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El Amiri L, Clavert P, Gaudias J, Klein S, Rondé Oustau C, Antoni M. High infection control rate after systematic one-stage procedure for shoulder arthroplasty chronic infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:2809-2826. [PMID: 37612523 DOI: 10.1007/s00264-023-05927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE The two stage revision procedure is the gold standard surgical technique in chronic shoulder periprosthetic joint infection (PJI). Series of one stage revision have been published with similar outcomes but with preoperative selection of patients. The aim of this work was to report the outcomes (infection eradication, functional, and radiographic) after systematic one stage revision, without preoperative selection of patients, in chronic shoulder PJI. METHODS This was a retrospective monocentric study including 40 patients (14 women and 26 men) with a diagnosis of periprosthetic joint infection after a shoulder arthroplasty. A one stage shoulder prosthesis revision was performed in all patients, for a PJI evolving for more than three weeks, without preoperative patient selection. The primary endpoint was the absence of signs of persistent infection at a minimum follow-up of two years. Secondary endpoints were clinical and radiological outcomes. RESULTS At the last follow-up, 36/40 patients had no recurrence of infection after the one stage revision, i.e., 90% of our series. In 45% (18/40) of the cases, the microbial organism was not known at the time of the one stage revision. Cutibacterium acnes was the most frequent pathogen, found in 67.5% (27/40) of the patients. The infection was polymicrobial in 40% (16/40) of the cases. At last follow-up, mean absolute Constant score was 48.4% (16-93) and weighted score was 65.5% (22-100), and satisfaction was evaluated by the patients as excellent or good in 75% (30/40). About 20% (8/40) of the patients had a postoperative complication. CONCLUSION A one stage revision procedure, combined with appropriate antibiotic therapy, made it possible to eradicate the PJI in 90% of the shoulders in our series with satisfactory functional outcomes.
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Affiliation(s)
- Laëla El Amiri
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France
| | - Philippe Clavert
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France
| | - Jeannot Gaudias
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Stéphane Klein
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Cécile Rondé Oustau
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Maxime Antoni
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France.
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Markes AR, Bigham J, Ma CB, Iyengar JJ, Feeley BT. Preventing and Treating Infection in Reverse Total Shoulder Arthroplasty. Curr Rev Musculoskelet Med 2023:10.1007/s12178-023-09843-1. [PMID: 37227587 PMCID: PMC10382412 DOI: 10.1007/s12178-023-09843-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE OF REVIEW Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty. RECENT FINDINGS The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.
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Affiliation(s)
- Alexander R Markes
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens Street, San Francisco, CA, 94158, USA.
| | - Joseph Bigham
- Department of Orthopaedic Surgery, University of Washington, Seattle, WA, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens Street, San Francisco, CA, 94158, USA
| | | | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California-San Francisco, 1500 Owens Street, San Francisco, CA, 94158, USA
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List K, Streck LE, Gaal C, Achenbach L, Dines D, Rudert M. Patient-specific articulating spacer for two-stage shoulder arthroplasty exchange. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023:10.1007/s00064-023-00801-1. [PMID: 37133809 DOI: 10.1007/s00064-023-00801-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE Two-stage exchange with an antibiotic-loaded polymethylmethacrylate (PMMA) spacer is standard treatment for chronic periprosthetic joint infection of the shoulder. We present a safe and simple technique for patient-specific spacer implants. INDICATION (Chronic) periprosthetic joint infection of the shoulder. RELATIVE CONTRAINDICATIONS Known allergy against components of PMMA bone cements. Inadequate compliance for two-stage exchange. Patient is unfit to undergo two-stage exchange. SURGICAL TECHNIQUE Hardware removal, histologic and microbiologic samples, and debridement. Preparation of targeted or calculated antibiotic-loaded PMMA. Tailoring of patient-specific spacer. Spacer implantation. POSTOPERATIVE MANAGEMENT Rehabilitation protocol. Antibiotic treatment. Reimplantation after successful eradication of infection.
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Affiliation(s)
- Kilian List
- Department of Orthopedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstraße 11, 97074, Wuerzburg, Germany.
| | - Laura Elisa Streck
- Department of Orthopedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstraße 11, 97074, Wuerzburg, Germany
| | - Chiara Gaal
- Department of Orthopedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstraße 11, 97074, Wuerzburg, Germany
| | - Leonard Achenbach
- Department of Orthopedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstraße 11, 97074, Wuerzburg, Germany
| | - David Dines
- Hospital for Special Surgery, 525 East 71st Street, 10021, New York, NY, USA
| | - Maximilian Rudert
- Department of Orthopedic Surgery, Koenig-Ludwig-Haus, University of Wuerzburg, Brettreichstraße 11, 97074, Wuerzburg, Germany
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Aksoy T, Yilmaz A, Beydemir A, Yataganbaba A, Huri G. Comparison of surgical treatment options in periprosthetic shoulder infections: a systematic review from 2016 to 2022. ANNALS OF JOINT 2023; 8:20. [PMID: 38529230 PMCID: PMC10929292 DOI: 10.21037/aoj-22-48] [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: 11/25/2022] [Accepted: 04/17/2023] [Indexed: 03/27/2024]
Abstract
Background Periprosthetic shoulder infection (PSI) management proves to be challenging because of patient morbidity, poor outcomes and need for reoperations. Different surgical treatment methods have been defined; however, a prominent method could not be determined. This systematic review investigated the most recent articles about various treatment modalities used in the surgical treatment of PSI to find the most effective method in terms of infection clearance and function. Methods The keywords were searched using PubMed (MEDLINE), ScienceDirect (Elsevier), and Google Scholar databases on September 30, 2022. Studies which report on operative treatment and have longer than 2-year follow-up were included in this review. Of the 555 studies in total, 16 were reviewed. The absence of symptomatic persistent infection (PI) during follow-up was regarded as a satisfactory outcome. Functional outcomes were analyzed according to the reported mean pooled Constant and Murley Score (CMS) and shoulder forward elevation degree (FE) for each treatment group. Results A total of 339 patients (139 female, 197 male) with 342 shoulders from sixteen studies were included. The mean age of the patients was 67.5±3.8 years, mean follow-up duration was 53.3±19.5 months. In total, 217 shoulders were treated with two-stage revision, 59 were treated with one-stage revision, 37 were treated with definitive spacer, 23 were treated with debridement, antibiotics, and implant retention (DAIR), and 6 were treated with resection arthroplasty. The PI rate in whole treatment groups was 9.9%. The PI rate was significantly highest in the DAIR group (30.4%, P=0.001), while there was no significant difference between other treatment groups (P=0.23). CMS and FE were available for 156 and 190 shoulders, respectively. CMS was highest in the one-stage revision group (63.4±5.9, P=0.001), and FE was highest in the DAIR group (119.3°±28.5°, P=0.001). Conclusions The revision surgeries (one-stage and two-stage revision) were more effective than the non-revision surgeries in functional outcomes. In terms of infection clearance, revision procedures were more successful. Surgeons should prefer revision methods over non-revision procedures when feasible.
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Affiliation(s)
- Taha Aksoy
- Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Abdurrahman Yilmaz
- Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Ataberk Beydemir
- Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey
| | - Alper Yataganbaba
- Department of Orthopaedics and Traumatology, Siverek State Hospital, Sanliurfa, Turkey
| | - Gazi Huri
- Department of Orthopaedics and Traumatology, Hacettepe University, Ankara, Turkey
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Lo EY, Ouseph A, Badejo M, Lund J, Bettacchi C, Garofalo R, Krishnan SG. Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection. J Shoulder Elbow Surg 2023; 32:625-635. [PMID: 36243299 DOI: 10.1016/j.jse.2022.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Management of periprosthetic joint infection (PJI) in shoulder arthroplasty remains a challenge, with no established gold standard treatment. This study presents the unique experience of a high-volume single-surgeon, single-institution approach on staged revision reverse total shoulder arthroplasty (RTSA) for infection. The authors theorize that staged revision RTSA is an effective treatment for PJI. MATERIALS AND METHODS Between 2013 and 2018, 38 patients underwent a staged RTSA for treatment of PJI. Patient histories were collected and classified using Cierny-Mader classification. Infection workup for all patients included radiographs, laboratory indices, and computed tomographic aspiration arthrogram. PJI was identified based on high clinical and radiographic suspicion, elevated serologic markers, and/or aspirate culture results per 2018 International Consensus Meeting Shoulder guidelines on Orthopedic Infections. All patients underwent first stage with implant removal, irrigation and débridement, and antibiotic spacer placement. Next, intravenous antibiotics were administered by infectious disease consultants for a minimum of 6 weeks. Infection workup was then repeated and, if normalized, final-stage revision commenced with antibiotic spacer removal and revision to RTSA. If indices were persistently abnormal, an additional stage of débridement and spacer placement procedure was performed. Treatment failure was defined as recurrent periprosthetic infection after final prosthesis implantation or persistently elevated indices despite adequate débridement and spacer placement. RESULTS Mean age of the cohort was 68 (standard deviation [SD] 8.9) years and mean follow-up was 33 (SD 14) months with 34 Cierny-Mader C hosts and 4 B hosts. Patients underwent a mean of 2 (SD 1.1) previous surgeries. The staged revision protocol was successful in 34 (89.5%) patients for management of PJI. Four patients (10.5%) were considered failures with recurrent infections at a mean of 13 months (range 2-26 months) after the final RTSA implantation and underwent repeat staged revisions. Of the 34 patients who had successful infection eradication, 31 had 2-stage treatment and 3 had to undergo 3 stages. There were no treatment-associated mortalities and 10 major complications (26%), including permanent neuropathy, instability, and periprosthetic fractures. The most common cultured microorganism was Cutibacterium acnes (18%), with no polymicrobial infections detected. DISCUSSION Although there are multiple treatment options for PJI management, staged revision remains an effective means of treatment. Although there were several patients who required an additional stage of treatment, and a significant complication rate, staged revision RTSA proved successful in the ultimate eradication of the PJI.
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Affiliation(s)
- Eddie Y Lo
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, TX, USA; The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, TX, USA.
| | - Alvin Ouseph
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, TX, USA; The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, TX, USA
| | | | - Julia Lund
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, TX, USA; The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, TX, USA
| | - Christopher Bettacchi
- North Texas Infectious Diseases Consultants, Baylor University Medical Center, Dallas, TX, USA
| | - Raffaele Garofalo
- Upper Limb Unit, F Miulli Hospital, Acquaviva Delle Fonti, BA, Italy
| | - Sumant G Krishnan
- The Shoulder Center Research, Baylor Scott and White Research Institute, Dallas, TX, USA; The Shoulder Service, Baylor University Medical Center, Baylor Scott and White Health, Dallas, TX, USA
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Faria G, Flood C, Muhammed AR, Narang A, Masood Q, Bakti N, Singh B. Prosthetic joint infections of the shoulder: A review of the recent literature. J Orthop 2023; 36:106-113. [PMID: 36685110 PMCID: PMC9851837 DOI: 10.1016/j.jor.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- Giles Faria
- Darent Valley Hospital, Darenth Wood Rd, Dartford, Kent, DA2 8DA, United Kingdom
| | - Catherine Flood
- Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, United Kingdom
| | | | - Ashish Narang
- Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, United Kingdom
| | - Qazi Masood
- Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, United Kingdom
| | - Nik Bakti
- Darent Valley Hospital, Darenth Wood Rd, Dartford, Kent, DA2 8DA, United Kingdom
| | - Bijayendra Singh
- Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY, United Kingdom
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Two-stage shoulder arthroplasty after deep infection of the shoulder caused by arthroplasty, osteosynthesis or other surgical procedures: microbial spectrum, complications and functional outcome after at least 1 year follow-up. Arch Orthop Trauma Surg 2023; 143:707-715. [PMID: 34432098 DOI: 10.1007/s00402-021-04129-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Infection represents probably the most challenging complication in shoulder arthroplasty and all other surgical procedures of the shoulder. A deep infection of the shoulder is often combined with a destruction of the joint and a loss of function. In many cases the arthroplasty is the last resort for these patients to obtain a satisfactory function. The objective of this study was to determine outcome data on microbiota and clinical results of a two-stage shoulder arthroplasty procedure after deep infection of the shoulder. METHODS Twenty-six patients with a deep shoulder infection after arthroplasty, osteosynthesis, or rotator-cuff repair were included, while two patients had an empyema without prior surgery. All underwent initial surgical debridement with implantation of an antibiotic-loaded spacer, followed by postoperative systemic antibiotics. The patients obtained definitive shoulder arthroplasty in a second surgery. None of the patients had to undergo more than two surgeries before the arthroplasty. The follow-up analysis including microbiota results, complication rates, and functional outcomes could be determined after at least 1 year in 60% of patients (n = 16). RESULTS The most frequently detected microorganisms were S. epidermidis (31%, n = 10) and Cutibacterium acnes (19%, n = 6). In 28% (n = 9) of cases multi-drug resistant bacteria were detected and in 35% (n = 8) of cases more than one microorganism was found. The overall revision rate was 42%, 11 of 26 patients, in the first 8 weeks after arthroplasty. Reasons for revision were joint dislocations in 23% (n = 6), 15% (n = 4) postoperative hematomas, one (4%) re-infection and one (4%) periprosthetic fracture. At follow-up after 19.3 ± 5.5 months postoperatively, a mean abduction of 113.4°, anteversion of 122.8° and external rotation of 14° was found, with an average age and gender-adjusted Constant Score of the affected shoulder of 63. The subjects' pain and impairment in normal life measured by a questionnaire with school grades were significantly reduced (p < 0.05) as compared to prior shoulder arthroplasty. CONCLUSION The most relevant bacteria in the study cohort were Staphylococcus subspecies and to a lower extent Cutibacterium acnes. A high number of multi-drug resistant and mixed microbiota spectra were detected, defining a need to adapt therapeutic regimen targeting these microbiotas. The two-stage shoulder arthroplasty after a deep infection resulted in excellent infection control with however high early postoperative rates for joint dislocation (23%) and hematomas (15%). At follow-up a stable joint was achieved with a sufficient functional outcome and satisfying outcome for activities of daily living and pain. CLINICAL TRIAL Trial registration number: DRKS00016927, date of registration: 2019/03/19.
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Antibiotic Spacers for Shoulder Periprosthetic Joint Infection: A Review. J Am Acad Orthop Surg 2022; 30:917-924. [PMID: 35452429 DOI: 10.5435/jaaos-d-21-00984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/20/2022] [Indexed: 02/01/2023] Open
Abstract
Periprosthetic joint infection is a rare but potentially devastating complication of shoulder arthroplasty. The most conservative treatment approach is a two-stage revision involving interval placement of an antibiotic cement spacer. The purpose of this study was to contextualize the use of antibiotic spacers in the current treatment paradigm of shoulder periprosthetic joint infection and to review the history of shoulder spacers, the different types (eg, stemmed versus stemless and prefabricated versus handmade), the antibiotic composition and dosage, and their efficacy and complications.
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9
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Changes in microbiological spectrum and antibiotic susceptibility in two-stage exchange for periprosthetic shoulder infections. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04635-7. [PMID: 36175674 DOI: 10.1007/s00402-022-04635-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 09/18/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Periprosthetic joint infections (PJI) are a major concern in shoulder arthroplasty, which in some cases require two-stage exchange. While it was shown that low-virulence bacteria are the most isolated pathogens in shoulder PJI, little is known about changes in microbiological spectrum and resistance patterns during two-stage revision. METHODS This retrospective study included all patients (n = 25) who received a two-stage revision from January 2011 to December 2020 for shoulder PJI in one institution. Microbiological spectrum, antimicrobial resistance patterns, and re-revision rates of culture positive first- and second-stage procedures were analyzed. The mean follow-up time was 29.7 months (range 8; 115 months). At final follow-up, subjective shoulder value (SSV) and visual analog scale (VAS) score for pain and satisfaction with the surgery were assessed. RESULTS In 25 patients, a total of 54 2-stage exchange procedures were performed and positive cultures were obtained in 36 of these surgeries (66.7%). A total of 7 out of 25 patients (28.0%) showed a positive microbiological culture at first and second stages. In those patients, the mean time between first and second stages was 30.9 weeks (range 6; 70). Three out of those seven patients (42.9%) had a polymicrobial spectrum with one microorganism persistent at stage two, including Cutibacterium acnes (n = 1) and Staphylococcus epidermidis (MRSE) (n = 2). In all these cases, antimicrobial resistance patterns changed. All cultures with monomicrobial spectrum (n = 4) at first stage showed a changed spectrum. Patients with positive first- and second-stage revisions showed a mean SSV of 49.3% ± 23.5 versus 52.9% ± 29.5 in single positive patients (p = 0.76). Re-revision was performed in five cases, two of those in patients with positive first- and second-stage cultures. CONCLUSION There is a high rate of changes in microbiological spectrum and resistance patterns between culture positive first- and second-stage procedures as well as subsequent re-revisions. Intraoperative samples during reimplantation should be taken and resistance reconsidered in case of re-revision.
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10
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Rondon AJ, Paziuk T, Gutman MJ, Williams GR, Namdari S. Spacers for life: high mortality rate associated with definitive treatment of shoulder periprosthetic infection with permanent antibiotic spacer. J Shoulder Elbow Surg 2021; 30:e732-e740. [PMID: 34087272 DOI: 10.1016/j.jse.2021.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/03/2021] [Accepted: 05/08/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infection following shoulder arthroplasty represents a challenging problem for orthopedic surgeons. Although recent studies have supported 2-stage exchanges, this treatment choice may not be appropriate for all patients. Definitive antibiotic spacer placement represents one treatment strategy with limited reported outcomes in the literature. The purpose of this study was to investigate the mortality rate and functional outcomes associated with definitive spacer placement. METHODS A retrospective chart review identified 17 patients who were treated with definitive antibiotic spacer placement (18 spacers) and were followed up for a minimum of 2 years after surgery. The mortality rate over the study period was determined. Demographic information, clinical course, patient-reported outcomes (American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, and Veterans RAND 12 [VR-12] score), infection parameters as defined by International Consensus Meeting criteria, radiographic evaluation findings, and rotator cuff integrity at the time of spacer placement were collected. RESULTS Seventeen patients underwent treatment with retained antibiotic spacers at a mean age of 62.4 years (range, 50-73 years). Ten patients were women, and the mean body mass index was 30.5 (range, 22.9-39.9). Spacer placement occurred at a mean of 6.1 years (range, 0.48-14.9 years) following index arthroplasty. Five patients required spacer exchange. The most common organisms were Cutibacterium acnes (6) and methicillin-sensitive Staphylococcus aureus (6); in addition, methicillin-resistant S aureus (2), coagulase-negative Staphylococcus (2), Serratia marcescens (1), gram-positive cocci (1), Enterobacter faecalis (1), Enterobacter cloacae (1), diphtheroids (1), and an infection with negative culture findings (1) were observed. The mortality rate was 52.9% (9 of 17 patients). Among the 8 surviving patients, the mean American Shoulder and Elbow Surgeons score was 33.9 (range, 13.3-80.0), the mean Single Assessment Numeric Evaluation score was 35.6 (range, 0.0-80.0), the mean VR-12 mental score was 57.2 (range, 36.6-66.9), and the mean VR-12 physical score was 37.1 (range, 21.7-64.0) at a mean of 4.7 years (range, 2.0-8.8 years). CONCLUSION Definitive antibiotic spacer placement is an acceptable method to treat infection in medically frail patients who have a high mortality risk. Spacer exchange may be necessary because of persistent infection, and functional results are poor.
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Affiliation(s)
| | - Taylor Paziuk
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael J Gutman
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Gerald R Williams
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.
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11
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Two-Stage Exchange Arthroplasty for Periprosthetic Shoulder Infection Is Associated with High Rate of Failure to Reimplant and Mortality. J Clin Med 2021; 10:jcm10215186. [PMID: 34768706 PMCID: PMC8584704 DOI: 10.3390/jcm10215186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Patients with a periprosthetic joint infection (PJI) of the shoulder, who fail to undergo reimplantation in an attempted two-stage exchange seem to be neglected in the current literature. The aim of this study was to assess the clinical course of patients after the first stage in the process of an attempted two-stage exchange for shoulder PJI. Methods: After a retrospective review of our institutional database between 2008 and 2018, 49 patients, who were treated with an intended two-stage exchange for shoulder PJI, were identified. Patients’ demographics, laboratory and health status parameters, along with records of clinical outcome were collected. The primary outcome measurements analyzed were infection eradication, successful reimplantation, and patient survival. Results: Reimplantation was completed in only 35 (71%) of 49 cases and eradication of infection was achieved in 85.7% of patients with successful reimplantation after a mean follow-up duration of 5.1 years (1.1 to 10.2 years). Reasons for failure to reimplant were premature death in 36%, high general morbidity in 29%, satisfaction with the current status in 21%, or severe infection with poor bone and soft tissues in 14% of the patients. Of the 14 cases without reimplantation, eradication rate of infection was 57% after a mean follow-up of 5 years (2.6 to 11 years). The overall mortality rate of the entire cohort was 25% at the latest follow-up and 10% within ninety days after implant removal. Patients who deceased or did not undergo reimplantation during the follow-up were significantly older and had a significantly higher Charlson comorbidity index (CCI). Conclusions: While the two-stage exchange arthroplasty can lead to high rates of infection eradication, a considerable subset of patients never undergoes the second stage for a variety of reasons. Shoulder PJI and its treatment are associated with a high risk of mortality, especially in patients with older age and higher CCI.
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Lemmens L, Geelen H, Depypere M, De Munter P, Verhaegen F, Zimmerli W, Nijs S, Debeer P, Metsemakers WJ. Management of periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2514-2522. [PMID: 33895302 DOI: 10.1016/j.jse.2021.04.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/29/2021] [Accepted: 04/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic shoulder infection (PSI) remains a devastating complication after reverse shoulder arthroplasty (RSA). Currently, scientific data related to the management of PSI are limited, and the optimal strategy and related clinical outcomes remain unclear. Guidelines from the Infectious Diseases Society of America for the management of periprosthetic joint infection are mainly based on data from patients after hip and knee arthroplasty. The aim of this study was to evaluate whether these guidelines are also valid for patients with PSI after RSA. In addition, the functional outcome according to the surgical intervention was assessed. METHODS An RSA database was retrospectively reviewed to identify infections after primary and revision RSAs, diagnosed between 2004 and 2018. Data collected included age, sex, indication for RSA, causative pathogen, surgical and antimicrobial treatment, functional outcome, and recurrence. RESULTS Thirty-six patients with a PSI were identified. Surgical treatment was subdivided into débridement and implant retention (DAIR) (n = 6, 17%); 1-stage revision (n = 1, 3%); 2-stage revision (n = 16, 44%); multiple-stage revision (>2 stages) (n = 7, 19%); definitive spacer implantation (n = 2, 6%); and resection arthroplasty (n = 4, 11%). The most common causative pathogens were Staphylococcus epidermidis (n = 11, 31%) and Cutibacterium acnes (n = 9, 25%). Recurrence was diagnosed in 4 patients (11%), all of whom were initially treated with a DAIR approach. The median follow-up period was 36 months (range, 24-132 months). CONCLUSION PSI is typically caused by low-virulence pathogens, which often are diagnosed with a delay, resulting in chronic infection at the time of surgery. Our results indicate that treatment of patients with chronic PSI with DAIR has a high recurrence rate. In addition, implant exchange (ie, 1- and 2-stage exchange) does not compromise the functional result as compared with implant retention. Thus, patients with chronic PSI should be treated with implant exchange. Future research should further clarify which surgical strategy (ie, 1-stage vs. 2-stage exchange) has a better outcome overall.
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Affiliation(s)
- Laura Lemmens
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Hans Geelen
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Melissa Depypere
- Department of Clinical Biology, University Hospitals Leuven, Leuven, Belgium
| | - Paul De Munter
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Filip Verhaegen
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Werner Zimmerli
- Interdisciplinary Unit for Orthopaedic Infections, Kantonsspital Baselland, Liestal, Switzerland
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Philippe Debeer
- Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, University of Leuven, Leuven, Belgium.
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Bordure P, Marc C, Hubert L, Rony L. Does the retention of osseointegrated prosthetic implants during the surgical management of chronic infections following reverse total shoulder arthroplasty (RTSA) influence functional outcomes without impacting the efficacy of the infection treatment? Orthop Traumatol Surg Res 2021; 107:102906. [PMID: 33789197 DOI: 10.1016/j.otsr.2021.102906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/22/2020] [Accepted: 11/23/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The gold standard (GS) for treating chronic infections following reverse total shoulder arthroplasty (RTSA) is a complete exchange of the prosthesis carried out in one or two stages. This surgical procedure, which may damage the bone stock, can result in poor functional outcomes due to intraoperative complications. The purpose of this study was to compare the GS to a surgical technique that retained osseointegrated implants: the partial one-stage exchange. HYPOTHESIS Partial one-stage exchange was effective in treating chronic infections after RTSA (no recurrent infection) and resulted in better functional outcomes than the GS. MATERIALS AND METHODS This retrospective single-center study included 18 patients with chronic infection after a primary RTSA. Two treatments were compared in a non-randomized fashion. The first included 11 patients who underwent a partial one-stage exchange with implant retention in case of macroscopic osseointegration. The second included seven patients who were treated with the GS: six patients with a complete one-stage exchange and one patient with a two-stage surgical approach. The absence of recurrent infection and functional outcomes were assessed after a minimum of two years. RESULTS There were no statistically significant differences in treatment efficacy between the two strategies: 91% vs. 100%, respectively. The partial one-stage exchange resulted in a significantly improved shoulder function compared to the GS with postoperative Constant scores of 55±14.58 vs. 44±14.45, respectively (p=.03). In the partial one-stage exchange group, there was a significantly improved shoulder function with a preoperative Constant score of 40 [28-55]±9.04 preoperatively vs. 55 [25-75]±14.58 postoperatively (p=.01). The GS treatment did not significantly improve the postoperative function (p=.09). DISCUSSION Partial one-stage exchange does not compromise treatment efficacy of chronic infections after RTSA. This technique resulted in better shoulder function than a conventional GS-type management. A study with greater statistical power is required. LEVEL OF EVIDENCE III; clinical series, retrospective, single-center.
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Affiliation(s)
- Pierre Bordure
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France.
| | - Clément Marc
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France
| | - Laurent Hubert
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France
| | - Louis Rony
- Orthopaedic & Traumatologic Surgery Department, University hospital, 4, rue Larrey, Angers, France
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Clinical Outcome of Two-Stage Revision after Periprosthetic Shoulder Infection. J Clin Med 2021; 10:jcm10020218. [PMID: 33435442 PMCID: PMC7826686 DOI: 10.3390/jcm10020218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 01/04/2023] Open
Abstract
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.
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Belay ES, Danilkowicz R, Bullock G, Wall K, Garrigues GE. Single-stage versus two-stage revision for shoulder periprosthetic joint infection: a systematic review and meta-analysis. J Shoulder Elbow Surg 2020; 29:2476-2486. [PMID: 32565412 DOI: 10.1016/j.jse.2020.05.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/21/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder periprosthetic joint infection (PJI) is a significant complication after arthroplasty with high morbidity. An evidence-based algorithm for the treatment of shoulder PJI is lacking in current practice. The purpose of this systematic review and meta-analysis was to understand and compare the role of single- and 2-stage shoulder arthroplasty revision for PJI. METHODS A comprehensive literature review was performed to identify all studies related to shoulder arthroplasty for PJI in PubMed, Scopus, and EMBASE. Inclusion criteria for this systematic review were studies that reported on single- or 2-stage revision, with infection eradication and a minimum follow-up of 12 months and a minimum of 5 patients for analysis. A random-effects meta-analysis was performed, and heterogeneity was assessed with Cochrane Q and I2. RESULTS A total of 13 studies reporting on single-stage revision and 30 studies reporting on 2-stage revision were included in final analysis. The majority of positive cultures from single-stage revision for PJI resulted in Cutibacterium acnes with 113 of 232 (48.7%) reported cases compared with 190 of 566 (33.7%) reported cases for 2-stage revision. However, there was a lower percentage of methicillin-resistant Staphylococcus aureus positive cultures, with 2.5% for single-stage compared with 9.7% for 2-stage revision. The overall pooled random-effect reinfection incidence was 0.05 (95% confidence interval: 0.02-0.08), with moderate heterogeneity (I2 = 34%, P = .02). The reinfection rate was 6.3% for single-stage and 10.1% for 2-stage revision, but this was not significant (Q = 0.9 and P = .40). CONCLUSION Based on a systematic review with meta-analysis, single-stage revision for shoulder PJI is an effective treatment. Indeed, our analysis showed single-stage to be more effective than 2-stage, but this is likely confounded by a treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with 2-stage in the published literature. This implies that shoulder surgeons treating PJI can be reassured of a low recurrence rate (6.3%) when using single-stage treatment for C acnes or other sensitive, low-virulence organisms.
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Affiliation(s)
- Elshaday S Belay
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Richard Danilkowicz
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Garrett Bullock
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Kevin Wall
- Department of Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA
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Cronin KJ, Hayes CB, Sajadi KR. Antibiotic cement spacer retention for chronic shoulder infection after minimum 2-year follow-up. J Shoulder Elbow Surg 2020; 29:e325-e329. [PMID: 32245728 DOI: 10.1016/j.jse.2020.01.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 12/21/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The treatment of periprosthetic shoulder infections and proximal humerus osteomyelitis is challenging. The outcomes of antibiotic cement spacer retention are poorly defined in the literature. The purpose of this study was to review long-term functional and patient-reported outcomes data of patients with retained antibiotic cement spacers. We predict reasonable functional outcomes and minimal pain. METHODS We identified 22 patients of the senior author who have been treated with definitive antibiotic spacer placement. All patients were originally offered a 2-stage revision and declined. Twelve patients had a minimum follow-up of 2 years and were included in our cohort. Mean age was 70.7 (range 59-81), 8/12 patients were female, and the average body mass index was 27.8 (range = 17-45). Functional outcome assessments included the Standardized Shoulder Assessment Form, the Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH), and visual analog scale (VAS) along with clinical range of motion examination. RESULTS The patients were followed up for a mean of 5.6 years. Eight patients had spacer placement for chronic shoulder arthroplasty infections, whereas 4 patients had spacer placement for chronic osteomyelitis of the proximal humerus. No patients were currently being treated with suppressive antibiotics. One patient had negative cultures at the time of antibiotic spacer placement. The most common organisms were Cutibacterium acnes (6), Staphylococcus epidermidis (6), and methicillin-resistant Staphylococcus aureus (4), with 4 patients growing more than 1 species. The average ASES score was 54 (range = 27-73), QuickDASH was 45 (range = 14-89), and VAS score 2.8 (range = 0-8). Average active range of motion was 68° of forward elevation and 35° of external rotation. CONCLUSIONS Retention of antibiotic cement spacer is a viable option in the treatment algorithm for chronic shoulder infections. Long-term antibiotic cement spacer may be considered for those patients who are unwilling or unable to undergo a 2-stage revision. Patients can expect a reasonable amount of function and little to no pain with an antibiotic cement spacer.
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Affiliation(s)
- Kevin J Cronin
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY, USA.
| | - Christopher B Hayes
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, KY, USA
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One- or two-stage exchange for periprosthetic shoulder infection: Systematic review and meta-analysis. Orthop Traumatol Surg Res 2020; 106:5-15. [PMID: 31862323 DOI: 10.1016/j.otsr.2019.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/07/2019] [Accepted: 10/21/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION One-stage exchange is the gold-standard for management of periprosthetic shoulder infection. The present review compares efficacy between 1- and 2-stage exchange in this indication. MATERIAL AND METHODS We performed a systematic literature review and meta-analysis following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) criteria. The literature search used the Medline, Embase and Central data-bases. The studies included assessed 1- and 2-stage exchange in periprosthetic shoulder infection. The main outcome was reinfection rate, and the secondary outcome postoperative complications rate. RESULTS Twenty-one studies, for 501 patients, were included: 5 assessing 1-stage exchange, 11 2-stage, and 5 both. Mean follow-up was 4.3 years (range, 2-6.1 years). Mean reinfection rates ranged between 0 and 50% in 1-stage exchange and between 0 and 36.8% in 2-stage exchange. The combined rate was 7% (95% CI, 3.8-12.5%) in 1-stage and 21.3% (95% CI, 16-27.9%) in 2-stage exchange. Mean complications rates ranged between 0 and 50% in 1-stage exchange and between 5.7% and 73%% in 2-stage exchange. The combined rate was 17% (95% CI, 11.9-23.9%) in 1-stage and 32.8% (95% CI, 25.8-40.6%) in 2-stage exchange. DISCUSSION To our knowledge, the present meta-analysis is the first to assess results in 1- and 2-stage exchange for chronic periprosthetic shoulder infection. CONCLUSION One-stage exchange seemed to provide better results, with less reinfection and fewer complications than 2-stage exchange. LEVEL OF EVIDENCE I, meta-analysis.
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Abstract
PURPOSE OF REVIEW The most common complications warranting revision consideration in reverse shoulder arthroplasty (RSA) include instability and its associated causes: infection, periprosthetic fracture, and glenoid baseplate loosening. Management of complications can be challenging and the nuances of treatment are still being elucidated. The focus of this paper is to review the treatment of the failed RSA and discuss evidence-based recommendations for revision. RECENT FINDINGS The most common complications requiring revision RSA are instability and infection. The causes for instability can be subdivided into three main subcategories: loss of compression, loss of containment, and impingement. Loss of compression is further broken down into 6 subcategories revolving around abnormal prosthesis positioning, undersized prostheses, or intrinsic soft-tissue tension loss leading to instability. Periprosthetic infection can also lead to instability, yet the most appropriate management for infected RSA remains controversial. Restoring stability by maximizing deltoid and soft tissue tension while avoiding impingement revolves around three basic methods: (1) lateralizing and/or upsizing the glenosphere to an inferior position on the glenoid, (2) use of a more constrained polyethylene insert, and (3) distalizing the humerus by increasing the polyethylene thickness and/or the thickness of the humeral tray. Management of periprosthetic joint infection can be performed in one-stage, two-stage, or "three-stage" procedures all showing good outcomes with two-stage procedures being the most commonly performed. However, persistent positive culture with propriobacterium acnes can occur in up to 25% of cases. In order to limit the associated morbidity from failed revision reverse shoulder arthroplasty, continued research on best management of associated complications is warranted.
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Affiliation(s)
- Alexander R Markes
- University of California San Francisco, School of Medicine, San Francisco, CA, USA.
| | - Edward Cheung
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
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19
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Phipatanakul WP, Petkovic D, Liu JN. Conservative management of chronic Cutibacterium acnes prosthetic shoulder infection: 2 case reports with minimum 6-year follow-up. JSES OPEN ACCESS 2019; 3:113-116. [PMID: 31334438 PMCID: PMC6620203 DOI: 10.1016/j.jses.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Wesley P Phipatanakul
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | | | - Joseph N Liu
- Department of Orthopedic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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Egglestone A, Ingoe H, Rees J, Thomas M, Jeavons R, Rangan A. Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty. Shoulder Elbow 2019; 11:167-181. [PMID: 31210788 PMCID: PMC6555110 DOI: 10.1177/1758573218779076] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 04/30/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this scoping review is to assess the current evidence regarding periprosthetic shoulder infection to inform development of evidence and consensus-based guidelines. METHODS A search of Medline, Embase and PubMed was performed; two authors screened the results independently for inclusion. RESULTS Totally 88 studies were included. Incidence of periprosthetic shoulder infection ranged from 0.7% to 7%. The most common organisms to cause periprosthetic shoulder infection were Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and coagulase-negative Staphylococcus. Male gender and younger age are the most reported risk factors. Erythrocyte sedimentation rate, C-reactive protein and serum/synovial biomarkers had limited diagnostic accuracy. Thirty-nine studies reported the outcome of surgical management of periprosthetic shoulder infection. Eradication rates vary from 54% to 100% for debridement procedures; 66-100% for permanent spacers; 50-100% following single-stage revision; 60-100% following two-stage revision; and 66-100% following resection arthroplasty. CONCLUSION There is wide heterogeneity in study designs and outcomes of studies are often contradictory and due to issues with methodology and small sample sizes the optimal pathways for diagnosis and management cannot be determined from this review. Future research should be based on larger cohorts and randomised trials where feasible to provide more valid research for guiding future treatment of periprosthetic shoulder infection.
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Affiliation(s)
- Anthony Egglestone
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
| | - Helen Ingoe
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedic Surgery, Nuffield Orthopaedic Centre, Oxford, UK
| | - Michael Thomas
- Heatherwood and Wexham Park Hospitals Trust, Berkshire, UK
| | - Richard Jeavons
- North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK
| | - Amar Rangan
- Trauma and Orthopaedic Department, James Cook University Hospital, Middlesbrough, UK
- Faculty of Medical Sciences & NDORMS, University of Oxford, Oxford, UK
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21
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Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S67-S99. [PMID: 31196516 DOI: 10.1016/j.jse.2019.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 04/20/2019] [Indexed: 02/05/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.
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Affiliation(s)
- Grant E Garrigues
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, IL, USA.
| | - Benjamin Zmistowski
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexus M Cooper
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, RI, USA
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Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections. Orthop Traumatol Surg Res 2019; 105:237-240. [PMID: 30497888 DOI: 10.1016/j.otsr.2018.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/21/2018] [Accepted: 10/26/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Periprosthetic shoulder infections (PSIs) represent a serious complication following shoulder arthroplasty. No consensus exists regarding the optimal option. We conducted a retrospective case-control study to compare the outcomes of 2-stage revision shoulder arthroplasty and those of definitive articulating antibiotic spacer implantation with regards to eradication of the infection, improvement of pain and shoulder function. MATERIALS AND METHODS Thirty patients treated for an infected shoulder arthroplasty were retrospectively reviewed after a mean follow-up of 8 years (range, 2-10 years). Nineteen underwent definitive articulating antibiotic spacer implantation and 11 underwent 2-stage revision arthroplasty. Mean age at surgery was 68.8 years. Assessment included Constant-Murley score, visual analog scale pain score, objective examination, patient subjective satisfaction score as well as standard radiographs. RESULTS At the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to preoperative values (p<0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. No statistically significant differences were reported between the two groups concerning Constant-Murley and VAS scores, while average forward flexion and abduction were significantly higher in patients undergoing 2-stage revision surgery. CONCLUSIONS Both surgical procedures provided infection eradication and satisfying subjective functional outcomes. Functional results were superior in patients treated with revision shoulder prosthesis, although a higher rate of complication was reported in this cohort of patients, thus suggesting the use of permanent spacer in high-risk or low-demanding elderly patients. LEVEL OF EVIDENCE III, Retrospective case-control study.
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Outcomes of revision arthroplasty for shoulder periprosthetic joint infection: a three-stage revision protocol. J Shoulder Elbow Surg 2019; 28:268-275. [PMID: 30293858 DOI: 10.1016/j.jse.2018.07.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 07/08/2018] [Accepted: 07/13/2018] [Indexed: 02/01/2023]
Abstract
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.
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Kunutsor SK, Wylde V, Beswick AD, Whitehouse MR, Blom AW. One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis. Sci Rep 2019; 9:232. [PMID: 30659227 PMCID: PMC6338765 DOI: 10.1038/s41598-018-36313-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 11/15/2018] [Indexed: 01/29/2023] Open
Abstract
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.
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Affiliation(s)
- Setor K Kunutsor
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Vikki Wylde
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Andrew D Beswick
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Michael R Whitehouse
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Ashley W Blom
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK
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Sevelda F, Fink B. One-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm. J Shoulder Elbow Surg 2018; 27:2175-2182. [PMID: 30104101 DOI: 10.1016/j.jse.2018.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/31/2018] [Accepted: 06/02/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Studies on 1-stage exchange in septic shoulder arthroplasty are limited and show a wide variation of treatment strategies. This retrospective study investigated infection-free survival and function of 1-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm. METHODS The requirement for 1-stage exchange was an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile prior to revision surgery. If no microorganism was isolated or the underlying pathogen was a difficult-to-treat microorganism (not accessible for biofilm-active antibiotics, enterococci, and fungi), 2-stage exchange was performed. Function was assessed by the Constant score. RESULTS Fourteen patients were included, with a mean follow-up period of 5.8 years. The most and second most commonly detected microorganisms were Cutibacterium acnes (formerly Propionibacterium acnes), and Staphylococcus epidermidis, respectively. At 1-stage exchange, patients received local and systemic antibiotics based on the susceptibility profile of the microorganism. Twelve patients with insufficient rotator cuffs received reverse shoulder arthroplasty, whereas 2 patients with intact rotator cuffs underwent anatomic total shoulder arthroplasty. The infection-free survival rate at 1 and 5 years was 100% and 93% (95% confidence interval [CI], 59%-99%), respectively, with 1 recurrence of infection 22 months after 1-stage exchange. Another patient with limited range of motion underwent revision 6 months postoperatively, leading to a revision-free survival rate of 93% (95% CI, 59%-99%) and 86% (95% CI, 54%-96%) at 1 and 5 years, respectively. The mean Constant score was 65 (range, 44-95). CONCLUSION One-stage exchange with prior detection of the underlying microorganism provides satisfactory infection-free survival and function.
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Affiliation(s)
- Florian Sevelda
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany; Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria.
| | - Bernd Fink
- Department of Joint Replacement, General and Rheumatic Orthopaedics, Orthopaedic Clinic Markgröningen gGmbH, Markgröningen, Germany; Orthopaedic Department, University-Hospital Hamburg-Eppendorf, Hamburg, Germany
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Implant Removal and Spacer Placement for Infected Shoulder Arthroplasty: Risk Factors for Repeat Procedures, Spacer Retention, and Mortality. HSS J 2018; 14:228-232. [PMID: 30258325 PMCID: PMC6148586 DOI: 10.1007/s11420-017-9586-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 10/03/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current studies reporting on patients following prosthesis removal and spacer placement for periprosthetic joint infection (PJI) of the shoulder have largely been descriptive and insufficiently powered to determine risk factors for outcomes other than reimplantation. PURPOSE The objective of the present study is to provide a national perspective on the 1-year outcomes following prosthesis removal and spacer placement and risk factors for outcomes other than reimplantation for treatment of PJI following shoulder arthroplasty. METHODS A national database was queried for Medicare patients who underwent prosthesis removal and spacer placement for PJI between 2005 and 2012. These patients were then evaluated for 5 major study endpoints including: (1) replantation of a shoulder prosthesis within 1 year postoperatively, (2) a repeat irrigation and debridement with second antibiotic spacer placement procedure within 1 year postoperatively, (3) in-hospital death within 1 year postoperatively, (4) a shoulder Girdlestone-type procedure within 1 year postoperatively, and (5) the remaining patients, who were considered to have a retained spacer. Patients with a study endpoint within 1 year postoperatively were included in the study: (1) mortality, (2) repeat debridement, (3) resection arthroplasty, and (4) reimplantation. While it is possible that some patients were not captured due to errors in coding, it is unlikely that patients were lost to follow-up due to change in location of services, given that the database captures all episodes of care that are coded throughout the USA. Independent risk factors were evaluated using logistic regression analysis. RESULTS Nine hundred seventy-five patients who underwent prosthesis removal and spacer placement were included. Within 1 year postoperatively, 21 patients died (2.2%), 70 patients had a repeat debridement procedure (7.2%), 55 patients had a resection arthroplasty procedure (5.6%), 349 patients retained their spacers (35.8%), and the remaining 480 patients had a shoulder arthroplasty reimplanted (49.2%). Numerous independent risk factors exist for all outcomes studied. CONCLUSION The fate of antibiotic spacers placed for PJI of the shoulder at 1 year is variable, with numerous independent risk factors for outcomes other than reimplantation. Patients with PJI following total shoulder arthroplasty should be counseled on the risk factors that influence the outcomes of staged revision for shoulder PJI.
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Pellegrini A, Legnani C, Macchi V, Meani E. Management of periprosthetic shoulder infections with the use of a permanent articulating antibiotic spacer. Arch Orthop Trauma Surg 2018; 138:605-609. [PMID: 29335894 DOI: 10.1007/s00402-018-2870-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Management of periprosthetic shoulder infections (PSIs) still remains challenging. We conducted a retrospective case study to assess the outcomes of definitive articulating antibiotic spacer implantation in a cohort of elderly, low-demanding patients. We hypothesized that in patients with low functional demands seeking pain relief with chronic PSIs, treatment with a definitive articulating antibiotic spacer would lead to satisfying results concerning eradication of the infection, improvement of pain, and improving shoulder function. MATERIALS AND METHODS 19 patients underwent definitive articulating antibiotic spacer implantation for the treatment of an infected shoulder arthroplasty. Mean age at surgery was 70.2 years. Patients were assessed pre-operatively with functional assessment including Constant-Murley score, and objective examination comprehending ROM, visual analog scale pain score, and patient subjective satisfaction (excellent, good, satisfied, or unsatisfied) score. Radiographs were taken to examine signs of loosening, and change in implant positioning. RESULTS At the most recent follow-up, none of the patients had clinical or radiographic signs suggesting recurrent infection. Most patients reported satisfying subjective and objective outcomes. Follow-up examination showed significant improvement of all variables compared to pre-operative values (p < 0.001). Radiographs did not show progressive radiolucent lines or change in the position of the functional spacer. In one case, glenoid osteolysis was reported, which did not affect the clinical outcome. CONCLUSIONS In selected elderly patients with low functional demands seeking pain relief with infected shoulder arthroplasty, definitive management with a cement spacer is a viable treatment option that helps in eradicating shoulder infection and brings satisfying subjective and objective outcomes. LEVEL OF EVIDENCE Case series, Level IV.
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Affiliation(s)
- Antonio Pellegrini
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Galeazzi Orthopaedic Institute, San Siro Clinical Institute Site, Milan, Italy
| | | | - Vittorio Macchi
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Galeazzi Orthopaedic Institute, San Siro Clinical Institute Site, Milan, Italy
| | - Enzo Meani
- Reconstructive Surgery and Septic Complications Surgery Center, IRCCS Galeazzi Orthopaedic Institute, San Siro Clinical Institute Site, Milan, Italy
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Torrens C, Santana F, Puig L, Sorli L, Alier A. Results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection. J Orthop Surg Res 2018; 13:58. [PMID: 29554935 PMCID: PMC5859682 DOI: 10.1186/s13018-018-0763-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/10/2018] [Indexed: 02/07/2023] Open
Abstract
Background The objective of this study is to present the results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection and to determine the rate of positive cultures in the second-stage surgery in shoulder arthroplasty and its meaning. Methods Twenty-one patients (22 cement spacers) treated with two-stage surgery because of a shoulder arthroplasty infection were included. In the second stage, the cement spacer was sent for sonication and at least four tissue cultures were obtained. Epidemiological data, comorbidities, sensitivity of the microorganisms to the antibiotic loaded in the cement spacer in the first revision surgery, time elapsed since an antibiotic was last administered until second revision procedure, functional shoulder status at last follow-up, and any complication were recorded. Results Three out of the 22 cases (13.6%) presented positive cultures at the second-stage surgery. Periprosthetic tissue culturing detected the three positive culture cases in the second stage while the cement spacer sonication detected two and missed one. Considering periprosthetic tissue culturing as the standard procedure, the cement spacer sonication showed sensitivity at 66.6%. Recurrent infection over time was considered present in 3 patients; two of them had been previously diagnosed with a positive culture at the second stage (66.6%). Conclusions A good number of patients (13.6%) present a positive culture at the second stage of the two-stage surgical procedure for infected shoulder arthroplasty, and those patients seem to be at high risk for recurrent infection. Periprosthetic tissue cultures have a higher sensitivity to detecting a positive culture at the second stage than cement spacer sonication.
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Affiliation(s)
- Carlos Torrens
- Department of Orthopedics, Hospital del Mar. Parc de Salut Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain.
| | - Fernando Santana
- Department of Orthopedics, Hospital del Mar. Parc de Salut Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Lluis Puig
- Department of Orthopedics, Hospital del Mar. Parc de Salut Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Luisa Sorli
- Service of Internal Medicine and Infectious Diseases, Hospital del Mar. Parc de Salut Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
| | - Albert Alier
- Department of Orthopedics, Hospital del Mar. Parc de Salut Mar, Passeig Marítim 25-29, 08003, Barcelona, Spain
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Staged Revision With Antibiotic Spacers for Shoulder Prosthetic Joint Infections Yields High Infection Control. Clin Orthop Relat Res 2018; 476:146-152. [PMID: 29389759 PMCID: PMC5919231 DOI: 10.1007/s11999.0000000000000049] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The treatment of periprosthetic joint infection (PJI) of the shoulder with two-stage revision arthroplasty using an antibiotic-loaded cement spacer is established strategy, but there is sparse information regarding the likelihood of infection control and restoration of shoulder. QUESTIONS/PURPOSE (1) What is the likelihood of infection control after two-stage revision using an antibiotic cement spacer for patients with PJI of the shoulder? (2) What are the improvements in Constant and Murley scores at 2 years after these staged revisions? PATIENTS AND METHODS Between 2000 and 2013, we treated 48 patients with PJI of the shoulder using two-stage revision including an antibiotic-containing cement spacer during the first stage. Of those, 38 (79%) were available for review at a minimum of 24 months (mean, 52 ± 34 months). Ten patients (21%) were excluded because they were deceased (n = 3), moved abroad (n = 4), or refused followup (n = 3), leaving 38 for analysis in this retrospective study. During the first stage, removal of the prosthesis, débridement, and implantation of a gentamicin and vancomycin-filled cement spacer were performed by four different surgeons followed by antibiotic therapy (2 weeks intravenous plus 10 weeks oral). For the second stage, we generally tried a reverse total shoulder arthroplasty (RTSA; n = 26). In case of severe glenoid destruction, hemiarthroplasty (HA; n = 8) was used as a salvage option. In 14 patients the cement spacer was left in place because the patients refused further surgery or were not operable owing to medical reasons. The primary outcome included the proportion of patients achieving infection control 2 years after the second-stage procedure after implantation of the cement spacer. Infection control was determined as the absence of the Musculoskeletal Infection Society PJI criteria. The clinical outcome assessed with the Constant and Murley scores served as the secondary outcome parameter. A subgroup (RTSA; HA, spacer retention) analysis of the Constant and Murley scores was performed. RESULTS Successful infection control was achieved in 36 of 38 patients (95%). Patients who underwent treatment with a cement spacer had increased Constant and Murley scores at latest followup compared with their pretreatment scores (mean ± SD, 27 ± 19 versus 43 ± 20; mean difference, 17; 95% CI, 10-24; p = 0.001). For patients who underwent staged treatment followed by second-stage RTSA (n = 23), the Constant and Murley scores increased (mean ± SD, 31 ± 20 versus 51 ± 20; mean difference, 20; 95% CI, 11-30; p = 0.001). The Constant and Murley scores did not improve in patients who underwent HA (mean ± SD, 22 ±15 versus 24 ± 90; mean difference, 3; 95% CI, -10 to 16; p = 0.509) or who retained the spacer (mean ± SD, 18 ±12 versus 35 ±10; mean difference, 19; 95% CI, -5 to 44; p = 0.093). CONCLUSION Revision arthroplasty using an antibiotic-loaded cement spacer provided successful infection control in patients with periprosthetic shoulder infections in this small, retrospective series. Functional improvement was obtained after reimplantation of a reverse total shoulder prosthesis but was not seen after HA and cement spacer; however, baseline differences among patient groups very likely contributed to these differences, and they should not be attributed to implant selection alone. LEVEL OF EVIDENCE Level III, therapeutic study.
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Periprosthetic Joint Infection of Shoulder Arthroplasties: Diagnostic and Treatment Options. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4582756. [PMID: 29423407 PMCID: PMC5750516 DOI: 10.1155/2017/4582756] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 11/05/2017] [Accepted: 11/26/2017] [Indexed: 12/21/2022]
Abstract
Periprosthetic joint infection (PJI) is one of the most frequent reasons for painful shoulder arthroplasties and revision surgery of shoulder arthroplasties. Cutibacterium acnes (Propionibacterium acnes) is one of the microorganisms that most often causes the infection. However, this slow growing microorganism is difficult to detect. This paper presents an overview of different diagnostic test to detect a periprosthetic shoulder infection. This includes nonspecific diagnostic tests and specific tests (with identifying the responsible microorganism). The aspiration can combine different specific and nonspecific tests. In dry aspiration and suspected joint infection, we recommend a biopsy. Several therapeutic options exist for the treatment of PJI of shoulder arthroplasties. In acute infections, the options include leaving the implant in place with open debridement, septic irrigation with antibacterial fluids like octenidine or polyhexanide solution, and exchange of all removable components. In late infections (more than four weeks after implantation) the therapeutic options are a permanent spacer, single-stage revision, and two-stage revision with a temporary spacer. The functional results are best after single-stage revisions with a success rate similar to two-stage revisions. For single-stage revisions, the microorganism should be known preoperatively so that specific antibiotics can be mixed into the cement for implantation of the new prosthesis and specific systemic antibiotic therapy can be applied to support the surgery.
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Does cemented or cementless single-stage exchange arthroplasty of chronic periprosthetic hip infections provide similar infection rates to a two-stage? A systematic review. BMC Infect Dis 2016; 16:553. [PMID: 27724919 PMCID: PMC5057405 DOI: 10.1186/s12879-016-1869-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 09/27/2016] [Indexed: 12/13/2022] Open
Abstract
Background The best surgical modality for treating chronic periprosthetic hip infections remains controversial, with a lack of randomised controlled studies. The aim of this systematic review is to compare the infection recurrence rate after a single-stage versus a two-stage exchange arthroplasty, and the rate of cemented versus cementless single-stage exchange arthroplasty for chronic periprosthetic hip infections. Methods We searched for eligible studies published up to December 2015. Full text or abstract in English were reviewed. We included studies reporting the infection recurrence rate as the outcome of interest following single- or two-stage exchange arthroplasty, or both, with a minimum follow-up of 12 months. Two reviewers independently abstracted data and appraised quality assessment. Results After study selection, 90 observational studies were included. The majority of studies were focused on a two-stage hip exchange arthroplasty (65 %), 18 % on a single-stage exchange, and only a 17 % were comparative studies. There was no statistically significant difference between a single-stage versus a two-stage exchange in terms of recurrence of infection in controlled studies (pooled odds ratio of 1.37 [95 % CI = 0.68-2.74, I2 = 45.5 %]). Similarly, the recurrence infection rate in cementless versus cemented single-stage hip exchanges failed to demonstrate a significant difference, due to the substantial heterogeneity among the studies. Conclusion Despite the methodological limitations and the heterogeneity between single cohorts studies, if we considered only the available controlled studies no superiority was demonstrated between a single- and two-stage exchange at a minimum of 12 months follow-up. The overalapping of confidence intervals related to single-stage cementless and cemented hip exchanges, showed no superiority of either technique.
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Moroder P, Gerhardt C, Renz N, Trampuz A, Scheibel M. Diagnostik und Management des Endoprotheseninfekts am Schultergelenk. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s11678-016-0361-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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