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Williams M, Harris RM. Efficacy of a Novel Intraoperative Surgical Irrigant in Preventing Periprosthetic Joint Infections in Primary Knee, Hip, and Shoulder Arthroplasties: A Retrospective Analysis. Orthop Surg 2024; 16:1277-1283. [PMID: 38627352 PMCID: PMC11144508 DOI: 10.1111/os.14052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 06/04/2024] Open
Abstract
OBJECTIVE Primary joint arthroplasty (JA) is one of the most common operating room (OR) procedures, with knee and hip arthroplasties being listed in the top five most frequent OR procedures and while not as common, shoulder arthroplasties are increasing at greater rates than knee and hip arthroplasties. Periprosthetic joint/shoulder infections (PJI/PSI) are a devastating complication of primary JAs with infection prevention deemed as the single most important strategy in combating them. The objective of this study was to retrospectively evaluate the efficacy of XPERIENCE® Advanced Surgical Irrigation (XP) in preventing PJI following primary joint arthroplasty. METHODS This is a retrospective study of primary knee, hip and shoulder arthroplasties that were performed by multiple orthopedic surgeons at a single hospital setting. XPERIENCE was used as an intraoperative surgical irrigant either solely, or with other intraoperative practices for prevention of infection. Incidence of acute PJI occurring within 90 days of index surgery were retrospectively collated. RESULTS Four hundred and twenty-three (423) primary joint replacement surgeries treated intraoperatively with XP, were evaluated for acute PJI incidence. Retrospective evaluations determined that 95% of the subjects had at least one risk factor predisposing them to PJI. There were zero PJIs diagnosed in the knee and hip arthroplasty cohorts and zero PSIs diagnosed in the shoulder arthroplasty cohorts. CONCLUSION The absence of PJI/PSI diagnoses in the JA cohorts treated intraoperatively with XP indicates that it could be an efficacious antimicrobial irrigant in preventing PJI, and warrants being evaluated in prospective, randomized controlled clinical trials as the sole intraoperative irrigant, as well as in combination with the other intraoperative infection prevention regimens evaluated in this retrospective study.
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MESH Headings
- Humans
- Retrospective Studies
- Prosthesis-Related Infections/prevention & control
- Male
- Female
- Therapeutic Irrigation/methods
- Aged
- Middle Aged
- Arthroplasty, Replacement, Shoulder/methods
- Intraoperative Care/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/adverse effects
- Aged, 80 and over
- Adult
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Affiliation(s)
- Marshall Williams
- Jack Hughston Memorial HospitalPhenix CityALUSA
- Hughston FoundationColumbusGAUSA
| | - Robert M. Harris
- Quillen College of Medicine, East Tennessee State UniversityJohnson CityTNUSA
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Hollier-Larousse B, Hardy A, El Sayed F, Roux AL, Ménigaux C, Bauer T, Werthel JD. Single-stage revision for total shoulder arthroplasty infection. Results at a minimum 2 years follow-up. Orthop Traumatol Surg Res 2024:103881. [PMID: 38582223 DOI: 10.1016/j.otsr.2024.103881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 10/10/2023] [Accepted: 12/22/2023] [Indexed: 04/08/2024]
Abstract
INTRODUCTION Similar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment. HYPOTHESIS Single-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results. METHODS This single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported. RESULTS The average follow-up was 40.4 months (24-102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42-57±21.83). DISCUSSION Single-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
| | - Alexandre Hardy
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
| | - Faten El Sayed
- Infection et Inflammation, université Paris-Saclay, UVSQ, Inserm, Montigny-Le-Bretonneux, France; Microbiology Department, GHU Paris-Saclay, hôpital Ambroise-Paré, AP-HP, Boulogne Billancourt, France
| | - Anne-Laure Roux
- Infection et Inflammation, université Paris-Saclay, UVSQ, Inserm, Montigny-Le-Bretonneux, France
| | - Christophe Ménigaux
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
| | - Thomas Bauer
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
| | - Jean-David Werthel
- Service d'orthopédie traumatologique, AP-HP, CHU Ambroise-Paré, Boulogne Billancourt, France
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Vegas A, Cannon D, Lewis S, Glener J, Mekkawy KL, Rodriguez HC, Schodlbauer DF, Levy JC. Impact of humeral stem length on calcar resorption in anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2024; 33:130-138. [PMID: 37419442 DOI: 10.1016/j.jse.2023.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/08/2023] [Accepted: 05/28/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Use of standard-length anatomic total shoulder (TSA) humeral stems has been associated with high rates of medial calcar bone loss. Calcar bone loss has been attributed to stress shielding, debris-induced osteolysis, and undiagnosed infection. Short stem and canal-sparing humeral components may provide more optimal stress distribution and thus lower rates of calcar bone loss related to stress shielding. The purpose of this study is to determine whether implant length will affect the rate and severity of medial calcar resorption. METHODS A retrospective review was performed on TSA patients treated with three different-length humeral implants (canal-sparing, short, and standard-length designs). Patients were matched 1:1:1 based on both gender and age (±4 years), resulting in 40 patients per cohort. Radiographic changes in medial calcar bone were evaluated and graded on a 4-point scale, from the initial postoperative radiographs to those at 3 months, 6 months, and 12 months. RESULTS The presence of any degree of medial calcar resorption demonstrated an overall rate of 73.3% at one year. At 3 months, calcar resorption was observed in 20% of the canal-sparing cohort, while the short and standard designs demonstrated resorption in 55% and 52.5%, respectively (P = .002). At 12 months, calcar resorption was seen in 65% of the canal-sparing design, while both the short and standard designs had a 77.5% rate of resorption (P = .345). The severity of calcar resorption for the canal-sparing cohort was significantly lower at all time points when compared to the short stem (3 months, P = .004; 6 months, P = .003; 12 months, P = .004) and at 3 months when compared to the standard-length stem (P = .009). CONCLUSION Patients treated with canal-sparing TSA humeral components have significantly lower rates of early calcar resorption with less severe bone loss when compared to patients treated using short and standard-length designs.
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Affiliation(s)
- Austin Vegas
- Department of Orthopedic Surgery, Larkin Community Hospital, South Miami, FL, USA
| | - Dylan Cannon
- Department of Orthopaedic Surgery, Oklahoma University, Oklahoma City, OK, USA
| | - Steven Lewis
- Holy Cross Orthopedic Institute, Fort Lauderdale, FL, USA
| | - Julie Glener
- Holy Cross Orthopedic Institute, Fort Lauderdale, FL, USA
| | | | - Hugo C Rodriguez
- Department of Orthopedic Surgery, Larkin Community Hospital, South Miami, FL, USA
| | - Daniel F Schodlbauer
- Levy Shoulder Center at Paley Orthopedic and Spine Institute, Boca Raton, FL, USA
| | - Jonathan C Levy
- Levy Shoulder Center at Paley Orthopedic and Spine Institute, Boca Raton, FL, USA.
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Barret H, Boileau P. Can Pyrocarbon be used as a functional spacer for the treatment of recalcitrant shoulder infections? JSES Int 2024; 8:167-175. [PMID: 38312269 PMCID: PMC10837719 DOI: 10.1016/j.jseint.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background The most common treatment approach in periprosthetic joint infection (PJI) and chronic shoulder joint infection (SJI) is a two-stage revision involving interval placement of an antibiotic cement spacer or a resection arthroplasty. Knowing that Pyrocarbon has a smooth surface that prevents pathogen adhesion, the question arises whether it could be used as a temporary or permanent functional spacer? Purpose The primary objective of the present study was to assess the rate of infection eradication after temporary or definitive implantation of Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in patients with recalcitrant PJI or SJI. Our secondary objective was to assess mid-term clinical and radiographic outcomes. Methods Fifteen patients (mean age: 52 ± 19 years) with chronic shoulder infection underwent, after joint débridement, implantation of PISA (InSpyre; Tornier-Stryker, Kalamazoo, MI, USA) with tailored perioperative antibiotics. In 7 cases, PJI occurred after hemiarthroplasty (n = 2), reverse shoulder arthroplasty (n = 2), hemireverse (n = 2), and resurfacing arthroplasty (n = 1). In 8 cases, SJI occurred in the context of failed surgery after fracture sequelae (n = 4), instability (n = 2), and cuff arthropathy (n = 2). Preoperatively, patients had a mean of 3 previous failed surgeries before PISA implantation. Patients were evaluated with clinical, laboratory, and radiographic assessment at a minimum of 2 years after surgery. Results At a mean follow-up of 55 ± 18 months, no patient experienced reinfection after temporary (3 cases) or definitive (12 cases) PISA implantation. The adjusted Constant score increased from 33% ± 20 preoperatively to 65% ± 28 at last follow-up and SSV from 22% ± 19 to 63% ± 23 (P < .001). Active forward elevation increased from 27° ± 19 to 113° ± 30, external rotation from 7° ± 21 to 25° ± 25, and internal rotation level 3 ± 2 to level 5 ± 2 points (P < . 001). On final radiographs of definitive PISA, complete humeral densification, or a neocortex, formed around the implant in 64% (7/11). Conclusion Our data suggest that, after washout, débridement and tailored antibiotics, PISA can be used as a temporary or definitive functional spacer for the treatment of recalcitrant shoulder infections and presents the following advantages: (1) PISA does not seem to be a risk for recurrent infection thanks to the antibacterial property of Pyrocarbon; (2) PISA can be used as a temporary or a definitive spacer without causing bone erosion, thanks to the low modulus of elasticity of Pyrocarbon; (3) PISA can be used as a salvage procedure in case of complete glenoid or humeral destruction, thanks to the sphericity of the implant needing no implant anchorage.
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Affiliation(s)
- Hugo Barret
- ICR-Institut de Chirurgie Réparatrice, Groupe Kantys, Nice, France
| | - Pascal Boileau
- ICR-Institut de Chirurgie Réparatrice, Groupe Kantys, Nice, France
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Jacquot A, Samargandi R, Peduzzi L, Mole D, Berhouet J. Infected Shoulder Arthroplasty in Patients Younger than 60 Years: Results of a Multicenter Study. Microorganisms 2023; 11:2770. [PMID: 38004781 PMCID: PMC10673608 DOI: 10.3390/microorganisms11112770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Background: Periprosthetic joint infection (PJI) after shoulder arthroplasty remains a significant complication. This study aimed to explore the epidemiology and risk factors of shoulder PJI in patients aged 60 and younger, analyze treatment options, and evaluate outcomes after 1-year follow-up. Methods: In this retrospective multicentric observational study, data from 1404 shoulders in patients under 60 who underwent primary shoulder arthroplasty were analyzed. Patients with PJI and at least 1-year follow-up after infection treatment were included. Results: The study identified 55 shoulders with PJI, resulting in a 2.35% infection rate after primary shoulder arthroplasty in the young population. Male gender and reverse shoulder arthroplasty were risk factors for infection, while previous surgeries did not significantly contribute. The most common causative agents were Cutibacterium acnes and Staphylococcus epidermidis. Open washout had a 52.9% success rate for acute infections, while one-stage and two-stage revisions achieved infection control rates of 91.3% and 85.7%, respectively. Resection arthroplasty had an 81.8% success rate but poorer functional outcomes. Conclusions: PJI following shoulder arthroplasty in young patients is a significant concern. Preoperative planning should be carefully considered to minimize infection risk. Treatment options such as open washout and one-stage and two-stage revisions offer effective infection control and improved functional outcomes. Resection arthroplasty should be reserved for complex cases where reimplantation is not a viable option.
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Affiliation(s)
- Adrien Jacquot
- Centre for Chirurgie des Articulations et du Sport (ARTICS), 24 rue du XXIème Régiment d’Aviation, 54000 Nancy, France; (A.J.); (D.M.)
| | - Ramy Samargandi
- Service de Chirurgie Orthopédique et Traumatologique, CHRU Trousseau, Faculté de Médecine de Tours, Université de Tours, 1C Avenue de la République, 37170 Chambray-les-Tours, France;
- Department of Orthopedic Surgery, Faculty of Medicine, University of Jeddah, Jeddah 23218, Saudi Arabia
| | - Lisa Peduzzi
- Service de Chirurgie Orthopédique, Centre Hospitalo-Universitaire Nancy-Emile Galle, 49, rue Hermite CS 5211, 54052 Nancy, France;
| | - Daniel Mole
- Centre for Chirurgie des Articulations et du Sport (ARTICS), 24 rue du XXIème Régiment d’Aviation, 54000 Nancy, France; (A.J.); (D.M.)
| | - Julien Berhouet
- Service de Chirurgie Orthopédique et Traumatologique, CHRU Trousseau, Faculté de Médecine de Tours, Université de Tours, 1C Avenue de la République, 37170 Chambray-les-Tours, France;
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El Amiri L, Clavert P, Gaudias J, Klein S, Rondé Oustau C, Antoni M. High infection control rate after systematic one-stage procedure for shoulder arthroplasty chronic infection. INTERNATIONAL ORTHOPAEDICS 2023; 47:2809-2826. [PMID: 37612523 DOI: 10.1007/s00264-023-05927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
PURPOSE The two stage revision procedure is the gold standard surgical technique in chronic shoulder periprosthetic joint infection (PJI). Series of one stage revision have been published with similar outcomes but with preoperative selection of patients. The aim of this work was to report the outcomes (infection eradication, functional, and radiographic) after systematic one stage revision, without preoperative selection of patients, in chronic shoulder PJI. METHODS This was a retrospective monocentric study including 40 patients (14 women and 26 men) with a diagnosis of periprosthetic joint infection after a shoulder arthroplasty. A one stage shoulder prosthesis revision was performed in all patients, for a PJI evolving for more than three weeks, without preoperative patient selection. The primary endpoint was the absence of signs of persistent infection at a minimum follow-up of two years. Secondary endpoints were clinical and radiological outcomes. RESULTS At the last follow-up, 36/40 patients had no recurrence of infection after the one stage revision, i.e., 90% of our series. In 45% (18/40) of the cases, the microbial organism was not known at the time of the one stage revision. Cutibacterium acnes was the most frequent pathogen, found in 67.5% (27/40) of the patients. The infection was polymicrobial in 40% (16/40) of the cases. At last follow-up, mean absolute Constant score was 48.4% (16-93) and weighted score was 65.5% (22-100), and satisfaction was evaluated by the patients as excellent or good in 75% (30/40). About 20% (8/40) of the patients had a postoperative complication. CONCLUSION A one stage revision procedure, combined with appropriate antibiotic therapy, made it possible to eradicate the PJI in 90% of the shoulders in our series with satisfactory functional outcomes.
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Affiliation(s)
- Laëla El Amiri
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France
| | - Philippe Clavert
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France
| | - Jeannot Gaudias
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Stéphane Klein
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Cécile Rondé Oustau
- Department of Orthopedic Septic Surgery, University Hospitals of Strasbourg, 1 place de l'hôpital, 67000, Strasbourg, France
| | - Maxime Antoni
- Shoulder and Elbow Surgery Department, Hautepierre Hospital 2 - CHU Strasbourg, Avenue Molière, 67000, Strasbourg, France.
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Haider Z, Domos P. Infected haematoma in non-immuno-compromised patients following conservatively managed glenohumeral fractures - case reports. Shoulder Elbow 2023; 15:522-526. [PMID: 37811387 PMCID: PMC10557927 DOI: 10.1177/17585732221088519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 11/21/2021] [Accepted: 02/12/2022] [Indexed: 10/10/2023]
Affiliation(s)
- Zakir Haider
- Trauma & Orthopaedics, Barnet Hospital, Wellhouse Lane, Barnet, London, EN5 3DJ, UK
| | - Peter Domos
- Trauma & Orthopaedics, Barnet Hospital, Wellhouse Lane, Barnet, London, EN5 3DJ, UK
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Orban C, Goetti P, Leduc JM, Sandman E, Balg F, Pelet S, Rouleau DM. The POSI study: gender differences in 94 cases of postoperative shoulder surgery infection: results of a 7-year retrospective multicenter study. J Shoulder Elbow Surg 2023; 32:813-819. [PMID: 36283562 DOI: 10.1016/j.jse.2022.09.023] [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: 02/28/2022] [Revised: 09/26/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Contrary to lower limb infection, POstoperative Shoulder surgery Infection (POSI) often involves Cutibacterium acnes. Our aim was to describe patient characteristics and pathogens retrieved in POSI to guide initial empiric antibiotic selection with suspected infection during revision. We also compared microorganisms in infection following trauma, arthroplasty (AP), and arthroscopy (AS). METHODS A multicenter retrospective study from 2010 to 2016 reviewed laboratory databases and medical records to identify patients with a previous shoulder surgery and a confirmed shoulder infection. The following procedures were included: AP, AS, fracture fixation (FF), and another open surgery (OS). A confirmed shoulder infection was defined as 2 positive cultures or more of the same microorganism, or clear clinical infection with 1 positive culture or more. RESULTS Among the 5 hospitals and 28 surgeons involved, 94 POSI cases were identified. Mean age was 59 years at index surgery (range: 22-91) with a majority of men (n = 70, 74%). Among POSI cases, AP was the most common index surgery (n = 41), followed by FF (n = 27), AS (n = 16), and OS (n = 10). The median time between index surgery and the first positive sample was 5 months and the mean was 23 months (minimum 6 days to maximum 27 years), illustrating a positively skewed distribution. Cutibacterium spp were identified in 64 patients (68%), including 59 C acnes patients (63%), which was the most frequent germ in all 4 surgical groups. In 86% of cases, C acnes was identified at the first revision. The other 2 most common germs were Staphylococcus epidermidis and Staphylococcus aureus, with 29% and 17%, respectively. Polymicrobial infection was present in 30% of patients. Gender analysis revealed that C acnes was twice as frequent in men (male = 52 of 70, female = 7 of 24; P < .001). S epidermidis was more prevalent in women (n = 11; 46%) compared with men (n = 16; 21%) (P = .032). C acnes infection was most frequent in arthroscopic surgery (n = 14; 70%, P = .049). S epidermidis was 3 times more prevalent in chronic than in acute cases. CONCLUSION Empiric antimicrobial therapy following POSI, while waiting for culture results, should cover C acnes, S epidermidis, and S aureus. There is a significant gender difference regarding POSI culture results. C acnes is more frequent in men, but should still be covered in women as it was found in 29% of cases.
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Affiliation(s)
| | - Patrick Goetti
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jean-Michel Leduc
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | - Emilie Sandman
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada
| | | | - Stéphane Pelet
- CHU de Québec-Hôpital de l'Enfant-Jésus, Quebec, Quebec, Canada
| | - Dominique M Rouleau
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montreal, Quebec, Canada.
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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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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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Kim DH, Bek CS, Cho CH. Short-term outcomes of two-stage reverse total shoulder arthroplasty with antibiotic-loaded cement spacer for shoulder infection. Clin Shoulder Elb 2022; 25:202-209. [PMID: 35971607 PMCID: PMC9471815 DOI: 10.5397/cise.2021.00745] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Background The purpose of our study was to investigate short-term outcomes of two-stage reverse total shoulder arthroplasty (RTSA) with an antibiotic-loaded cement spacer for shoulder infection. Methods Eleven patients with shoulder infection were treated by two-stage RTSA following temporary antibiotic-loaded cement spacer. Of the 11 shoulders, nine had pyogenic arthritis combined with complex conditions such as recurrent infection, extensive osteomyelitis, osteoarthritis, or massive rotator cuff tear and two had periprosthetic joint infection (PJI). The mean follow-up period was 29.9 months (range, 12–48 months) after RTSA. Clinical and radiographic outcomes were evaluated using the visual analog scale (VAS) score for pain, American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value (SSV), and serial plain radiographs. Results The mean time from antibiotic-loaded cement spacer to RTSA was 9.2 months (range, 1–35 months). All patients had no clinical and radiographic signs of recurrent infection at final follow-up. The mean final VAS score, ASES score, and SSV were significantly improved from 4.5, 38.6, and 29.1% before RTSA to 1.7, 75.1, and 75.9% at final follow-up, respectively. The mean forward flexion, abduction, external rotation, and internal rotation were improved from 50.0°, 50.9°, 17.7°, and sacrum level before RTSA to 127.3°, 110.0°, 51.8°, and L2 level at final follow-up, respectively. Conclusions Two-stage RTSA with antibiotic-loaded cement spacer yields satisfactory short-term clinical and radiographic outcomes. In patients with pyogenic arthritis combined with complex conditions or PJI, two-stage RTSA with an antibiotic-loaded cement spacer would be a successful approach to eradicate infection and to improve function with pain relief.
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12
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Collins AP, Simpson J, Richey B, Zaruta D, Levin S, Lewellyn B, Service BC. Efficacy of antimicrobial washes before shoulder surgery against Cutibacterium: a systematic review and meta-analysis. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:315-322. [PMID: 37588870 PMCID: PMC10426554 DOI: 10.1016/j.xrrt.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Cutibacterium acnes is a commensal intradermal microorganism that is commonly isolated at revision shoulder arthroplasty. Standard practice chlorhexidine gluconate (CHG) skin preparation agents have limited effectiveness at eradicating C. acnes in the dermis. Benzoyl peroxide (BPO) has demonstrated effectiveness against C. acnes. This meta-analysis compares the efficacy of at-home shoulder decolonization before surgery using CHG vs. BPO to reduce shoulder C. acnes burden. Methods This was a Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review. PubMed and MEDLINE databases were searched for studies evaluating the effects of CHG and BPO in reducing C. acnes at the shoulder. Trial results were extracted and pooled using a random effects model, separating data from randomized controlled trials (RCTs) and non-RCTs. Methodologic quality of studies was assessed using the Cochrane Risk of Bias Assessment Tools. Results Ten studies (589 patients) were included. RCTs showed that both BPO and CHG led to significant reductions in culture positivity compared with negative controls (risk ratio [RR] with 95% confidence interval [CI] = 0.20 [0.13, 0.30], P < .0001 and 0.46 [0.37, 0.57], P < .0001, respectively). Non-RCT data demonstrated similar results comparing BPO and CHG to the control (RR with 95% CI = 0.34 [0.21, 0.57], P < .0001 and 0.31 [0.20, 0.49], P < .0001, respectively). Comparing BPO and CHG, RCT data showed a significant reduction in culture positivity with BPO (RR with 95% CI = 0.46 [0.27, 0.77], P < .009). Of RCTs, 5 were low and one was of moderate risk of bias. Of non-RCTs, 3 had low risk of bias, whereas one had moderate risk of bias. Conclusion This review demonstrated that preoperative CHG and BPO can reduce C. acnes at the shoulder. However, BPO exhibits greater efficacy than CHG, potentially because of the compound's ability to penetrate the dermis. BPO is a simple and economical agent that may reduce joint exposure to C. acnes in shoulder surgery.
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Affiliation(s)
| | - Jeffrey Simpson
- Orlando Health Jewett Orthopedic Institute, Orlando, FL, USA
| | - Bradley Richey
- Orlando Health Jewett Orthopedic Institute, Orlando, FL, USA
| | - Douglas Zaruta
- Orlando Health Jewett Orthopedic Institute, Orlando, FL, USA
| | - Samantha Levin
- Orlando Health Jewett Orthopedic Institute, Orlando, FL, USA
| | - Brett Lewellyn
- Orlando Health Jewett Orthopedic Institute, Orlando, FL, USA
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13
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The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study. J Shoulder Elbow Surg 2022; 31:1193-1199. [PMID: 34902586 DOI: 10.1016/j.jse.2021.11.003] [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: 07/11/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes. METHODS A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected. RESULTS Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P < .001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2 ± 2.14 preoperation, 1.06 ± 1.75 postoperation; P < .001). CONCLUSION When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.
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14
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Prior Nonshoulder Periprosthetic Joint Infection Increases the Risk of Surgical Site Infection, Sepsis, and All-Cause Revision After Primary Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2022; 30:133-139. [PMID: 34921545 DOI: 10.5435/jaaos-d-21-00745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/03/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) after total joint arthroplasty is a known risk factor for infection in subsequent joint arthroplasty. The purpose of this study was to determine whether prior nonshoulder PJI contributes to the increased risk of infectious complications, greater healthcare utilization, and increased revision surgery after primary total shoulder arthroplasty (TSA). METHODS Patients who underwent primary TSA for osteoarthritis with prior nonshoulder PJI were identified in a national database (PearlDiver Technologies) using Current Procedural Terminology and International Classification of Diseases codes. These patients were propensity matched based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index >30 kg/m2) to a control cohort of patients who underwent primary TSA for osteoarthritis without any prior PJI. Primary outcomes include 1- and 2-year revision rates. Secondary outcomes include healthcare-specific outcomes of readmission, emergency department visits, length of stay, and mortality. Bivariate analysis was conducted using chi-square tests to compare all outcomes and complications between both cohorts. RESULTS Compared with patients without prior PJI, those with prior PJI had a significantly higher risk of 90-day surgical site infection (7.61% versus 0.56%) and sepsis (1.79% versus 0.56%) after TSA (P < 0.05 for both). Patients with prior PJI also had a higher risk of 90-day readmission compared with those without prior PJI (3.36% versus 1.23%, P = 0.008). In terms of surgical complications, patients with prior PJI had significantly higher risk of 2-year revision surgery compared with patients without prior PJI (3.36% versus 1.57%, P = 0.034). CONCLUSION Prior nonshoulder PJI of any joint increases rates of 90-day surgical site infection, sepsis, and hospital readmission, as well as 2-year all-cause revision after TSA. These results are important for risk-stratifying patients undergoing TSA with prior history of PJI. LEVEL OF EVIDENCE III.
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Razmjou H, van Osnabrugge V, Anunciacion M, Nunn A, Drosdowech D, Roszkowski A, Szafirowicz A, Boljanovic D, Wainwright A, Nam D. Maximizing Muscle Function in Cuff-Deficient Shoulders: A Rehabilitation Proposal for Reverse Arthroplasty. J Shoulder Elb Arthroplast 2022; 5:24715492211023302. [PMID: 34993379 PMCID: PMC8492033 DOI: 10.1177/24715492211023302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/17/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose The purpose of this review is to describe the role of altered joint biomechanics in reverse shoulder arthroplasty and to propose a rehabilitation protocol for a cuff-deficient glenohumeral joint based on the current evidence.Methods and Materials: The proposed rehabilitation incorporates the principles of pertinent muscle loading while considering risk factors and surgical complications. Results In light of altered function of shoulder muscles in reverse arthroplasty, scapular plane abduction should be more often utilized as it better activates deltoid, teres minor, upper trapezius, and serratus anterior. Given the absence of supraspinatus and infraspinatus and reduction of external rotation moment arm of the deltoid in reverse arthroplasty, significant recovery of external rotation may not occur, although an intact teres minor may assist external rotation in the elevated position. Conclusion Improving the efficiency of deltoid function before and after reverse shoulder arthroplasty is a key factor in the rehabilitation of the cuff deficient shoulders. Performing exercises in scapular plane and higher abduction angles activates deltoid and other important muscles more efficiently and optimizes surgical outcomes.
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Affiliation(s)
- Helen Razmjou
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Varda van Osnabrugge
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mark Anunciacion
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Nunn
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Darren Drosdowech
- Roth
- McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada
| | - Ania Roszkowski
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Analia Szafirowicz
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dragana Boljanovic
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amy Wainwright
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Diane Nam
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Orthopedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Miyazaki AN, Checchia CS, Fonseca Filho JM, Gonçalves GV, Conte LHG, Sella GDV. Detecção de Cutibacterium acnes em amostras de tecidos de cirurgias limpas primárias do ombro – Parte I. Rev Bras Ortop 2021; 57:606-611. [PMID: 35966421 PMCID: PMC9365456 DOI: 10.1055/s-0041-1735170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/12/2021] [Indexed: 11/05/2022] Open
Abstract
Objective
The present study aimed to identify bacterial agents in shoulder surgery specimens from patients with no history of previous shoulder infection or surgery.
Methods
Tendon, bursa, and bone specimens were collected during surgery, stored in sterile dry bottles, and sent to a hospital-associated laboratory for culture growth analysis in media for aerobic and anaerobic agents. Findings from 141 samples from 47 shoulders were analyzed.
Results
The cultures were negative in 46 cases (97.8%) and in 140 samples (99.2%). The culture was positive in a single patient, with growth of
Staphylococcus hominis
from one of three specimens collected.
Conclusions
The rates of bacterial growth were not consistent with the international literature, indicating the low effectiveness of laboratory methods used in Brazil.
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Affiliation(s)
- Alberto Naoki Miyazaki
- Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brasil
- Hospital Alemão Oswaldo Cruz em São Paulo, São Paulo, SP, Brasil
| | - Caio Santos Checchia
- Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brasil
| | | | - Guilherme Vieira Gonçalves
- Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Luiz Henrique Gallego Conte
- Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brasil
| | - Guilherme do Val Sella
- Departamento de Ortopedia e Traumatologia, Faculdade de Ciências Médicas, Santa Casa de São Paulo, São Paulo, SP, Brasil
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Falstie-Jensen T, Lange J, Daugaard H, Sørensen AKB, Ovesen J, Søballe K. Unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome? J Shoulder Elbow Surg 2021; 30:1299-1308. [PMID: 33548396 DOI: 10.1016/j.jse.2020.12.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several studies have confirmed a high rate of unexpected positive cultures (UPCs) after presumably aseptic revisions of shoulder arthroplasties; however, the impact on the outcome is still unclear. The purpose of this prospective study is to compare the patient-reported outcomes of standard revisions with and without the emergence of UPCs. METHODS During a 3-year period, we included all patients who were revised for reasons other than suspicion of infection from 2 orthopedic centers. Five biopsies were obtained from every revision, and only cultures with the same bacteria in at least 3 biopsy specimens were classified as UPCs. All patients were assessed using the Oxford Shoulder Score (OSS) and range of motion preoperatively and after at least a 2-year follow-up. RESULTS In this study, 124 patients were included, with a median follow-up of 29 months (range 29-32), and UPCs emerged after 27 revisions (22%), with Cutibacterium acnes accounting for 67% (18/27). At baseline, the OSS was 22 in both the culture-negative and UPC groups (P = .46). Then, at follow-up, the OSS was 37 in the culture-negative group and 35 in the UPC group (P = .91). The forward elevation increased significantly by 44° and 41°, respectively, in the 2 groups, but no statistically significant difference between the culture-negative group and the UPC group was found (P = .66). In contrast, the external rotation was unchanged after the revision, and again, no difference in the change between the culture-negative and UPC groups (P = .54) was observed. Subgroup analyses stratified by different implant designs revealed equal patterns with no statistical differences in outcome. CONCLUSION We did not find a difference in outcome after a presumed aseptic revision regardless of the emergence of UPCs. Similarly, we could not demonstrate that patients with UPCs presented with poorer function at baseline compared with culture-negative patients. The clinical relevance of UPCs thus requires further evaluation, especially in the case of C acnes as a potential pathogenic versus a merely colonizing microbe.
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Affiliation(s)
| | - Jeppe Lange
- Orthopedic Department, Horsens Regional Hospital, Horsens, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Daugaard
- Orthopedic Department, Herlev-Gentofte Hospital, Herlev, Denmark
| | | | - Janne Ovesen
- Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopedic Department, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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18
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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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Klingebiel S, Theil JC, Gosheger G, Schneider KN, Timme M, Schorn D, Liem D, Rickert C. Postoperative Trends of Serum C-Reactive Protein Levels after Primary Shoulder Arthroplasty-Normal Trajectory and Influencing Factors. J Clin Med 2020; 9:jcm9123893. [PMID: 33266181 PMCID: PMC7760886 DOI: 10.3390/jcm9123893] [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: 11/03/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022] Open
Abstract
Background-Postoperative serum C-reactive protein (CRP) is an important diagnostic parameter for systemic inflammation and reflects surgical trauma. While trends and normal trajectories after total knee (TKA) or hip arthroplasty (THA) are established, there is no reference standard for shoulder arthroplasty (SA). Therefore, the aim of this study was to research CRP trends and influencing factors following SA. Methods-This retrospective study analyzed postoperative serum CRP levels and trajectories in 280 patients following SA. Influence of prosthesis design, sex, operating time, BMI, and humeral augmentation with bone cement were analyzed using descriptive statistics and (non-) parametric testing. Results-There is a CRP trend with a peak on day two or three, with a subsequent decrease until day seven. Reverse and stemmed prostheses show a statistically higher CRP peak than stemless prostheses or hemiarthroplasties (HA). There was no influence of gender, body mass index (BMI), operating time, or bone cement. Conclusion-The presented findings may contribute to a better understanding of the postoperative CRP course after SA. The results of this retrospective study should be validated by a prospective study design in the future.
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Affiliation(s)
- Sebastian Klingebiel
- Department of Orthopedics and Tumororthopedics, University Hospital Muenster, 48149 Münster, Germany; (J.C.T.); (G.G.); (K.N.S.); (C.R.)
- Correspondence: ; Tel.: +49-251-83-0
| | - Jan Christoph Theil
- Department of Orthopedics and Tumororthopedics, University Hospital Muenster, 48149 Münster, Germany; (J.C.T.); (G.G.); (K.N.S.); (C.R.)
| | - Georg Gosheger
- Department of Orthopedics and Tumororthopedics, University Hospital Muenster, 48149 Münster, Germany; (J.C.T.); (G.G.); (K.N.S.); (C.R.)
| | - Kristian Nikolaus Schneider
- Department of Orthopedics and Tumororthopedics, University Hospital Muenster, 48149 Münster, Germany; (J.C.T.); (G.G.); (K.N.S.); (C.R.)
| | - Maximilian Timme
- Department of Forensic Medicine, Institute for Legal Medicine, University Hospital Muenster, 48149 Münster, Germany;
| | - Dominik Schorn
- Department for Shoulder and Elbow Surgery, Paracelsus Clinic Bremen, 28329 Bremen, Germany;
| | - Dennis Liem
- Sporthopaedicum Berlin, Medical Practice, 10627 Berlin, Germany;
| | - Carolin Rickert
- Department of Orthopedics and Tumororthopedics, University Hospital Muenster, 48149 Münster, Germany; (J.C.T.); (G.G.); (K.N.S.); (C.R.)
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20
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Arenas-Miquelez A, Arbeloa-Gutierrez L, Familiari F, de Pablos J. Salvage Procedures of the Shoulder: Glenohumeral Arthrodesis and Resection Arthroplasty. Indian J Orthop 2020; 55:27-37. [PMID: 34122752 PMCID: PMC8149774 DOI: 10.1007/s43465-020-00279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND With the advances of modern medicine and technology there has been an increase of indications of shoulder reconstruction techniques and shoulder arthroplasty. Consequently, the number of complications and failures have increased in parallel. Not negligible number of cases are driven to an end-stage situation where salvage procedures, such as glenohumeral arthrodesis (GHA) and shoulder resection arthroplasty (SRA), are the only remaining solution. METHODS The current literature on glenohumeral arthrodesis and shoulder resection arthroplasty was reviewed to determine the indications, surgical technique, complications and outcomes. The electronic search was conducted using the MEDLINE and EMBASE databases and the strategies used were "glenohumeral arthrodesis", "glenohumeral fusion", "shoulder arthrodesis" and "shoulder resection arthroplasty". RESULTS Indications for glenohumeral arthrodesis (GHA) include brachial plexus injury, tumor resections, chronic infection, failed prosthetic arthroplasty, persistent refractory instability or pseudoparalysis of the shoulder with combined irreparable rotator cuff and deltoid injuries. GHA provides good stability, pain resolution, although function is markedly compromised and relying mostly on scapulothoracic joint. The gold standard surgical technique continues to be open shoulder arthrodesis and still has a high complication rate. Shoulder resection arthroplasty (SRA) indications have evolved through the years, being nowadays a salvage procedure for recalcitrant infection of shoulder arthroplasty the main indication. Shoulder function after SRA is often severely compromised, but has a high infection rate resolution. SRA is not technically demanding and complications are rare, being the persistence of infection the most common one. DISCUSSION Despite GHA and SRA having negative connotations, in selected patients, these procedures can diminish pain, resolve persistent infections and provide an acceptable shoulder function. Hence, they should be retained as part of the treatment algorithm for complex shoulder pathology.
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Affiliation(s)
- Antonio Arenas-Miquelez
- grid.1004.50000 0001 2158 5405Shoulder and Elbow, Orthopaedics, Macquarie University Hospital, Suite 303, 2 Technology Place, Sydney, NSW 2109 Australia
| | | | - Filippo Familiari
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro, Italy
| | - Julio de Pablos
- Advanced Reconstructive Osseous Surgery, San Juan de Dios Hospital, Pamplona, Spain
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21
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Alessio-Mazzola M, Repetto I, Russo A, Clemente A, Ventura N, Formica M, Burastero G, Felli L. Permanent Spacers Are a Reliable Solution for Peri-prosthetic Shoulder Infection: A Systematic Review. HSS J 2020; 16:272-279. [PMID: 33082722 PMCID: PMC7534885 DOI: 10.1007/s11420-020-09755-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 02/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peri-prosthetic shoulder infection (PSI), a highly disabling complication of shoulder arthroplasty, often requires additional surgery and prolonged antibiotic therapy. Of strategies proposed to manage this devastating condition, the use of cement spacers, perhaps even as a definitive treatment, is debated. QUESTIONS/PURPOSES We sought to systematically review the literature on antibiotic-loaded cement spacers as a viable, perhaps definitive, treatment for PSI, evaluating the eradication rates, mechanical reliability, and functional results related to its use. METHODS We conducted a systematic review of studies published from January 1, 1980, through September 1, 2019. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Review and Meta-analysis, we searched for studies reporting functional and clinical outcomes in patients with PSI treated with a permanent spacer of the shoulder. Two independent reviewers searched eight databases, as well as reference lists of the retrieved articles. RESULTS After exclusion criteria were applied, 12 studies were included, involving a total of 143 patients. The mean age was 65.8 years; the mean follow-up was 37.4 months. A total of 133 patients (93%) were free from infection at latest follow-up. The mean post-operative active elevation of the shoulder ranged from 48.6 to 90°, the mean abduction ranged from 51 to 75°, and external rotation ranged from 3.6 to 29°. The mean Constant-Murley score ranged from 20.6 to 42 points (out of 100, from worst to best). CONCLUSION The use of a permanent cement spacer is a reliable solution to PSI in low-demand, older patients with comorbidities, a population in whom it is desirable to avoid additional surgery. Our review found a high rate of infection eradication and moderate-to-good objective and subjective results. However, the overall level of evidence of included studies was very low, and higher-quality studies are needed to clarify the role of permanent spacers in the treatment of PSI.
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Affiliation(s)
- Mattia Alessio-Mazzola
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Ilaria Repetto
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Russo
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Antonio Clemente
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Niccolò Ventura
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Matteo Formica
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
| | - Giorgio Burastero
- Joint Replacement Unit, Azienda Ospedaliera Santa Corona, Pietra Ligure, Italy
| | - Lamberto Felli
- grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV, 6, 2° piano, 16132 Genoa, Italy ,Orthopedic Clinic, Ospedale Policlinico San Martino, Genoa, Italy
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22
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Aguilar-Gonzalez J, Luengo-Alonso G, Calvo E. Arthroscopic Circumferential Release for Stiff Reverse Total Shoulder Arthroplasty. Arthrosc Tech 2020; 9:e1369-e1374. [PMID: 33024679 PMCID: PMC7528875 DOI: 10.1016/j.eats.2020.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/25/2020] [Indexed: 02/03/2023] Open
Abstract
Stiffness is a well-known complication after reverse shoulder arthroplasty. Although multiple factors may be involved, the main cause for stiffness is rarely identified. Imaging studies frequently are inconclusive in ruling out mechanical or biological causes. Periprosthetic infection should be always suspected, but the absence of major clinical signs and accurate diagnostic tests is frequent. A lack of objective criteria establishing a diagnosis and when to proceed with revision surgery is often present in such cases. Moreover, additional surgical procedures should be carefully evaluated, as they can represent a point of no return. Shoulder arthroscopy plays an increasingly important role in these cases, either as a diagnostic or therapeutic tool. There are no reports about arthroscopy on stiffness after reverse shoulder arthroplasty. In this Technical Note, we describe an arthroscopic technique aimed to identify potential causes of reverse shoulder arthroplasty stiffness. Subsequent circumferential release is described and discussed.
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Affiliation(s)
- Juan Aguilar-Gonzalez
- Hospital Universitario y Politécnico La Fe, Avinguda de Fernando Abril Martorell, Valencia, Spain
| | | | - Emilio Calvo
- Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain,Address correspondence to Emilio Calvo, M.D., Ph.D., M.B.A., Hospital Universitario Fundación Jiménez Díaz, Avenida de los Reyes Católicos, 2, 28040, Madrid, Spain.
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23
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Laky B, Alram I, Frank JK, Pauzenberger L, Anderl W, Wagner KH, Heuberer PR. Mildly decreased preoperative bilirubin levels are associated with infections after shoulder and knee arthroplasty. J Orthop Res 2020; 38:2074-2082. [PMID: 32017198 DOI: 10.1002/jor.24620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 01/17/2020] [Accepted: 01/30/2020] [Indexed: 02/04/2023]
Abstract
Increasing numbers of arthroplasties are also accompanied by postoperative infections. The main purpose was to evaluate preoperative serum bilirubin levels between patients with and without infections after shoulder and knee arthroplasties. For this retrospective case-control single-center study, a total of 108 patients were extracted from a prospectively collected database. Eighteen patients with infections after shoulder (n = 8) and knee (n = 10) arthroplasty were matched by age, gender, and implant type in a 1:5-scenario to 90 patients (40 shoulders and 50 knees) without postoperative infection. Demographic data, preoperative blood parameters, and postoperative infection-related outcomes were evaluated. Total bilirubin was the only preoperative parameter significantly different between the infection (8.21 ± 3.25 μmol/L or 0.48 ± 0.19 mg/dL) and noninfection (10.78 ± 4.62 μmol/L or 0.63 ± 0.27 mg/dL; P = .014) group, while C-reactive protein and other liver parameters were similar between the groups. Significantly more controls (92.1%) had preoperative bilirubin levels above 8.72 μmol/L or 0.51 mg/dL than cases (7.9%; P = .007). The 5-year infection survival-rate was 65.6% for patients with preoperative bilirubin levels < 8.72 μmol/L or < 0.51 mg/dL and 91.2% with ≥ 8.72 μmol/L or ≥ 0.51 mg/dL. Mildly decreased preoperative bilirubin levels with a cutoff at 8.72 μmol/L or 0.51 mg/dL were significantly associated to patients with infections after shoulder and knee arthroplasty. There were no differences in other blood parameters or comorbidities between patients with infections and their matched-controls.
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Affiliation(s)
- Brenda Laky
- Department of Orthopedic Surgery, Vienna Shoulder and Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Division Orthopedic Research, Vienna, Austria.,Department for Nutritional Sciences, The University of Vienna, Vienna, Austria.,MedSciCare, Institute for Medical Research, Vienna, Austria
| | - Isabella Alram
- Department for Nutritional Sciences, The University of Vienna, Vienna, Austria
| | - Julia K Frank
- Department of Orthopedic Surgery, Vienna Shoulder and Sports Clinic, Vienna, Austria
| | - Leo Pauzenberger
- Department of Orthopedic Surgery, Vienna Shoulder and Sports Clinic, Vienna, Austria.,Department of Orthopedic Surgery, Sports Surgery Clinic, Dublin, Ireland
| | - Werner Anderl
- Department of Orthopedic Surgery, Vienna Shoulder and Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Division Orthopedic Research, Vienna, Austria.,Shoulder and Sports Center, Orthopedic Unit, Mödling, Austria
| | - Karl-Heinz Wagner
- Department for Nutritional Sciences, The University of Vienna, Vienna, Austria.,Department for Nutritional Sciences, Research Platform Active Ageing, The University of Vienna, Vienna, Austria
| | - Philipp R Heuberer
- Department of Orthopedic Surgery, Vienna Shoulder and Sports Clinic, Vienna, Austria.,Austrian Research Group for Regenerative and Orthopedic Medicine (AURROM), Division Orthopedic Research, Vienna, Austria.,HealthPi Medical Center, Orthopedic Unit, Vienna, Austria
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24
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Kunutsor SK, Barrett MC, Whitehouse MR, Craig RS, Lenguerrand E, Beswick AD, Blom AW. Incidence, temporal trends and potential risk factors for prosthetic joint infection after primary total shoulder and elbow replacement: Systematic review and meta-analysis. J Infect 2020; 80:426-436. [DOI: 10.1016/j.jinf.2020.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 12/16/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
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25
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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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26
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Affiliation(s)
- Siddartha Simha
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | | | - J Michael Wiater
- Department of Orthopaedics, Beaumont Health System, Royal Oak, Michigan
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27
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Medial calcar bone resorption after anatomic total shoulder arthroplasty: does it affect outcomes? J Shoulder Elbow Surg 2019; 28:2128-2138. [PMID: 31272889 DOI: 10.1016/j.jse.2019.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 03/23/2019] [Accepted: 03/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. METHODS We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. RESULTS A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P = .001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P = .003) and humeral (9%, P = .039) radiolucencies. CONCLUSION Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening.
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28
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Arthroscopy of the symptomatic shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:1971-1976. [PMID: 31085032 DOI: 10.1016/j.jse.2019.02.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Assessment of a painful or stiff shoulder arthroplasty can be challenging. The cause of pain can sometimes be easily identified. However, some patients have normal levels of inflammatory markers, normal plain films, and no clinical signs to indicate a diagnosis. Indolent organisms may not raise blood marker levels or result in obvious radiologic findings such as loosening. We report the utility of performing arthroscopy in these patients for a diagnostic advantage. METHODS We retrospectively reviewed the health records of all patients who underwent diagnostic shoulder arthroscopy over a 3-year period. Patients were included if they were aged 18 years or older, had undergone previous arthroplasty surgery, and had symptoms of shoulder pain or stiffness. Patients were excluded if they had any traditional symptoms of infection or had a raised serum white cell count or C-reactive protein level prior to diagnostic arthroscopy. RESULTS Fourteen patients met the initial inclusion criteria. The mean interval between index surgery and arthroscopic evaluation was 65.4 months (standard deviation, 58 months; range, 17-192 months). Arthroscopic biopsy specimens returned positive culture results in 3 patients (21%). Rotator cuff tears were noted in 8 patients (57%). Capsular contraction requiring release was noted in 2 patients (10%). In all patients, the diagnostic arthroscopy directed the next stage of management. CONCLUSIONS Diagnostic arthroscopy allows a full assessment of implants, the rotator cuff, the native articular surfaces, and scar tissue, as well as biopsy specimens to be obtained for indolent infection, in patients considering revision arthroplasty surgery. This allows a more informative consent process for patients, directs surgical management, and on occasion, allows for therapeutic intervention in a painful or stiff shoulder arthroplasty.
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29
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Patrick M, Vincent HK, Farmer KW, King JJ, Struk AM, Wright TW. Management of infected shoulder arthroplasty: a comparison of treatment strategies. J Shoulder Elbow Surg 2019; 28:1658-1665. [PMID: 31208895 DOI: 10.1016/j.jse.2019.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/12/2019] [Accepted: 03/13/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The study purpose was to determine whether 2-stage revision procedures result in superior outcomes and whether reverse shoulder arthroplasty produced superior outcomes to hemiarthroplasty or anatomic total shoulder arthroplasty at the time of reimplantation. METHODS Our prospectively collected database was retrospectively reviewed for all surgically treated infected shoulder arthroplasties between 2006 and 2014. We included 47 patients in this study: 27 underwent a 2-stage revision, and 20 were treated with an antibiotic spacer as definitive treatment. Preoperative laboratory results, intraoperative cultures and pathology findings, recurrence of infection, complications, and outcome measures were compared between treatment groups. RESULTS A recurrent infection developed in 3 patients in the antibiotic spacer group and 2 patients in the 2-stage revision group (P = .25). A total of 20 procedure-related complications and 11 medical complications occurred between the 2 groups; however, there was no statistically significant difference between groups. The 2-stage group had statistically significantly better Constant scores (58.1 vs. 33.3, P = .04) and elevation (94.4° vs. 48.6°, P = .02) than the antibiotic spacer group. Subanalysis of the 2-stage revision group showed that reverse total shoulder arthroplasties had statistically superior Shoulder Pain and Disability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Constant scores; elevation; and abduction compared with hemiarthroplasties or anatomic total shoulder arthroplasties. CONCLUSION Two-stage revision procedures and use of an antibiotic spacer for definitive management of periprosthetic shoulder infections appear to be similar and effective in eradicating infections. Two-stage revisions using a reverse total shoulder arthroplasty at the time of reimplantation generate superior range of motion and functional outcome scores.
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Affiliation(s)
- Matthew Patrick
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Heather K Vincent
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Kevin W Farmer
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Aimee M Struk
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
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30
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Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: evaluation of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28:S32-S66. [PMID: 31196514 DOI: 10.1016/j.jse.2019.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/20/2019] [Indexed: 02/01/2023]
Abstract
The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. More than 800 experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form the International Consensus Group. The shoulder workgroup reached consensus on 27 questions related to culture techniques, inflammatory markers, and diagnostic criteria used to evaluate patients for periprosthetic shoulder infection. This document contains the group's recommendations and rationale for each question related to evaluating periprosthetic shoulder infection.
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Mercurio M, Castioni D, Iannò B, Gasparini G, Galasso O. Outcomes of revision surgery after periprosthetic shoulder infection: a systematic review. J Shoulder Elbow Surg 2019; 28:1193-1203. [PMID: 31003887 DOI: 10.1016/j.jse.2019.02.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/04/2019] [Accepted: 02/15/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic shoulder infection (PSI) is one of the most challenging complications after shoulder arthroplasty. Different treatments have been proposed, but the best surgical procedure remains disputed in the current literature. This systematic review investigated the outcomes of revision surgery after PSI. METHODS The PubMed and Scopus databases were used to search keywords in April 2018. Of 2157 titles, 34 studies were finally analyzed. Demographics, laboratory and microbiological data, types of implants, surgical techniques with complications and reoperations, eradication rates, and clinical and functional outcomes were reported. RESULTS A total of 754 patients were identified. Cutibacterium acnes (C. acnes) was the most common microorganism found both in PSI (33%) and persistent infections (40%). Preoperatively, C-reactive protein was elevated in 70% of patients with PSI. Reverse shoulder arthroplasty had a lower prevalence of infection (P < .001). The eradication rate was 96% with 1 stage, 93% with permanent spacers, 86% with 2 stages, 85% with resection arthroplasty, and 65% with irrigation and débridement. One-stage revision was the best treatment, considering postoperative flexion and abduction, compared with resection arthroplasty, permanent spacers, and 2-stage revision. One-stage revision showed fewer postoperative complications than irrigation and débridement, resection arthroplasty, and 2-stage surgery. Two-stage surgery was the most common treatment, and the functional score demonstrated no differences between 2-stage and 1-stage procedures. CONCLUSIONS Our review suggests that a 1-stage procedure should be recommended to treat PSI. Two-stage revision could be reserved for select cases in which the bacterium involved is unknown.
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Affiliation(s)
- Michele Mercurio
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Davide Castioni
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy.
| | - Bruno Iannò
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Giorgio Gasparini
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Olimpio Galasso
- Department of Orthopaedic and Trauma Surgery, "Magna Græcia" University, "Mater Domini" University Hospital, Catanzaro, Italy
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32
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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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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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Thélu-Vanysacker M, Frédéric P, Charles-Edouard T, Alban B, Nicolas B, Tanguy B. SPECT/CT in Postoperative Shoulder Pain. Semin Nucl Med 2018; 48:469-482. [DOI: 10.1053/j.semnuclmed.2018.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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35
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Rangan A, Falworth M, Watts AC, Scarborough M, Thomas M, Kulkarni R, Rees J. Investigation and Management of Periprosthetic Joint Infection in the Shoulder and Elbow: Evidence and consensus based guidelines of the British Elbow and Shoulder Society. Shoulder Elbow 2018; 10:S5-S19. [PMID: 29796102 PMCID: PMC5958475 DOI: 10.1177/1758573218772976] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amar Rangan
- United Kingdom of Great Britain and Northern
Ireland
| | - Mark Falworth
- United Kingdom of Great Britain and Northern
Ireland
| | - Adam C Watts
- United Kingdom of Great Britain and Northern
Ireland
| | | | | | | | - Jonathan Rees
- United Kingdom of Great Britain and Northern
Ireland
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Parsons M. CORR Insights®: Chlorhexidine Antiseptic Irrigation Eradicates Staphylococcus epidermidis From Biofilm: An In Vitro Study. Clin Orthop Relat Res 2018; 476:654-655. [PMID: 29443853 PMCID: PMC6260040 DOI: 10.1007/s11999.0000000000000142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Moby Parsons
- M. Parsons, Seacoast Orthopedics and Sports Medicine, Somersworth, NH, USA
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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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