We now recognize that Propionibacterium can be found just about everywhere in the human body, including sites once thought to be sterile.
Of particular interest is the finding of Propionibacterium in joints such as the shoulder. While the culturing of these organisms from failed arthroplasties suggests that they entered the joint at the time of the original surgery, the culturing of Propionibacterium from previously unoperated joints suggests that these bacteria may enter the joint from the overlying skin or hematogenously from remote sites such as the mouth.
We have learned that Propionibacterium is but one member of the complex human biome, which also includes other bacteria, viruses and fungi. As in other ecosystems, the diversity of organisms and the products (including bacterosins) that they produce keep us healthy in the same way that animal and plant diversity provide balance in nature.
However, like a certain high school chemistry teacher, Propionibacterium can turn bad and become associated with poor outcomes of shoulder arthroplasty and rotator cuff surgery.
The reasons for this transformation are uncertain, but may include
*changes in the host microbiome from societal changes such as antibiotic exposure,
*changes in the host environment related to glucose levels
*changes in the host environment related to glucose levels
*changes in host immunity
*changes in the local environment from surgical intervention creating anaerobic biofilms resistant to host defenses,
*selection for more virulent strains
*increased expression of virulence genes
*symbiotic interaction with other bacteria.
It is becoming increasingly clear that Propionibacterium can not be eliminated from the shoulder surgery field by prophylactic antibiotics and surgical preparation of the skin.
As we move to the New Year, we can look forward to increased efforts to understand the role of Propionibacterium in the outcomes of shoulder surgery and to innovative methods for managing its adverse effects. Some of the innovations may include trying to restore normal biodiversity (probiotics), rather than the traditional approach of trying to sterilize the environment (Agent Orange).
It will be an interesting year.
It will be an interesting year.
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