Sunday, November 24, 2013

Diagnosis of infection after shoulder arthroplasty

Diagnosis of Periprosthetic Infection After Shoulder Arthroplasty

This is a timely review of the evolving information regarding infections after shoulder joint replacement.

The authors point out that the organisms commonly found in failed shoulder arthroplasties differ from those associated with infected hip and knee prostheses. In that the most commonly found organisms in failed shoulder arthroplasties are Propionibacterium and since Propionibacterium usually do not cause typical clinical or laboratory (elevated white blood cell count, erythrocyte sedimentation rate [ESR], C-reactive protein [CRP] levels, and serum interleukin-6 [IL-6] levels) ) signs of infection, the diagnosis may not be suspected and the failed arthroplasty attributed to 'aseptic' loosening. It is of note that not all of the Propionibacterium recovered from revision shoulder arthroplasties are P. Acnes. The presence of Propionibacterium may escape diagnosis because of the special culture methods required, including a up to three weeks of culture observation. Because of these factors, the commonly quoted incidence of periprosthetic shoulder infection may be falsely low.

They also point out that empiric antibiotic therapy after revision arthroplasty should be considered to avoid delay in treatment, recognizing that the presence of Propionibacterium may not be evident at surgery. Since Propionibacterium tend to form adherent biofilms resistant to antibiotics, elimination of the organism may require a complete prosthesis exchange.

Our practice is to suspect the presence of Propionibacterium in all revision arthroplasties, especially in males with humeral or glenoid component loosening or osteolysis. Preference is given to complete prosthesis exchange using Vancomycin-soaked allograft to fix the new humeral component. Depending on the level of suspicion, patients are maintained on either oral Augmentin or IV Ceftriaxone until the results of the five intraoperative cultures routinely obtained become final.

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