The hospital cost of two-stage reimplantation for deep infection after shoulder arthroplasty

Prior fragility fractures are associated with a higher risk of 8-year complications following total shoulder arthroplasty

Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications.

PURPOSE

As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture.

METHODS

Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery.

RESULTS

The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001).

CONCLUSIONS

Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

LEVEL OF EVIDENCE

III.

Cutibacterium adaptation to life on humans provides a novel biomarker of C. acnes infections

The domestication of cattle provided Propionibacteriaceae the opportunity to adapt to human skin. These bacteria constitute a distinct genus ( Cutibacterium ), and a single species within that genus ( C. acnes ) dominates 25% of human skin. C. acnes protects humans from pathogen colonization, but it can also infect indwelling medical devices inserted through human skin. Proteins that help Cutibacteria live on our skin may also act as virulence factors during an opportunistic infection, like a shoulder periprosthetic joint infection (PJI). To better understand the evolution of this commensal and opportunistic pathogen, we sought to extensively characterize one of these proteins, RoxP. This secreted protein is only found in the Cutibacterium genus, helps C. acnes grow in oxic environments, and is required for C. acnes to colonize human skin. Structure-based sequence analysis of twenty-one RoxP orthologs (71-100% identity to C. acnes strain KPA171202 RoxP_1) revealed a high-degree of molecular surface conservation and helped identify a potential heme-binding interface. Biophysical evaluation of a subset of seven RoxP orthologs (71-100% identity) demonstrated that heme-binding is conserved. Computational modeling of these orthologs suggests that RoxP heme-binding is mediated by an invariant molecular surface composed of a surface-exposed tryptophan (W66), adjacent cationic pocket, and nearby potential heme axial ligands. Further, these orthologs were found to undergo heme-dependent oligomerization. To further probe the role of this protein in C. acnes biology, we developed four monoclonal anti-RoxP antibodies, assessed the binding of those antibodies to a subset of ten RoxP orthologs (71-100% identity), developed an anti-RoxP sandwich ELISA (sELISA) with sub-nanogram sensitivity, and adapted that sELISA to quantitate RoxP in human biofluids that can be infected by C. acnes (serum, synovial fluid, cerebrospinal fluid). This study expands our understanding of how an environmental bacterium evolved to live on humans, and the assays developed in this work can now be used to identify this organism when it gains access to sterile sites to cause opportunistic infections.

Author Summary

The longer humans live, the more they require internal "replacement parts," like prosthetic joints. Increased placement of these and other medical devices has increased their complications, which frequently are infections caused by microbes that live on humans. One of these microbes is Cutibacterium acnes , which dominates 25% of human skin. It appears that when humans domesticated cattle, a C. acnes ancestor adapted from living in cows to living on people. One of these adaptations was RoxP, a protein only found in Cutibacterium and carried by all C. acnes . Here, we describe our extensive characterization of RoxP. We found that distantly related RoxP conserve high stability at the low pH found on human skin. They also conserve the ability to bind heme, a source of iron used by microbes when they infect humans. As a part of this work, we developed tests that measure RoxP to identify C. acnes growth. In a clinic or hospital, these tests could allow a doctor to rapidly identify C. acnes infections, which would improve patient outcomes and lower healthcare costs. This work has helped us better understand how C. acnes adapted to live on humans and to identify C. acnes infections of medical devices.

Single-stage revision for total shoulder arthroplasty infection. Results at a minimum 2 years follow-up

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.

Cost-effectiveness of shoulder arthroplasty for osteoarthritis and rotator cuff tear arthropathy. An economic analysis using real-world data

INTRODUCTION

This study aimed to assess cost-effectiveness of shoulder arthroplasty for osteoarthritis (OA) and rotator cuff tear arthropathy (CTA) from the perspective of a publicly funded health care system using patient data, health utilities and costs from a real-world situation.

HYPOTHESIS

Our hypothesis was that arthroplasty for OA is more cost-effective than for CTA.

MATERIAL AND METHODS

We gathered a cohort of patients with 153 anatomic total shoulder arthroplasty (TSA) for OA and 107 reverse shoulder arthroplasty (RSA) for CTA between years 2016-2020 at a university hospital. Short-term (mean 2.8years) shoulder function, health utilities and costs were obtained from prospectively collected data, and a Markov cohort simulation was carried out to assess lifetime cost-utility. The primary outcome measures were change in 15D score to calculate gain in quality-adjusted life years (QALYs) and change in Western Ontario osteoarthritis score of the shoulder (WOOS).

RESULTS

Both TSA and RSA restored shoulder function well, WOOS improvement was 59.7 (95% CI: 56.2-63.2) and 55.8 (95% CI: 50.4-61.2), respectively. The cost/QALY gained was 20,846.82 € for TSA and 38,711.90 € for RSA. The cost-utility was not remarkable sensitive to costs, discounting of future costs or estimated revision rates. However, the cost-effectiveness was very sensitive to change in 15D health utility scores and thus QALY gain, especially for RSA patients.

DISCUSSION

Shoulder arthroplasty restores shoulder function well in both OA and CTA. In health economic terms, RSA is less cost-effective than TSA in an everyday setting, mainly due to inferior improvement of health-related quality-of-life and reduced life expectancy of CTA patients.

LEVEL OF EVIDENCE

III; case series.

Outcomes following revision reverse shoulder arthroplasty for infection

BACKGROUND

In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and health care systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared with rRSA for noninfectious causes.

METHODS

Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into 2 cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi) and (2) rRSA due to noninfectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart score, and active range of motion (ROM) were collected preoperatively and at a minimum 1-year follow-up. Postoperative complications and revision rates were also collected.

RESULTS

A total of 93 patients (n = 19 rRSAi group, n = 74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the 2 groups. Postoperative complication rates and revision rates were comparable between the groups.

CONCLUSION

RSA due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for noninfectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. More efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

Quantitative Real-Time Polymerase Chain Reaction May Serve as a Useful Adjunct to Conventional Culture in The Detection of Cutibacterium acnes in the Glenohumeral Joint: A Study of 100 Consecutive Patients

Objectives

Synovial fluid or tissue culture is the current gold standard for diagnosis of infection, but Cutibacterium acnes (C. acnes) is a frequent cause of shoulder PJI and is a notoriously fastidious organism. The purpose of this study was to compare quantitative real-time polymerase chain reaction (qRT-PCR) to standard culture as a more rapid, sensitive means of identifying C. acnes from the glenohumeral joint. We hypothesized that qRT-PCR would be more effective than standard culture at identifying C. acnes and would have greater sensitivity and specificity for detecting infection.

Methods

This was a prospective observational study with 100 consecutive patients undergoing arthroscopic or open shoulder surgery with known positive and negative controls. Intraoperatively, synovial fluid and tissue was obtained for C. acnes qRT-PCR and results were blinded to the gold standard microbiology cultures.

Results

Clinical review demonstrated 3 patients (3%) with positive cultures, none of which were positive for C. acnes. Of the samples tested by the C. acnes qRT-PCR standard curve, 12.2% of tissue samples and 4.5% of fluid samples were positive. Culture sensitivity was 60.0%, specificity was 100.0%, PPV was 100.0%, and NPV was 97.9%. C. acnes qRT-PCR standard curve sensitivity, specificity, PPV, and NPV was 60.0%, 90.3%, 25.0%, and 97.7% respectively for tissue specimens and 0%, 95.2%, 0%, and 95.2% respectively, for fluid specimens. For combination of culture and tissue qRT-PCR, the sensitivity, specificity, PPV and NPV was 100%, 90.3%, 35.7%, and 100%, respectively.

Conclusion

We report that qRT-PCR for C. acnes identified the organism more frequently than conventional culture. While these findings demonstrate the potential utility of qRT-PCR, the likelihood of false positive results of qRT-PCR should be considered. Thus, qRT-PCR may be useful as an adjuvant to current gold standard workup of synovial fluid or tissue culture for the diagnosis of infection.

Management of periprosthetic joint infection of shoulder arthroplasty: Single-stage versus two-stage protocols. A systematic review and meta-analysis of the literature

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.

Healthcare costs of failed rotator cuff repairs

Background

The goal of this study was to estimate the short-term (∼2 years) healthcare costs of failed primary arthroscopic rotator cuff repair (RCR) in the United States.

Methods

A review of current literature was performed to estimate the number of RCR performed in the United States in the year 2022 and the rate of progression of these patients to lose repair continuity, reach clinical failure, and progress to nonoperative intervention and revision procedures. A review of the current literature was performed to estimate the costs incurred by these failures over the ensuing 2-year postoperative time period.

Results

The direct and indirect healthcare costs of structural and clinical failure of primary RCR performed in 2022 are estimated to reach $438,892,670 in the short-term postoperative period. The majority of the costs come from the estimated $229,390,898 in nonoperative management that these patients undergo after they reach clinical failure.

Conclusion

The short-term healthcare costs of failed arthroscopic RCR performed in the United States in 2022 are predicted to be $438,892,670. Although RCR improves quality of life, pain, function, and is cost-effective, there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

Clinical Relevance

Although RCR improves quality of life, pain, function, and is cost-effective, this study provides evidence that there remains great potential for reducing the economic burden of failed RCR repairs on the US society. Investments into research aimed to improve RCR healing rates are warranted.

The incidence of shoulder arthroplasty infection presents a substantial economic burden in the United States: a predictive model

Background

Periprosthetic joint infections (PJIs) are a major cause of morbidity after shoulder arthroplasty. Prior national database studies have estimated the trends of shoulder PJI up to 2012.²¹ Since 2012, the landscape of shoulder arthroplasty has changed drastically with the expanding popularity of reverse total shoulder arthroplasty. The dramatic growth in primary shoulder arthroplasties is likely paralleled with an increase of PJI case volume. The purpose of this study is to quantify the rise in shoulder PJIs and the economic stress they currently place on the American healthcare system as well as the toll they will incur over the coming decade.

Methods

The Nationwide Inpatient Sample database was queried for primary and revision anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty from 2011-2018. Multivariate regression was used to predict cases and charges through the year 2030 adjusted to 2021 purchasing power parity.

Results

From 2011 to 2018, PJI was found to be 1.1% shoulder arthroplasties, from 0.8% (2011) to 1.4% (2018). Anatomic total shoulder arthroplasty experienced the greatest proportion of infections at 2.0%, followed by hemiarthroplasty at 1.0% and reverse total shoulder arthroplasty at 0.3%. Total hospital charges grew 324%, from $44.8 million (2011) to $190.3 million (2018). Our regression model projects 176% growth in cases and 141% growth in annual charges by 2030.

Conclusion

This study demonstrates the large economic burden that shoulder PJIs pose on the American healthcare system, which is predicted to reach nearly $500 million in charges annually by 2030. Understanding trends in procedure volume and hospital charges will be critical in evaluating strategies to reduce shoulder PJIs.

Prosthetic joint infections of the shoulder: A review of the recent literature

Introduction

Shoulder arthroplasty is a common treatment for shoulder arthritis. Prosthetic joint infection of the shoulder (PJIS) is a debilitating complication to the patient and the healthcare system. Incidence of infection is 0.98-5% for primary arthroplasty. The mean hospital cost for two-stage revision was approximately $35,824. The aim of this paper is to review the recent literature and collate the latest evidence to aid diagnosis and treatment of this serious complication.

Methods

A literature review was performed using PubMed and Google Scholar databases. A search strategy was adopted using the keywords: 'infection' AND 'shoulder arthroplasty' OR 'total shoulder arthroplasty'OR 'TSA' OR 'reverse shoulder arthroplasty' OR 'RSA' OR 'rTSA'. This initial search resulted in 349 articles. A PRISMA flowchart process was followed. Duplicates were removed, screening was performed and the resulting full texts were analysed and further excluded, leaving 46 articles suitable for inclusion. A PICO search strategy was also used.

Results and interpretation

Risk factors for PJIS include procedure type, trauma indications and patient factors.The organism commonly isolated is Cutebacterium acnes, which makes diagnosis challenging due to its indolent nature. Investigations include biochemical tests, synovial aspirate, tissue cultures and radiological examinations.Treatment depends on the depth of the infection and the patient requirements. Medical treatment with antibiotics to local debridement, cement spacer and revision arthroplasty have all been described in the literature. A multidisciplinary decision is made on the microbiological evidence and patient factors.

Conclusion

PJIS is a rare but potentially devastating complication of shoulder arthroplasty and diagnosis is often challenging. There has been much research performed recently, providing more evidence on how to optimise management.

The influence of prior dental pathology on medical complications and peri-prosthetic joint infections following primary shoulder arthroplasty

PURPOSE

Antibiotic prophylaxis before invasive dental procedures is a common practice in the USA. Consensus regarding the influence of prior dental pathology (DP) on postoperative complications is lacking. The objectives are to determine the association of DP prior to shoulder arthroplasty (SA) on: (1) lengths of stay (LOS), (2) medical complications, (3) readmissions, (4) implant-related complications including peri-prosthetic joint infections (PJIs) and (5) healthcare expenditures.

METHODS

The PearlDiver database was queried for primary shoulder arthroplasty from 2010 to 2020. Patients with history of dental caries or dental implant placement before SA represented the study group (n = 1419). Patients without prior DP represented controls (n = 7062). Study group patients were 1:5 ratio matched to controls by age, sex, and comorbidities. Outcomes included LOS, 90-day complications, readmissions, 2-year implant-related complications, and healthcare reimbursements. Logistic regression was used to calculate odds ratios (OR) of complications and readmissions. T tests compared LOS and costs. P values < 0.003 were significant.

RESULTS

LOS (2.17 vs. 2.07 days; p = 0.071) were similar between groups. Patients with DP had higher 90-day medical complications compared to controls (OR: 1.74, p < 0.0001), including myocardial infarctions (2.2% vs. 0.8%; OR: 2.79, p < 0.0001), acute kidney injuries (8.3% vs. 4.6%; OR: 1.92, p < 0.0001), and pneumonias (8.7% vs. 5.3%; OR: 1.72, p < 0.0001). Readmission rates (1.97% vs. 1.54%; p = 0.248) were similar. Two-year implant complications were higher in patients with DP compared to controls (16.1% vs. 11.5%; OR: 1.38, p = 0.0003), including dislocations (6.4% vs. 4.5%; OR: 1.45, p = 0.002) and mechanical loosenings (4.0% vs. 2.4%; OR: 1.67, p = 0.001); however, PJIs were similar (2.2% vs. 1.9%; OR: 1.12, p = 0.583). Healthcare expenditures between groups were similar ($12,611 vs. $12,059; p = 0.075).

CONCLUSION

Patients with prior DP have higher 90-day medical complications and 2-year implant-related complications. Two-year incidence of PJIs were similar between groups. These findings can help shoulder surgeons counsel patients with a pertinent dental history.

LEVEL OF EVIDENCE III

Retrospective comparative study.

Risk of revision based on timing of corticosteroid injection prior to shoulder arthroplasty

AIMS

Corticosteroid injections are often used to manage glenohumeral arthritis in patients who may be candidates for future total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (rTSA). In the conservative management of these patients, corticosteroid injections are often provided for symptomatic relief. The purpose of this study was to determine if the timing of corticosteroid injections prior to TSA or rTSA is associated with changes in rates of revision and periprosthetic joint infection (PJI) following these procedures.

METHODS

Data were collected from a national insurance database from January 2006 to December 2017. Patients who underwent shoulder corticosteroid injection within one year prior to ipsilateral TSA or rTSA were identified and stratified into the following cohorts: < three months, three to six months, six to nine months, and nine to 12 months from time of corticosteroid injection to TSA or rTSA. A control cohort with no corticosteroid injection within one year prior to TSA or rTSA was used for comparison. Univariate and multivariate analyses were conducted to determine the association between specific time intervals and outcomes.

RESULTS

In total, 4,252 patients were included in this study. Among those, 1,632 patients (38.4%) received corticosteroid injection(s) within one year prior to TSA or rTSA and 2,620 patients (61.6%) did not. On multivariate analysis, patients who received corticosteroid injection < three months prior to TSA or rTSA were at significantly increased risk for revision (odds ratio (OR) 2.61 (95% confidence interval (CI) 1.77 to 3.28); p < 0.001) when compared with the control cohort. However, there was no significant increase in revision risk for all other timing interval cohorts. Notably, Charlson Comorbidity Index ≥ 3 was a significant independent risk factor for all-cause revision (OR 4.00 (95% CI 1.40 to 8.92); p = 0.036).

CONCLUSION

There is a time-dependent relationship between the preoperative timing of corticosteroid injection and the incidence of all-cause revision surgery following TSA or rTSA. This analysis suggests that an interval of at least three months should be maintained between corticosteroid injection and TSA or rTSA to minimize risks of subsequent revision surgery. Cite this article: Bone Joint J 2022;104-B(5):620-626.

Shoulder Periprosthetic Joint Infection and All-Cause Mortality: A Worrisome Association

Background

Periprosthetic joint infection (PJI) can be a devastating complication following shoulder arthroplasty. PJI following hip and knee arthroplasties has been found to increase mortality. However, anatomical and bacteriologic differences could potentially result in a different trend after shoulder arthroplasties. Thus, the purpose of the present study was to determine whether there is an association between shoulder PJI and all-cause mortality.

Methods

Our institutional Total Joint Registry Database was queried to identify patients who underwent revision shoulder arthroplasty procedures between 2000 and 2018. A total of 1,160 procedures were then classified as either septic (21.8%) or aseptic (78.2%). Septic revisions were further subdivided into (1) debridement, antibiotics, irrigation, and implant retention (9.1%); (2) 2-stage reimplantation for deep infection (61.3%); (3) implant resection without reimplantation (3.6%); and (4) unexpected positive cultures at revision surgery (26.1%). The most common bacterium isolated was Cutibacterium acnes (64.4%). All-cause patient mortality was determined with use of our registry and confirmed with use of a nationwide mortality database. All-cause crude and adjusted mortality rates were then compared between groups.

Results

The 1-year crude mortality rate was 1.8% (95% confidence interval [CI], 0.9% to 2.6%) for the aseptic group and 2.8% (95% CI, 0.7% to 4.8%) for the septic group (p = 0.31). Multivariate Cox regression analysis demonstrated an elevated but statistically similar adjusted hazard ratio for 1-year all-cause mortality of 1.9 (95% CI, 0.8 to 4.6) when comparing the septic to the aseptic group (p = 0.17). The risk of 2-year all-cause mortality was significantly higher in the septic group, with a hazard ratio of 2.2 (95% CI, 1.1 to 4.5; p = 0.029). In univariate analyses, increased 5-year mortality in the septic revision group was associated with age, Charlson Comorbidity Index, and methicillin-resistant Staphylococcus aureus infection, whereas C. acnes infection was associated with lower mortality.

Conclusions

Shoulder PJI is associated with an adjusted 2-year all-cause mortality rate that is double that of aseptic patients. The results of the present study should be utilized to appropriately counsel patients who are considered to be at risk for infection following shoulder arthroplasty.

Level of Evidence

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The impact of prior ipsilateral arthroscopy on infection rates after shoulder arthroplasty

BACKGROUND

Patients frequently undergo interventions before shoulder arthroplasty, including injections and arthroscopy. Although the potential impact of injections on postoperative outcomes such as infection has been well studied, it is less clear whether prior arthroscopy has an impact on infection rates after shoulder arthroplasty. The purpose of this study was to determine whether prior ipsilateral shoulder arthroscopy is associated with an increased risk of postoperative infection after shoulder arthroplasty.

METHODS

Patients who underwent shoulder arthroplasty, including hemiarthroplasty, total shoulder arthroplasty, or reverse shoulder arthroplasty with a minimum of 1-year preoperative database exposure, were queried using Current Procedural Terminology codes from 2 large insurance databases, including both private-payer (Humana, 2008-2017) and Medicare (2006-2014) data. Patients with procedures for infection, fractures, or without laterality data were excluded. Those who underwent ipsilateral shoulder arthroscopy within 2 years before their arthroplasty were identified and compared with controls who did not undergo prior arthroscopy. Each database was analyzed separately. Periprosthetic infection within 1 year after arthroplasty was queried for each group and compared using a logistic regression analysis with control for demographic and comorbidity confounders.

RESULTS

A total of 9362 Medicare patients and 17,716 private-payer patients were included in the study. Of these, 486 (5.2%) Medicare patients and 685 (3.9%) private-payer patients underwent prior arthroscopy. In the Medicare database, prior arthroscopy was also associated with a postarthroplasty infection rate of 3.9% as compared with 1.9% in the control group (odds ratio: 1.96, 95% confidence interval: 1.20-3.22, P = .003). Similarly, in the private insurance cohort, prior shoulder arthroscopy was associated with a postarthroplasty infection rate of 2.9% as compared with 1.4% in the control group (odds ratio: 1.85, 95% confidence interval: 1.13-3.03, P = .005).

CONCLUSION

Shoulder arthroscopy performed within 2 years before shoulder arthroplasty is associated with a higher infection rate in the first year after shoulder arthroplasty.

Clinical Outcome of Two-Stage Revision after Periprosthetic Shoulder Infection

Background: Periprosthetic shoulder infections are devastating complications after shoulder arthroplasty. A potential treatment concept is a two-stage prosthesis exchange. Data are sparse in terms of clinical outcome, including infection-free survival and patient satisfaction after this procedure. In the present study, we investigated recurrence of infection, revision-free survivorship and clinical outcome following two-stage revision due to periprosthetic shoulder infection. Furthermore, reasons for poor outcome were analyzed. Methods: Sixteen patients undergoing two-stage revision after shoulder joint infection were retrospectively identified. Recurrence of infection was analyzed by Kaplan–Meier survival curve. Clinical outcome was quantified with subjective shoulder value (SSV), “quick” Disabilities of the Arm, Shoulder and Hand (qDASH) and Rowe score. Range of motion (ROM) was measured pre- and postoperatively. Postoperative scores and ROM were compared in a subgroup analysis according to different reimplanted prosthesis types. Results: The reinfection-free implant survival was 81% after one year and at final follow-up (FU; mean of 33.2 months). The overall revision-free survival amounted to 56% after one year and at final FU. Patients who received reverse shoulder arthroplasty (RSA) as part of reimplantation had less disability and long-term complications. This group demonstrated better subjective stability and function compared to patients revised to megaprostheses or large-head hemiarthroplasties. Conclusions: Two-stage revision following periprosthetic joint infection of the shoulder allows appropriate infection control in the majority of patients. However, the overall complications and revision rates due to mechanical failure or reinfection are high. Reimplantation of RSA seem superior to alternative prosthesis models in terms of function and patient satisfaction. Therefore, bone-saving surgery and reconstruction of the glenoid may increase the likelihood of reimplantation of RSA and potentially improve outcome in the case of infection-related two-stage revision of the shoulder.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty

Aims

The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

Methods

Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors.

Results

A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively.

Conclusion

Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA. Cite this article: Bone Joint J 2020;102-B(11):1549–1554.

The use of tobacco is a modifiable risk factor for poor outcomes and readmissions after shoulder arthroplasty

AIMS

The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

METHODS

Data for patients who underwent arthroplasty of the shoulder in the USA between January 2011 and December 2015 were obtained from the National Readmission Database, and 90-day readmissions and complications were documented using validated coding methods. Multivariate regression analysis was performed to quantify the risk of smoking on the outcome after TSA, while controlling for patient demographics, comorbidities, and hospital-level confounding factors.

RESULTS

A total of 196,325 non-smokers (93.1%) and 14,461 smokers (6.9%) underwent TSA during the five-year study period. Smokers had significantly increased rates of 30- and 90-day readmission (p = 0.025 and 0.001, respectively), revision within 90 days (p < 0.001), infection (p < 0.001), wound complications (p < 0.001), and instability of the prosthesis (p < 0.001). They were also at significantly greater risk of suffering from pneumonia (p < 0.001), sepsis (p = 0.001), and myocardial infarction (p < 0.001), postoperatively.

CONCLUSION

Smokers have an increased risk of readmission and medical and surgical complications after TSA. These risks are similar to those found for smokers after hip and knee arthroplasty. Many surgeons choose to avoid these elective procedures in patients who smoke. The increased risks should be considered when counselling patients who smoke before undertaking TSA.

Cost Effectiveness of Laminar Flow Systems for Total Shoulder Arthroplasty: Filtering Money from the OR?

Background

Laminar flow ventilation systems were developed to reduce surgical contamination in joint arthroplasty to avoid periprosthetic joint infection (PJI). The goals of this study are to evaluate the cost-effectiveness and economic viability of installing and maintaining a laminar flow system in an operating room.

Methods

A Monte Carlo simulation was used to evaluate the cost effectiveness of laminar flow. The variables included were cost to treat PJI, incidence of PJI, cost of laminar flow, years of operating room use, and arthroplasty volume as the dependent variable.

Results

Laminar flow would be financially-justified when 1,217 (SD: 319) TSA cases are performed annually with assumed 10% reduction in PJI from laminar flow and 487 (SD: 127) with assumed 25% reduction. In a high volume OR, laminar flow costs $25.24 per case (assuming 10% reduction) and $8.24 per case (assuming 25% reduction). Laminar flow would need to reduce the incidence of PJI by 35.1% (SD: 9.1) to be a cost-effective strategy.

Conclusion

This analysis demonstrates the substantial arthroplasty volume and large reduction in PJI rates required to justify the installation and maintenance costs of this technology. This high cost of implementation should be considered prior to installing laminar flow systems.

Pearls and Tips in Shoulder Arthroplasty

There has been rapid evolution in new techniques and technology in shoulder arthroplasty. This has improved the efficiency of the procedures as well as expanded our ability to manage some of the most challenging cases. This article will review key aspects of patient evaluation, discuss key technical steps in primary anatomic and reverse arthroplasty, and lastly provide tips to facilitate revision surgery.

Outcomes of revision arthroplasty for shoulder periprosthetic joint infection: a three-stage revision protocol

BACKGROUND

This study evaluated outcomes after treatment of shoulder periprosthetic joint infection (PJI) with a 3-stage revision protocol consisting of (1) débridement, explantation, and cement spacer placement, followed by parenteral antibiotics; (2) open biopsy and débridement; and (3) reimplantation if cultures were negative. We hypothesized this protocol would eradicate persistent infection while producing excellent functional and subjective outcomes, and there would be no difference in these parameters for patients with shoulder PJI compared with patients with revision for aseptic indications.

METHODS

We retrospectively analyzed a prospectively collected revision shoulder arthroplasty cohort to identify shoulder PJI patients treated with a 3-stage protocol. Demographics, culture data, range of motion, and patient-reported outcomes were collected. Outcomes for patients with shoulder PJI and revision to RTSA were compared with patients revised to RTSA for noninfectious indications. Significance was defined as P < .05.

RESULTS

There were 28 cases of shoulder PJI in 27 patients (age, 66.4 ± 11.2 years,); of these, 21 shoulders were revised to RTSA, and 7 shoulders were revised to hemiarthroplasty. There was no recurrent infection at a mean 32-month follow-up. One year after surgery, mean forward flexion was 110° ± 41° and abduction was 106° ± 42°. Mean final American Shoulder and Elbow Surgeons subjective score was 66.5 ± 23.3. The 21 shoulders with PJI revised to RTSA had no differences for functional and subjective outcomes compared with revised patients without shoulder PJI.

CONCLUSIONS

A 3-stage revision protocol for shoulder PJI reliably eradicated infection. Patients with PJI revised to RTSA can have similar outcomes as patients with noninfectious revision to RTSA.

One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis

Periprosthetic joint infection (PJI) is a catastrophic complication of shoulder arthroplasty. Commonly used surgical treatments include one- or two-stage revision, but their effectiveness in controlling infection is uncertain. We aimed to compare re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and two-stage revision surgery for shoulder PJI using a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or two-stage revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation. The re-infection rate (95% CI) in pooled analysis of eight one-stage studies (147 participants) was 5.3% (1.4-10.6). The corresponding rate for 27 two-stage studies (351 participants) was 11.5% (6.0-18.1). Postoperative clinical measures of function and pain were not significantly different between the two revision strategies. The pooled noninfection complication rate (95% CI) for one-stage and two-stage revision was 12.1% (6.1-19.5) and 18.9% (8.4-31.9) respectively. New evidence suggests one-stage revision is at least equally as effective as the two-stage in controlling infection, maintaining joint function, and improving complications in shoulder PJI.