Saturday, February 2, 2013

Failed resurfacing - Propionibacterium

While some persist in downplaying the significance of 'unexpectedly positive cultures', we do take them seriously.

Here's an example - a gentleman from a state south of us who had a fall around 7 years ago off of a ladder. He had left shoulder pain after that and eventually had an MRI. He had an arthroscopic labral repair.  He later had his a biceps tenodesis and was told that when a hole was drilled in his bone the bone "cracked".  Early last year he had a Biomet Copeland humeral head resurfacing size 5. Eight months later he presented to us with pain, stiffness, a Simple Shoulder Test of 1/12, and no clinical evidence of infection. Here are his films. We offered a revision to address stiffness, overstuffing, and possible loosening.

At surgery, the component was well fixed, cuff was intact, and there was a small amount of slightly cloudy fluid. Gram stain showed rare polys and no organisms. According to our revision routine, four cultures, in addition to the fluid, were taken and sent for culture no triple medial to be held for up to three weeks.

The arthroplasty was revised to a hemiarthroplasty fixed with Vancomycin soaked allograft. Note the unstuffing. He was placed on Augmentin until his cultures finalized.

Three days after surgery his humeral head explant cultured positive for coagulase negative staph. At eight days after surgery the humeral head explant became positive for Propionibacterium. At 10 days, Propionibacterium grew from the bone beneath his implant, from the membrane between the implant and bone and from his labrum - i.e. all four non-fluid cultures were positive for Propi. The fluid remains negative.

On the basis of these culture results, a PICC line was inserted and a 6 weeks course of Vancomycin planned.ddd

In the meanwhile, his shoulder feels much improved and he is maintaining the improved motion he achieved in the hospital.

This experience reinforces our usual protocol for the revision of painful arthroplasties: thorough preopoerative discussion about the chance of infection and the implications, hold antibiotics until at least four non-fluid cultures are obtained, administer Cephtriaxone and Vancomycin X 24 h, remove humeral implant, vigorous debridement and irrigation with Cephtriaxone and Vancomycin solution, implant new humeral prosthesis with Vancomycin allograft, place patient on Augmentin until cultures are final, adjust antibiotics according to culture results.
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