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Abdelmalek A, Haines S, Tadros BJ, Evans JT, Judge A. Re-operation rates of arthroscopic management versus arthrotomy in treatment of septic arthritis of native shoulder joint in adults. A systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2717-2727. [PMID: 36869912 DOI: 10.1007/s00590-023-03495-0] [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: 11/11/2022] [Accepted: 02/13/2023] [Indexed: 03/05/2023]
Abstract
AIMS Previous studies have reported concern regarding high reoperation rates when septic arthritis of the native shoulder is treated arthroscopically, compared to open arthrotomy. We aimed to compare re-operation rate between the two strategies. PATIENTS AND METHODS The review was registered prospectively at PROSPERO, (CRD42021226518). We searched common databases and references lists (8 February 2021). The inclusion criteria included interventional or observational studies of adult patients with a confirmed diagnosis of native shoulder joint septic arthritis and had either arthroscopy or arthrotomy. The exclusion criteria included patients with periprosthetic or post-surgical infections, patients who had atypical infections, and studies that did not report re-operation rate. Cochrane Collaboration's tool for assessing risk of bias (ROBINS-I) was used. RESULTS Nine studies (retrospective cohort studies) were included that involved 5,643 patients (5,645 shoulders). Mean age ranged from 55.6 to 75.5 years, and follow-up time ranged from 1-41 months. Mean duration of symptoms prior to presentation ranged from 8.3-23.3 days. Metanalysis observed a higher re-operation rate for reinfection at any time point following initial arthroscopy in comparison to arthrotomy, odds ratio 2.61 (95% confidence interval 1.04, 6.56). There was marked heterogeneity (I2 = 78.8%) among studies including surgical techniques and missing data. CONCLUSION This metanalysis observed a higher reoperation rate in arthroscopy in comparison to arthrotomy for the treatment of native shoulder septic arthritis in adults. The quality of the included evidence is low and the heterogeneity among included studies is marked. Higher quality evidence is still needed that address limitations of previous studies.
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Affiliation(s)
- Amir Abdelmalek
- Musculoskeletal Research Unit, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, United Kingdom.
| | - Samuel Haines
- Musculoskeletal Research Unit, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, United Kingdom
| | - Baha John Tadros
- Musculoskeletal Research Unit, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, United Kingdom
| | - Jonathan T Evans
- Musculoskeletal Research Unit, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, United Kingdom
| | - Andrew Judge
- Musculoskeletal Research Unit, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, United Kingdom
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Straub J, Lingitz MT, Apprich S, Staats K, Windhager R, Böhler C. Early postoperative laboratory parameters are predictive of initial treatment failure in acute septic arthritis of the knee and shoulder joint. Sci Rep 2023; 13:8192. [PMID: 37210581 DOI: 10.1038/s41598-023-35384-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/17/2023] [Indexed: 05/22/2023] Open
Abstract
Septic arthritis is an orthopedic emergency potentially causing irreversible joint damage. However, the predictive value of potential risk factors such as early postoperative laboratory parameters remains uncertain. We investigated risk factors for initial surgical treatment failure using data from 249 patients (194 knees, 55 shoulders) treated for acute septic arthritis between 2003 and 2018. Necessity for further surgical intervention was defined as primary outcome. Demographic data, medical history, initial and postoperative laboratory parameters, Charlson Comorbidity Index (CCI), and Kellgren and Lawrence classification were collected. Two scoring systems were developed as tools for failure risk estimation after initial surgical irrigation and debridement. More than one intervention was necessary in 26.1% of cases. Treatment failure occurred significantly more often for those with longer symptom duration (p = 0.003), higher CCI grades (p = 0.027), Kellgren-Lawrence grade IV (p = 0.013), shoulder arthroscopy (p = 0.010), positive bacterial culture results (p < 0.001), slow postoperative CRP decline until day three (p = 0.032) and five (p = 0.015), reduced WBC-decline (p = 0.008), and lower hemoglobin (p < 0.001). Scores for third and fifth postoperative day achieved AUCs of 0.80 and 0.85, respectively. This study identified risk factors for treatment failure in patients with septic arthritis, suggesting that early postoperative laboratory parameters can guide further treatment.
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Affiliation(s)
- Jennifer Straub
- Department of Orthopaedics and Trauma Surgery, Division of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Marie-Therese Lingitz
- Department of Orthopaedics and Trauma Surgery, Division of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Sebastian Apprich
- Department of Orthopaedics and Trauma Surgery, Division of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Kevin Staats
- Department of Orthopaedics and Trauma Surgery, Division of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Reinhard Windhager
- Department of Orthopaedics and Trauma Surgery, Division of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Christoph Böhler
- Department of Orthopaedics and Trauma Surgery, Division of Orthopaedics, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Lower Risk of Revision Surgery After Arthroscopic Versus Open Irrigation and Débridement for Shoulder Septic Arthritis. J Am Acad Orthop Surg 2022; 30:e1504-e1514. [PMID: 36084333 DOI: 10.5435/jaaos-d-22-00428] [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: 04/27/2022] [Accepted: 07/03/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In the treatment of native shoulder septic arthritis, the optimal irrigation and débridement modality-arthroscopic versus open-is a matter of controversy. We aim to compare revision-free survival (RFS), complications, and resource utilization between these approaches. METHODS The National Readmission Database was queried from 2016 to 2019 to identify patients using International Classification of Diseases, 10th revision, diagnostic and procedure codes. Days to revision irrigation and débridement (I&D) were calculated for patients during index admission or subsequent readmissions. Multivariate regression was used for healthcare utilization analysis. Survival analysis was done using Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS A total of 4,113 patients with native shoulder septic arthritis undergoing I&D were identified, 2,775 arthroscopic (67.5%) and 1,338 open (32.5%). The median follow-up was 170 days (interquartile range 79 to 265). A total of 341 patients (8.3%) underwent revision I&D at a median of 9 days. On multivariate analysis, arthroscopic I&D was associated with a reduction in hospital costs of $4,154 ( P < 0.001) and length of stay of 0.78 days ( P = 0.030). Arthroscopic I&D was associated with reduced blood transfusions (odds ratio 0.69, P = 0.001) and wound complications (odds ratio 0.30, P < 0.001). RFS was 96.4%, 94.9%, 93.3%, and 92.6% for arthroscopic I&D and 94.1%, 92.6%, 90.4%, and 89.0% for open I&D at 10, 30, 90 and 180 days, respectively ( P = 0.00043). On multivariate Cox modeling, arthroscopic I&D was associated with improved survival (hazard ratio 0.67, P = 0.00035). On stratified analysis, arthroscopic I&D was associated with improved RFS in patients aged 65 years or older ( P < 0.001), but RFS was similar in those younger than 65 years ( P = 0.17). CONCLUSION Risk of revision I&D was markedly lower after arthroscopic I&D compared with open, although the protective benefit was limited to patients aged 65 years or older. Arthroscopy was also associated with decreased costs, length of stay, and complications. Although surgeons must consider specific patient factors, our results suggest that arthroscopic I&D is superior to open I&D. LEVEL OF EVIDENCE III.
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Salazar LM, Gutierrez-Naranjo JM, Meza C, Gabig A, Bois AJ, Brady CI, Dutta AK. Joint aspiration and serum markers - do they matter in the diagnosis of native shoulder sepsis? A systematic review. BMC Musculoskelet Disord 2022; 23:470. [PMID: 35590311 PMCID: PMC9118805 DOI: 10.1186/s12891-022-05385-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/29/2022] [Indexed: 11/21/2022] Open
Abstract
Background Septic arthritis of the native shoulder is traditionally diagnosed with the same strategies as knee or hip septic arthritis. However, septic arthritis of the shoulder is frequently a missed or delayed diagnosis. Reliance on aspiration and serum markers has been called into question recently. The purpose of this study was to conduct a systematic review investigating the value of joint aspiration and serum markers in the diagnosis of native shoulder joint sepsis. Methods PubMed/MEDLINE, Scopus, and the Cochrane Library were used in the systematic literature search from January 1, 1960, through January 23, 2021. The primary outcome was to report on the synovial white cell count of patients with native shoulder sepsis. Descriptive statistics using percentages, means, and intraclass correlation coefficient (ICC) values were used to summarize the results. Results Thirty-one studies, including 25 case series, one case-control, and five cohort studies with a total of 7434 native shoulder joints, were included. There was no standardized approach to diagnosing septic arthritis of the shoulder. Only 10 studies (32%) reported on synovial white cell count with the majority yielding aspiration counts greater than 50,000 cells/mm3, although one study was as low as 30,000 cells/mm3. Conclusions The diagnosis of native shoulder joint sepsis lacks uniformity. Methods used to evaluate shoulder sepsis are heterogeneous and may lead to delays or misdiagnosis with devastating sequelae. Synovial white cell count is underutilized and may also present with a lower value than expected, which is likely related to the time interval between symptom onset and diagnosis.
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Affiliation(s)
- Luis M Salazar
- UT Health San Antonio, Long School of Medicine, San Antonio, TX, USA.
| | - Jose M Gutierrez-Naranjo
- UT Health San Antonio, Department of Orthopaedics, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229-3900, USA
| | - Clarissa Meza
- UT Health San Antonio, Long School of Medicine, San Antonio, TX, USA
| | - Andrew Gabig
- UT Health San Antonio, Long School of Medicine, San Antonio, TX, USA
| | - Aaron J Bois
- University of Calgary, Sport Medicine Centre, Calgary, AB, Canada
| | - Christina I Brady
- UT Health San Antonio, Department of Orthopaedics, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229-3900, USA
| | - Anil K Dutta
- UT Health San Antonio, Department of Orthopaedics, Floyd Curl Dr, MC 7774, San Antonio, TX, 78229-3900, USA
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Choi MH, Shin WC, Bae H, Park C, Moon NH, Kang SW. Factors affecting the occurrence of osseous lesions in septic shoulder arthritis and the recurrence rate after arthroscopic surgery. J Shoulder Elbow Surg 2022; 31:26-34. [PMID: 34174449 DOI: 10.1016/j.jse.2021.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/07/2021] [Accepted: 05/16/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The purpose of this study was to determine the incidence of osseous lesions and the recurrence rate after arthroscopic surgery in shoulder septic arthritis patients and evaluate the influencing factors. MATERIALS AND METHODS We retrospectively reviewed 44 patients who underwent arthroscopic surgery for septic arthritis of the shoulder between January 2012 and September 2019. The average age of the patients was 65.57 ± 14.2 years, and 56.8% were female patients. The minimum follow-up period was 12 months (average, 32.8 ± 14.2 months; range, 12-72 months). We assessed variables including sex, age, underlying diseases, duration from symptom onset to magnetic resonance imaging (MRI), duration from symptom onset to surgery, radiologic results (radiography and MRI), history of injection therapy, and postoperative infection. The incidence of osseous lesions and the recurrence rate were calculated according to independent variables. In addition, multivariate logistic regression was performed to identify the risk factors for osseous lesions and recurrent infection after adjustment for other variables. RESULTS Twenty-one patients had an osseous lesion on MRI, and 12 patients had evidence of bone erosion on radiographs. In univariate analyses, significant (P < .05) risk factors for the presence of osseous lesions were female sex, lower C-reactive protein level, and longer duration from symptom onset to MRI. The overall infection recurrence rate was 22.7% (10 of 44 patients). Culture results and the duration from symptom onset to surgery were significant risk factors for recurrent infection (P < .05). As the duration from symptom onset to MRI increased by 1 day, the probability of osseous lesions increased 1.31-fold (95% confidence interval, 1.08- to 1.59-fold; P = .007), and this probability was significantly higher after correction for other risk factors. CONCLUSIONS To reduce the severity of septic shoulder infection, timely diagnosis and treatment are essential. Even if osseous lesions are present, good results can be obtained if meticulous débridement is performed through arthroscopic surgery. However, functional and radiologic long-term follow-up studies are needed in patients with osseous lesions.
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Affiliation(s)
- Min Hyeok Choi
- Department of Preventive, and Occupational & Environmental Medicine, Medical College, Pusan National University Yangsan Hospital, Pusan National University, Yangsan, Repulic of Korea; Office of Public Healthcare Service, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Won Chul Shin
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Hyuk Bae
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Chankue Park
- Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Nam Hoon Moon
- Department of Orthopedics, Pusan National University Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Suk-Woong Kang
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea.
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Osteomyelitis on MR imaging as a key predictor of recurrent septic arthritis of the shoulder. Eur Radiol 2021; 32:1419-1428. [PMID: 34642809 DOI: 10.1007/s00330-021-08238-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/15/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To investigate the clinical and radiologic predictors of postoperative recurrent septic arthritis of the shoulder (SAS) using multivariable analysis. METHODS Forty-three patients (mean age, 65 years; 24 women) who underwent surgery for SAS between January 2011 and October 2019 were retrospectively enrolled. An orthopedic surgeon assessed clinical (age, sex, comorbidity, duration from symptom onset to MR imaging and surgery, surgical method, antibiotic usage), laboratory (serum white blood cell [WBC] count, C-reactive protein [CRP] level, synovial cell count), and surgical findings (culture/biopsy results). Two musculoskeletal radiologists evaluated MR imaging findings (bone marrow [reactive bone marrow edema, osteomyelitis, osteochondral erosion] and soft tissue [synovitis, bursitis, muscle edema, abscess] abnormalities). Recurrent SAS was evaluated at ≥ 12 months postoperatively. Univariable and multivariable analyses were performed to determine the best predictor of recurrent SAS. RESULTS The overall recurrent SAS rate was 33% (14/43). On univariable analysis, mean age (without recurrence vs. recurrence: 68 vs. 59 years, p = .04), mean duration from symptom onset to surgery (18 vs. 25 days, p = .02), serum WBC count (12,000 vs. 9,000 cells/mL3, p = .04), CRP level (13 vs. 6 mg/L, p = .01), and osteomyelitis on MR imaging (p < .01 for both readers) significantly differed between patients with and without recurrence; on multivariable analysis, only osteomyelitis on MR imaging was significantly associated with recurrent SAS for both readers (p = .02 and .01 for each reader respectively). The inter-reader agreement was good (κ = .62-1.0) for all MR imaging findings, except for muscle edema (fair, κ = .37). CONCLUSION Osteomyelitis on MR imaging was the best predictor of recurrent SAS. KEY POINTS • Osteomyelitis on preoperative MR imaging was the best predictor associated with recurrent septic arthritis of the shoulder on multivariable analysis including clinical, laboratory, and MR findings. • In multivariable analyses focused on each bone marrow abnormality, with adjustment for clinical and laboratory parameters, the presence of reactive bone marrow edema and osteochondral erosion on MR imaging showed no significant association with recurrent septic arthritis of the shoulder.
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Chun YM. Arthroscopic Treatment of Septic Arthritis of the Shoulder: Decision-Making for Reoperation. Clin Shoulder Elb 2020; 23:1-2. [PMID: 33330226 PMCID: PMC7714318 DOI: 10.5397/cise.2020.00073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/13/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Yong-Min Chun
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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