Wednesday, August 28, 2013

Failed shoulder joint replacement arthroplasty - our current management.

A great article on the ecology of skin bacteria is shown here. These two figures come from that article. Note that Propionibacterium are common in the oily areas (face, chest, back) and not the moist areas (axilla and groin).

They point out that presurgical preparation of the skin is ineffective in eliminating Propionibacterium from the hair follicles and sebaceous glands.

We are not infrequently consulted about a shoulder joint replacement that has become stiff and painful - often months or years after the original surgery.

As explained in this post we have learned that a substantial number of these failures will have positive cultures for bacteria such as Propionibacterium or Coagulase Negative Staphylococcus.
For this reason we assume that any shoulder with enough of a clinical problem to have a surgical revision merits strong consideration for
(1) holding preoperative antibiotics until cultures can be obtained
(2) taking multiple specimens for culture and observing them for three weeks on special media as explained here
(3) removing all the existing implants and all reactive tissue
(4) re-implanting a new humeral component, fixing it with Vancomycin soaked allograft
(5) keeping the patient on intravenous or oral antibiotics (depending on the surgeon's suspicion of bacterial presence) for three weeks until the cultures become finalized.
(6) if the cultures become positive an infectious disease consultation is obtained, usually resulting in a six week course of intravenous antibiotics through a PICC line is often used followed by a year of suppressive oral antibiotics.
(7) We work closely with our expert Infectious Disease team at the University of Washington to manage our patients both locally and at a distance. If patients live outside the Seattle area, it becomes important that the patient have a local prescribing provider that can assist us in coordinating their care.

Our logic is based on the observation that these bugs tend to form a biofilm that is resistant to antibiotics. Only by removing the prosthesis and thoroughly washing the wound with antibiotic saline can we be sure that the maximal amount of bacteria have been removed prior to the replacement of the new implant. The reason for immediately instituting vigorous antibiotic treatment is based on our desire to minimize the risk that residual bacteria contaminate the new prosthesis.

While this is a truly aggressive approach, it has been remarkably successful. The details of our current protocol are shown in the color figure at the bottom of this post.

As explained in this post, sometimes the x-ray appearance strongly suggests the presence of bacteria - see the bone resorption around the glenoid and humeral stem in the example below.

 In other cases, it is not so obvious as in the case below, in which cultures of the humeral implant, the glenoid implant and soft tissues were all positive for Propionibacterium.
 The x-ray below shows the same shoulder after the humeral and glenoid components were removed, all abnormal tissue removed, thorough washout and re-implantation of a new humeral component with Vancomycin allograft. After this procedure the shoulder is started on immediate motion as we do for a primary joint replacement. The patient will remain on Ceftriaxone by PICC line for 6 weeks followed by a year of Augmentin.

There is a belief held by many that probiotics are helpful in preventing and treating gastrointestinal distress while and after taking antibiotics.  Consideration can be given supplements containing a mixture of lactobacillus (casei, acidophilus, plantarum, rhamnosus, lactis, bulgaricus, helveticus), Bifidobacterium (longum, bifidum, breve, infantis), Streptococcus thermophilus and Saccharomyces boulardii or to active culture yogurt, which contains Lactobacillus bulgaricus and Streptococcus thermophilus.
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