Saturday, June 20, 2015

Shoulder joint replacement arthroplasty - the challenging problem of the loose glenoid

As shown in this link, glenoid component loosening always presents challenges.

Here is the instructive case of a sixty year old man who presented with shoulder pain that had been progressively increasing over the seven years after a total shoulder arthroplasty. On exam his findings included pain and stiffness.
His x-rays on presentation showed a superiorly positioned humeral component and a loose keeled glenoid component:

A revision surgery was performed eight years after his index procedure. There was no evidence of inflammation and the joint fluid was clear. The humeral stem was tightly fixed and could not be easily removed. The glenoid component was grossly loose and was removed. The humeral head was exchanged for one that was eccentric inferior to optimize its fit with the glenoid and to compensate for the superior position of the stem. Cultures were obtained and the patient discharged on oral Augmentin and standard post-arthroplasty rehabilitation. He quickly regained comfort and function in the shoulder.

At 9 days after surgery his cultures became positive as shown below.

With these results he was transitioned to IV Ceftriaxone and Rifampin through a PICC line for 6 weeks after which Augmentin was restarted. At six weeks the shoulder was doing well and the x-rays were satisfactory as shown below.

Within three weeks of discontinuance of the IV Ceftriaxone, the shoulder pain started to worsen and became severe with loss of passive and active motion and the ability to perform activities of daily living.

He is now contemplating the prospect of revision surgery to remove the incarcerated stem.

Comment: This case again illustrates the challenges for patient with a loose glenoid presenting without clinical evidence of infection. In this case the decision was made not to remove the humeral stem because of its incarceration and the absence of surgical findings suggesting infection. However, with the recurrence of symptoms after discontinuance of the IV antibiotics, there is concern about residual bacterial presence in a biofilm on the stem that can only be resolved by the removal of the incarcerated humeral prosthesis. An additional element of this case is the multiple organisms culture from this shoulder: coagulase negative staph and several colony types of Propionibacterium. Finally it is of interest that the presentation of this failed shoulder eight years after the index procedure, reinforcing the view that vigilance for infection should never stop.


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