Sunday, January 8, 2012

Infections of the shoulder - resection - JSES Dec 2011

In a previous post we reviewed a report of the use of cement spacers in the management of deep shoulder infections. This series did not have a comparison group, that is the authors did not compare their results with a spacer (removal of all components followed by insertion of a cement spacer with antibiotics) to those with a primary exchange (removing all components and reinserting new ones) or to those with a resection arthroplasty (removing all prosthetic components without reinsertion).

Verhelst et al recently published a series of cases of resection arthroplasty comparing patients in which a spacer (containing gentamycin)  was used to those with a resection alone. This was not a controlled series so it cannot be assumed that the two patient populations were comparable prior to the revision surgery.  The initial surgeries ranged from acromioplasties and rotator cuff repairs to total and reverse shoulder arthroplasties. An average of 9 months elapsed between the initial surgery and the diagnosis of infection. The culture results were: 9 Staph aureus, 12 coagulase negative Staph, 4 Propionibacterium, and 2 Corynebacterium. No differences were observed in the results of the patients treated with and without spacers.  The authors believed infection was eradicated in 19 of the 21 cases.

Importantly, five of the ten patients treated with a spacer required a second procedure to reimplant a prosthesis at an average of 7 months after the spacer placement because of pain. Severe glenoid erosion occurred in those patients who received a stemmed spacer.  None of the patients having a resection had revision surgery. No significant differences in function were noted between the two groups.

The authors point out that preservation of the tuberosities is a key prognosticator of a good functional result.

The authors provide a thorough review of the literature on resection, primary exchange and two stage exchange.

Our management of infections depends on the clinical presentation. Patients with draining sinuses, patients with local or systemic evidence of sepsis are likely to be managed with resection arthroplasty as suggested by Verhelst et al. Patients suspected of having low grade infections with organisms such as P. acnes are likely to be managed with a primary exchange using antibiotic-soaked allograft and prolonged antibiotic management in anticipation of a better functional outcome.


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