95%CI: 2.40 to 3.80%) for shoulder samples, with p < 0.0001 for all comparisons. The false-positive SF culture rate among 90,156 samples, representing half of all samples with the lowest standardized inflammation scores, was 0.47% (95%CI: 0.43 to 0.52%). Stratification by joint revealed a false-positive rate of 0.33% (95%CI: 0.29 to 0.37%) for knee samples, 1.45% (95%CI: 1.19 to 1.77%) for hip samples, and 3.09% (95%CI: 2.41 to 3.95%) for shoulder samples, with p<0.0001 for all comparisons. Multivariate logistic regression demonstrated the joint source (hip, shoulder) and poor sample quality as collection-based factors associated with a false-positive culture. Evaluation of a cohort of samples selected to minimize collection-based causes of false-positive culture demonstrated a false-positive rate of 0.30%, representing the ceiling limit for laboratory-based SF culture false-positivity. Conclusions This study utilizes two methods to estimate the false-positive SF culture rate at a single specialized clinical laboratory, demonstrating an overall false-positive rate of approximately 0.5%. Stratification of samples by source joint demonstrated that periprosthetic SF from the shoulder and hip have a substantially higher false-positive culture rate than that of the knee. The lowest false-positive SF culture rate (0.30%) was observed among samples from the knee-passing quality control. Culture positivity due to contamination at this specific laboratory is less than 0.30% because all specimens undergo identical processing.
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Affiliation(s)
- Carl Deirmengian
- Orthopaedic Surgery, The Rothman Orthopaedic Institute, Philadelphia, USA
- Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Krista Toler
- Diagnostics Research and Development, Zimmer Biomet, Warsaw, USA
| | - Varun Sharma
- Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - John L Miamidian
- Diagnostics Research and Development, Zimmer Biomet, Claymont, USA
| | - Alex McLaren
- Orthopaedic Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, USA
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Saccomanno MF, Lädermann A, Collin P. Two-Stage Exchange Arthroplasty for Periprosthetic Reverse Shoulder Arthroplasty Infection Provides Comparable Functional Outcomes to Primary Reverse Shoulder Arthroplasty. J Clin Med 2024; 13:904. [PMID: 38337598 PMCID: PMC10856729 DOI: 10.3390/jcm13030904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/12/2024] Open
Abstract
This study aimed to compare functional outcomes after two-stage revision reverse shoulder arthroplasty (RSA) for periprosthetic joint infection (PJI) with the results of primary RSA. Patients affected by PJI and treated by means of two-stage revision RSA were 1:1 matched with a group of patients who were treated electively with RSA without developing any complications. Out of 1477 RSAs performed between 2009 and 2021, 16 patients developed a PJI. Each matched cohort comprised 16 patients (3 females, 13 males). The mean age was 69.13 ± 5.43 years old in the PJI group and 70.28 ± 5.04 (p = 0.543) in the matched cohort. The mean follow-up was 41.23 ± 26.9 months in the PJI group and 28.5 ± 20.2 (p = 0.142) in the matched group. Only one patient showed recurrent PJI five years after revision RSA. Comparison between the PJI patients and matched patients did not show any significant differences at the latest follow-up, nor for subjective shoulder value (SSV) (p = 0.101) or Constant score (p = 0.134). Two-stage exchange RSA for PJI allows for appropriate control of the disease and good functional outcomes. Comparison with an age- and sex-matched cohort of uninfected patients showed no significant differences, thus confirming the idea that revision surgeries may lead to satisfactory functional outcomes, as expected after primary surgery.
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Affiliation(s)
- Maristella Francesca Saccomanno
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, 25123 Brescia, Italy;
- Department of Bone and Joint Surgery, Spedali Civili, 25123 Brescia, Italy
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Rue J.-D. Maillard 3, 1217 Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1211 Geneva, Switzerland
| | - Philippe Collin
- CHP Saint-Gregoire, 6 Boulevard de la Boutière, 35760 Saint-Grégoire, France;
- Clinique Victor Hugo, 5 Bis Rue du Dôme, 75016 Paris, France
- American Hospital of Paris, 55 Boulevard du Château, 92200 Neuilly-sur-Seine, France
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Berger GK, Schwartz AK, Kent WT. Safe and Effective Aspirations and Nerve Blocks for the On-Call Orthopaedic Surgeon. J Am Acad Orthop Surg 2023; 31:957-967. [PMID: 37276580 DOI: 10.5435/jaaos-d-23-00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/17/2023] [Indexed: 06/07/2023] Open
Abstract
The on-call orthopaedic surgeon is faced with a wide array of orthopaedic pathology for which intra-articular aspiration, injection, and/or nerve/hematoma block may be used. Efficient use of these diagnostic and therapeutic modalities affords better patient care and a more effective on-call period. Often, these interventions are the rate limiting factor in a reduction or diagnosis. In this review, we describe joint aspirations, saline load tests, hematoma blocks, and nerve blocks in detail to include their indications, techniques, related pharmacology, pearls, and pitfalls.
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Affiliation(s)
- Garrett K Berger
- From the Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA
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5
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Patel RP, McGill K, Motamedi D, Morgan T. Ultrasound-guided interventions of the upper extremity joints. Skeletal Radiol 2023; 52:897-909. [PMID: 35962837 PMCID: PMC10027633 DOI: 10.1007/s00256-022-04148-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023]
Abstract
Ultrasound guidance is valuable for performing precise joint interventions. Joint interventions may be requested for therapeutic and diagnostic pain injections, joint aspiration in the setting of suspected infection, or contrast injection for arthrography. In practice, interventions of the shoulder girdle, elbow, and hand/wrist joints may be performed without any imaging guidance. However, imaging guidance results in more accurate interventions and better patient outcomes than those performed by palpation alone. When compared to other modalities used for imaging guidance, ultrasound has many potential advantages. Radiologists should be prepared to perform ultrasound-guided upper extremity joint interventions utilizing recommended techniques to optimize clinical practice and patient outcomes. KEY POINTS: 1. Ultrasound-guided injections of the glenohumeral, acromioclavicular, sternoclavicular, elbow, and hand/wrist joints have higher accuracy than injections performed without imaging guidance. 2. Ultrasound-guided aspirations of upper extremity joints have advantages to fluoroscopic-guided aspirations because of the potential to identify effusions, soft tissue abscess, or bursitis. 3. Ultrasound-guided contrast injection prior to MR arthrography is as accurate as fluoroscopic-guided injection for upper extremity joints.
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Affiliation(s)
- Rina P Patel
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Kevin McGill
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Daria Motamedi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Tara Morgan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA
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Cochrane N, Kim B, Kelly P, Seidelman J, Seyler T, Klifto C, Jiranek W. Cutibacterium positive cultures in total joint arthroplasty: a comparison of the hip, knee, and shoulder. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05804-y. [PMID: 37059870 DOI: 10.1007/s00264-023-05804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/01/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE Cutibacterium spp. (formerly Propionibacterium) is a slow growing, Gram-positive, anaerobic bacteria and is an emerging clinical entity in prosthetic joint infection (PJI). This study compares the presentation, surgical management, and post-operative antibiotic therapy of patients with positive intraoperative cultures during revision total joint arthroplasty (TJA) of the hip, knee, and shoulder. METHODS This was a retrospective cohort study of patients from 2014 to 2020 of 57 revision TJAs (27 total hip arthroplasty (THA), 17 total shoulder arthroplasty (TSA), and 13 total knee arthroplasty (TKA)) with intraoperative cultures positive for Cutibacterium at a tertiary academic centre. Patient demographics, pre-operative labs, radiographs, and aspirate results were collected. Intraoperative data was reviewed. Post-operative antibiotic therapy and repeat infections were recorded. Data was compared with univariate analyses. RESULTS There was no significant difference in pre-operative lab values between the cohorts. All cohorts had > 58% radiographic lucency. Revision TSA patients had significantly fewer pre-operative aspirates. Six patients undergoing revision THA, three TKA and one TSA had a repeat infection requiring further surgery. Four in the THA cohort and one in the TKA cohort with repeat infections did not receive prolonged antibiotic therapy. CONCLUSION Cutibacterium is an infectious agent that can present in an indolent fashion after TJA. It commonly causes progressive radiographic lucency. The workup and post-operative management differs in the hip, knee, and shoulder, which is likely due to existing literature guiding physician practice. In all joints, Cutibacterium is a virulent pathogen that can cause repeat infections requiring surgical treatment.
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Affiliation(s)
- Niall Cochrane
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Billy Kim
- School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Patrick Kelly
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Jessica Seidelman
- Department of Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Thorsten Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christopher Klifto
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - William Jiranek
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Kobayashi EF, Namdari S, Schenker M, Athwal GS, Ahn J. Evaluation and treatment of postoperative periprosthetic humeral fragility fractures. OTA Int 2023; 6:e244. [PMID: 37006451 PMCID: PMC10064642 DOI: 10.1097/oi9.0000000000000244] [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] [Received: 12/06/2022] [Accepted: 12/22/2022] [Indexed: 06/19/2023]
Abstract
Postoperative periprosthetic humeral shaft fractures represent a growing and difficult complication to treat given the aging patient population and associated bone loss. Determining the best treatment option is multifactorial, including patient characteristics, fracture pattern, remaining bone stock, and implant stability. Possible treatment options include nonoperative management with bracing or surgical intervention. Nonoperative treatment has been shown to have higher nonunion rates, thus should only be selected for a specific patient population with minimally displaced fractures or those that are unfit for surgery. Surgical management is recommended with prosthetic loosening, fracture nonunion, or failure of nonoperative treatment. Surgical options include open reduction and internal fixation, revision arthroplasty, or hybrid fixation. Careful evaluation, decision making, and planning is required in the treatment of these fractures.
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Affiliation(s)
- Evangeline F. Kobayashi
- Department of Orthopaedic Surgery, University of Michigan, Division of Trauma Surgery, Ann Arbor, MI
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Division of Shoulder and Elbow Surgery, Bensalem, PA
| | - Mara Schenker
- Department of Orthopaedic Surgery, Emory University, Division of Trauma Surgery, Atlanta, GA
| | - George S. Athwal
- Department of Orthopaedic Surgery, Roth/McFarlane Hand and Upper Limb Centre, Division of Shoulder and Elbow Surgery, London, ON, Canada; and
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, University of Michigan, Division of Trauma Surgery, Ann Arbor, MI
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8
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Zanna L, Sangaletti R, Akkaya M, Shen T, Abuljadail S, Gehrke T, Citak M. What is the concordance rate of preoperative synovial fluid aspiration and intraoperative biopsy in detecting periprosthetic joint infection of the shoulder? J Shoulder Elbow Surg 2023; 32:492-499. [PMID: 36343792 DOI: 10.1016/j.jse.2022.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The accuracy of preoperative synovial fluid culture for microbe detection in shoulder periprosthetic joint infection (PJI) is poorly described. To evaluate the utility of preoperative culture data for early pathogen identification for shoulder PJI, we determined the concordance between preoperative synovial fluid culture results and intraoperative tissue culture results. METHODS Fifty patients who met the 2014 Musculoskeletal Infection Society criteria for shoulder PJI between January 2016 and December 2019 were retrospectively reviewed for clinical and demographic data. This cohort of patients was divided into 2 groups based on the concordance between preoperative and intraoperative culture results. The pathogens identified on preoperative and intraoperative cultures were classified as high-virulence or low-virulence. Student's t tests and Mann-Whitney U tests were used as appropriate for continuous variables, and χ2 and Fisher's exact tests were used as appropriate for categorical variables. RESULTS Concordance between preoperative aspiration and intraoperative tissue culture was identified in 28 of 50 patients (56%). Preoperative cultures positive for Gram-positive species were more likely to be concordant than discordant (P = .015). Preoperative cultures positive for Cutibacterium acnes were more likely to be concordant with intraoperative cultures (P = .022). There were more patients with polymicrobial infection in the discordant group compared with the concordant group (P < .001). No statistically significant correlation between the preoperative serum C-reactive protein level and the intraoperative category of bacteria was reported. Staphylococcus aureus and coagulase-negative Staphylococci were associated with high specificity and negative predictive value. Preoperative cultures positive for C. acnes demonstrated sensitivity, specificity, positive predictive value, and negative predictive value lower than 0.8. Gram-negative pathogens demonstrated the highest sensitivity (1) and specificity (1), whereas polymicrobial infections exhibited the lowest sensitivity and positive predictive value. CONCLUSION Preoperative synovial fluid aspiration for shoulder PJI poorly predicts intraoperative culture results, with a discordance of 44%. More favorable concordance was observed for monomicrobial preoperative cultures, particularly for Gram-negative organisms and methicillin-sensitive S. aureus. The overall high rate of discordance between preoperative and intraoperative culture may prompt surgeons to base medical and surgical management on patient history and other factors and avoid relying solely on preoperative synovial fluid culture data.
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Affiliation(s)
- Luigi Zanna
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; Department of Orthopaedic Surgery, Aou Careggi, University Hospital of Florence, Florence, Italy.
| | - Rudy Sangaletti
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Akkaya
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Tony Shen
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Salahulddin Abuljadail
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany; College of Medicine, King Faisal University, Hofuf, Saudi Arabia
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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9
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Treatment outcomes of patients with Cutibacterium acnes-positive cultures during total joint replacement revision surgery: a minimum 2-year follow-up. Arch Orthop Trauma Surg 2022; 143:2951-2958. [PMID: 35759014 DOI: 10.1007/s00402-022-04489-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) is a devastating complication following total joint replacement (TJR). Cutibacterium acnes (C. acnes) is a low virulent skin commensal, commonly found during TJR revision surgery for "aseptic" causes. The purpose of the present study was to report the treatment outcomes of patients with C. acnes contamination or infection in the presence of a TJR treated with a revision surgery ± implant exchange ± prolonged (≥ 8 weeks) postoperative antibiotics. METHODS Medical records of patients with at least one positive C. acnes culture in intraoperative tissue samples or sonication fluid from a TJR revision surgery between January 2005 and December 2014 were retrospectively evaluated. The primary endpoint was infection eradication according to Delphi criteria. The diagnostic accuracy of preoperative TJR aspiration regarding the diagnosis of C. acnes PJI was also investigated. RESULTS A total of 52 TJR (28 shoulders, 17 hips, 7 knees) in 52 patients (35 males, 17 females) with an average age of 63 ± 11 (33-86) years were included. At an average follow-up of 67 ± 33 (24-127) months, the infection eradication of C. acnes PJI was 97% regardless of the surgical treatment or administration of prolonged postoperative antibiotics. The incidence of unsuspected C. acnes PJI was 28.8%. The sensitivity and specificity of preoperative joint aspiration in detecting C. acnes PJI were 59% and 88%, whereas the PPV and NNV were 83% and 67%, respectively. CONCLUSION Infection eradication of C. acnes PJI was very high at a minimum follow-up of 24 months, suggesting that C. acnes PJI could be adequately treated with a combination of revision surgery and prolonged postoperative antibiotics. The preoperative diagnosis of C. acnes PJI might be challenging with more than one-quarter of patients presenting without suspicion of C. acnes PJI. The appropriate treatment of patients with a single positive culture remains still unclear. A negative TJR aspiration should not rule out a C. acnes PJI, especially in the presence of clinical correlates of infection. LEVEL OF EVIDENCE Retrospective case-control study, Level III. IRB APPROVAL Kantonale Ethikkommission Zürich, BASEC Nr.:2017-00567.
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Roberts CC, Metter DF, Fox MG, Appel M, Jawetz ST, Morrison WB, Nacey N, Said N, Stensby JD, Subhas N, Tynus KM, Walker EA, Yu JS, Kransdorf MJ. ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update. J Am Coll Radiol 2022; 19:S53-S66. [PMID: 35550805 DOI: 10.1016/j.jacr.2022.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 11/19/2022]
Abstract
Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Michael G Fox
- Panel Chair, Musculoskeletal Division Chair and Diagnostic Radiology Program Director, Mayo Clinic Arizona, Phoenix, Arizona
| | - Marc Appel
- James J. Peters VA Medical Center, Bronx, New York; American Academy of Orthopaedic Surgeons; and liaison with AOOS
| | - Shari T Jawetz
- Director, Radiology Quality Assurance; Director, Radiology Resident and Medical Student Education; and Chief, Division of Body CT, Hospital for Special Surgery, New York, New York
| | - William B Morrison
- Director, Division of Musculoskeletal Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; ACR education center faculty; ACR AIRP faculty; ACR CPI author
| | - Nicholas Nacey
- Fellowship Director, Imaging Center Medical Director, University of Virginia Health System, Charlottesville, Virginia
| | - Nicholas Said
- Medical Director of MRI Duke University Health System, Access Champion Department of Radiology, Director of Musculoskeletal Intervention, Duke University Medical Center, Durham, North Carolina
| | - James D Stensby
- MSK Imaging Fellowship Director, University of Missouri Health Care, Columbia, Missouri
| | - Naveen Subhas
- Vice Chair of Clinical Effectiveness and Efficiency, Imaging Institute Program Director, Musculoskeletal Radiology; and Director, Bone Mineral Densitometry, Cleveland Clinic, Cleveland, Ohio
| | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania and Uniformed Services University of the Health Sciences, Bethesda, Maryland; Past President of the Penn State College of Medicine Faculty Organization, ACR local chapter PRS President Elect
| | - Joseph S Yu
- The Ohio State University Wexner Medical Center, Columbus, Ohio
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11
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Pullen WM, Money AJ, Ray TE, Freehill MT, Sherman SL. Postoperative Infection: Prevention, Diagnosis, and Treatment Guidelines for the Sports Surgeon. Sports Med Arthrosc Rev 2022; 30:17-23. [PMID: 35113838 DOI: 10.1097/jsa.0000000000000335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postoperative infection remains a potentially devastating complication facing the sports medicine surgeon. Infection prevention begins with a thorough history and physical examination to identify patient specific risk factors and aid in risk stratification. Perioperative steroid injections should be used cautiously, with increased time prior to or following surgery being associated with lower infection risk. Sterile preparation with an alcohol containing solution is typically preferred, though there is limited evidence to identify which product is superior. Diagnosis can be challenging with a high index of suspicion needed to identify and appropriately manage patients. Treatment involves prompt irrigation and debridement with deep cultures. Antibiotic coverage should begin with empiric broad treatment and be tailored based on culture results. Early consultation with an infectious disease specialist is recommended to ensure appropriate antibiotic coverage and duration of treatment.
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Affiliation(s)
- W Michael Pullen
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC
| | - Adam J Money
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC
- Department of Orthopaedic Surgery, Rothman Institute, Philadelphia, PA
| | - Taylor E Ray
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
| | | | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, CA
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Abstract
With advances in the understanding of elbow anatomy, pathologies of the elbow, arthroscopic instrumentation, and surgical techniques over recent decades, elbow arthroscopy has become a valuable treatment modality for a variety of conditions. Elbow arthroscopy has gained utility for treating problems such as septic arthritis, osteoarthritis, synovitis, osteophyte and loose body excision, contracture release, osteochondral defects, select fractures, instability, and lateral epicondylitis. Accordingly, precise knowledge of the neurovascular anatomy, safe arthroscopic portal placement, indications, and potential complications are required to maximize patient outcomes and assist in educating patients. This comprehensive review provides the reader an understanding of the potential complications associated with arthroscopic procedures of the elbow and to describe strategies for prevention and management.
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Thangarajah T, Lo IKY. Management of the failed rotator cuff repair. Br J Hosp Med (Lond) 2022; 83:1-10. [DOI: 10.12968/hmed.2021.0446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rotator cuff repair is increasingly being performed, and this is likely to continue to given the ageing population. An improvement in functional outcome can be achieved, with the best results noted in those tendons that go on to heal. Failure of repair following surgery can be associated with debilitating symptoms that are not always amenable to non-operative measures, so further surgery may be indicated for these patients. Several operative strategies have been described, but careful evaluation is required to determine the most suitable option. This review describes the decision-making strategies and treatment options available during management of a failed rotator cuff repair.
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Affiliation(s)
- Tanujan Thangarajah
- Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Ian KY Lo
- Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
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The significance of synovial biopsy in the diagnostic workup of the low-grade periprosthetic joint infection of shoulder arthroplasty. Arch Orthop Trauma Surg 2022; 142:3157-3164. [PMID: 33991235 PMCID: PMC9522757 DOI: 10.1007/s00402-021-03932-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/30/2021] [Indexed: 12/02/2022]
Abstract
INTRODUCTION A common reason for painful shoulder arthroplasties and revision surgery is a low-grade periprosthetic joint infection (PJI). Diagnosing a low-grade infection is, however, a major diagnostic challenge. This applies even more to the shoulder, which differs from other large joints in terms of clinical features and microbiological spectrum. Aim of this study was to evaluate the diagnostic value of the synovial biopsy in the diagnostic workup of low-grade PJI of the shoulder. MATERIALS AND METHODS A retrospective evaluation was conducted on 56 patients receiving revision surgery on their shoulder arthroplasty. A standardized preoperative workup was performed comprising CRP value, leukocyte blood count, synovial fluid microbiological analyses and leukocyte count from joint aspiration, and five synovial biopsy samples for bacteriologic and histologic analysis obtained through an arthroscopic approach. During revision surgery, five samples of periprosthetic tissue were harvested for bacteriologic and histologic analyses. The MSIS-Criteria 2014 were used to evaluate the diagnostic results. RESULTS In total, 15 of 56 revised prostheses turned out as PJI (27%). When applying our diagnostic workup, we obtained a sensitivity of 67% with a specificity of 95%. When performing a subgroup analysis on those patients that had received diagnostic biopsy, a sensitivity of 100% and a specificity of 83% could be achieved. With a sensitivity and specificity of 90% and 83%, respectively, the biopsy is the single method with the highest diagnostic value. CONCLUSIONS The sensitivity of only 67% of our standard workup emphasizes the difficulty to adequately diagnose low-grade infections after shoulder arthroplasty. The excellent specificity of 95% ensures, however, that non-infected prostheses are not incorrectly explanted. This study highlights that synovial biopsy has a high diagnostic value and should be done prior to complex revision surgeries to raise sensitivity in diagnosing a PJI.
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Hecker A, Waltenspül M, Ernstbrunner L, Sutter R, Wieser K, Bouaicha S. Perforated flexible catheters improve joint fluid aspiration in shoulder cadavers. Sci Rep 2021; 11:22024. [PMID: 34764411 PMCID: PMC8586244 DOI: 10.1038/s41598-021-01613-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 10/25/2021] [Indexed: 11/26/2022] Open
Abstract
A fluoroscopically controlled anterior approach in supine position is often used for arthrocentesis of the shoulder, but can lead to a high rate of dry aspirations. The aim of this study was to compare the aspiration performance of rigid needles and flexible catheters used with this approach. We hypothesized that a flexible catheter can significantly improve the amount of the obtained fluid. The glenohumeral joint of ten human cadaveric shoulder specimens were sequentially filled with 5, 10, 20 and 30 mL of contrast agent. For each volume the maximum aspirated amount of contrast agent with 4 different aspiration devices (20 gauge needle, 16 gauge needle, 16 gauge flexible catheter and 16 gauge perforated flexible catheter) were compared. All aspirations were done in supine cadaver position from anterior under fluoroscopic control. The aspirated amount of fluid was significantly higher using the 16 gauge perforated flexible catheter (p = 0.002–0.028) compared with all other devices when 5, 10 and 20 mL of contrast agent were in the joint. This perforated flexible catheter aspirated 80–96% of the available fluid while the standard 20 gauge needle aspirated 40–60%. Using a 16 gauge perforated flexible catheter in a supine anterior arthrocentesis technique results in aspiration of most of the fluid in human cadaveric shoulder specimens, while standard needles aspirate only about 50% of it. This can be clinically relevant when there is very little synovial fluid available and might reduce the number of insufficient aspirations.
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Affiliation(s)
- Andreas Hecker
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland. .,Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lukas Ernstbrunner
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reto Sutter
- Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Jauregui JJ, Tran A, Kaveeshwar S, Nadarajah V, Chaudhri MW, Henn RF, Gilotra MN, Hasan SA. Diagnosing a periprosthetic shoulder infection: A systematic review. J Orthop 2021; 26:58-66. [PMID: 34305349 DOI: 10.1016/j.jor.2021.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/11/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction The aim of this study was to systematically review the literature regarding accurate shoulder prosthetic joint infection (PJI) diagnosis. Methods Using PRISMA guidelines, we analyzed 25 studies reporting on 5535 patients and 646 infections. Results Cutibacterium acnes (C. acnes) cultures were positive in 60% of patients. Serum markers WBC, CRP, ESR, and IL-6 appear to lack diagnostic reliability. Synovial IL-6 and alpha-defensin may be more accurate in detecting infections. Conclusion Synovial IL-6 and alpha-defensin appear to have greater utility than serum markers. These may be incorporated into new criteria to accurately diagnose shoulder PJI. Level of evidence IV.
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Affiliation(s)
- Julio J Jauregui
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew Tran
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samir Kaveeshwar
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vidushan Nadarajah
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Moiuz W Chaudhri
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mohit N Gilotra
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Ashfaq Hasan
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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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: 6] [Impact Index Per Article: 2.0] [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.
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Voss A, Pfeifer CG, Kerschbaum M, Rupp M, Angele P, Alt V. Post-operative septic arthritis after arthroscopy: modern diagnostic and therapeutic concepts. Knee Surg Sports Traumatol Arthrosc 2021; 29:3149-3158. [PMID: 33755737 PMCID: PMC8458194 DOI: 10.1007/s00167-021-06525-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Septic arthritis is a significant complication following arthroscopic surgery, with an estimated overall incidence of less than 1%. Despite the low incidence, an appropriate diagnostic and therapeutic pathway is required to avoid serious long-term consequences, eradicate the infection, and ensure good treatment outcomes. The aim of this current review article is to summarize evidence-based literature regarding diagnostic and therapeutic options of post-operative septic arthritis after arthroscopy. METHODS Through a literature review, up-to-date treatment algorithms and therapies have been identified. Additionally, a supportive new algorithm is proposed for diagnosis and treatment of suspected septic arthritis following arthroscopic intervention. RESULTS A major challenge in diagnostics is the differentiation of the post-operative status between a non-infected hyperinflammatory joint versus septic arthritis, due to clinical symptoms, (e.g., rubor, calor, or tumor) can appear identical. Therefore, joint puncture for microbiological evaluation, especially for fast leukocyte cell-count diagnostics, is advocated. A cell count of more than 20.000 leukocyte/µl with more than 70% of polymorphonuclear cells is the generally accepted threshold for septic arthritis. CONCLUSION The therapy is based on arthroscopic or open surgical debridement for synovectomy and irrigation of the joint, in combination with an adequate antibiotic therapy for 6-12 weeks. Removal of indwelling hardware, such as interference screws for ACL repair or anchors for rotator cuff repair, is recommended in chronic cases. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andreas Voss
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
- Sporthopaedicum, Regensburg, Straubing, Germany.
| | - Christian G Pfeifer
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Markus Rupp
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Peter Angele
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
- Sporthopaedicum, Regensburg, Straubing, Germany
| | - Volker Alt
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Kriechling P, Bouaicha S, Andronic O, Uçkay I, Bock D, Wieser K. Limited improvement and high rate of complication in patients undergoing reverse total shoulder arthroplasty for previous native shoulder infection. J Shoulder Elbow Surg 2021; 30:34-39. [PMID: 32807379 DOI: 10.1016/j.jse.2020.04.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/17/2020] [Accepted: 04/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The outcomes of reverse total shoulder arthroplasty (RTSA) surgery for the sequelae of former septic native joint shoulder arthritis are unknown but might be inferior to patients without prior bacterial arthritis. METHODS We performed a single-center case-control study embedded in our prospective RTSA cohort. We matched all patients with prior infections in a 1:1 ratio with patients who underwent RTSA for other indications. The matching variables were indication for surgery, age, sex, dominant/nondominant shoulder, and body mass index. We evaluated outcomes by Constant score and active function. RESULTS Among 1249 patients in the RTSA cohort, 14 were operated for sequelae of previous native shoulder joint infections. Although both groups significantly improved from preoperative to postoperative values, the outcome of postinfectious patients was clearly inferior in comparison with the control group (absolute [38 ± 17 vs. 75 ± 8, P < .01], relative Constant score [47 ± 19 vs. 88 ± 9, P < .01], Constant pain score [11.0 ± 3.1 vs. 14.3 ± 1.3, P < .01], subjective shoulder value [43 ± 26 vs. 85 ± 10, P < .01], abduction [70 ± 43 vs. 148 ± 29°, P = .001], and elevation [82 ± 49° to 131 ± 16°, P = .02]). Moreover, in the postinfectious group, overall surgical complications occurred in 36%, with the need for revision in 21%. There was, however, no recurrence of infection in any of the patients' shoulders. CONCLUSION RTSA for end-stage postinfectious joint disease is associated with a high number of complications and reoperations. Clinical outcomes are inferior to those without past infection.
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Affiliation(s)
- Philipp Kriechling
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland.
| | - Samy Bouaicha
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Octavian Andronic
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Ilker Uçkay
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland; Department of Infectiology, Balgrist University Hospital, Zürich, Switzerland
| | - David Bock
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, Zürich, Switzerland
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Contreras ES, Frantz TL, Bishop JY, Cvetanovich GL. Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review. Curr Rev Musculoskelet Med 2020; 13:757-768. [PMID: 32827305 PMCID: PMC7661562 DOI: 10.1007/s12178-020-09670-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years. RECENT FINDINGS The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.
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Affiliation(s)
- Erik S. Contreras
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Travis L. Frantz
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Julie Y. Bishop
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Gregory L. Cvetanovich
- Department of Orthopaedic Surgery, The Ohio State University Wexner Medical Center, Columbus, OH USA
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Matsen FA, Whitson A, Hsu JE. Preoperative Skin Cultures Predict Periprosthetic Infections in Revised Shoulder Arthroplasties: A Preliminary Report. JB JS Open Access 2020; 5:e20.00095. [PMID: 33376924 PMCID: PMC7757832 DOI: 10.2106/jbjs.oa.20.00095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Current approaches do not provide a practical method for the accurate prediction of a Cutibacterium periprosthetic joint infection (PJI) in failed arthroplasties. Thus, surgeons revising failed arthroplasties must decide whether to exchange the implants and to institute antibiotic treatment without knowing the results of cultures of deep specimens obtained at the revision procedure. This study tests the hypothesis that the results of preoperative culture specimens of the skin surface obtained in the clinic can predict the presence of culture-positive Cutibacterium PJIs. METHODS Revision shoulder arthroplasties performed between October 3, 2017, and February 4, 2020, that had both preoperative clinic culture specimens and surgical culture specimens were included in this analysis. Culture results were assigned a value from 0 to 4. The percentage of the total skin bacterial load contributed by Cutibacterium (Cutibacterium percentage) was determined. To reduce concern about contamination, a robust criterion for culture-positive Cutibacterium PJI was applied: ≥2 surgical specimens with a Cutibacterium value of ≥1. The predictive values for a culture-positive Cutibacterium PJI were determined for a clinic skin culture Cutibacterium value of >1 and a clinic skin percentage of Cutibacterium of ≥75%. RESULTS Eighteen cases met the inclusion criteria; of these, 7 (6 male patients) met our criterion for a culture-positive Cutibacterium PJI. For all patients, a preoperative clinic skin Cutibacterium value of >1 predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 89%, and a clinic skin Cutibacterium percentage of ≥75% predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 94%. For male patients, a preoperative clinic skin Cutibacterium value of >1 predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 91%, and a clinic skin Cutibacterium percentage of ≥75% predicted the presence of a culture-positive Cutibacterium PJI with an accuracy of 100%. CONCLUSIONS A simple culture specimen of the unprepared skin surface obtained in a clinic prior to revision shoulder arthroplasty may provide valuable assistance to surgeons planning a revision arthroplasty. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Frederick A. Matsen
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Anastasia Whitson
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jason E. Hsu
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington
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