Friday, August 28, 2015

Reverse total shoulder after shoulder infection

Reverse Shoulder Arthroplasty for Management of Postinfectious Arthropathy With Rotator Cuff Deficiency.

These authors present a series of 8 patients having reverse total shoulders after prior shoulder infections with cuff deficiency.

Patients with a clinical presentation of an acute infection (eg, fluctuance, open draining wound) or positive cultures from joint aspiration were initially treated with open irrigation and debridement procedures. Two to 3 open irrigation and debridement procedures were completed with antibiotic spacer placement, typically 2 to 3 days apart during the same hospitalization. The number of debridement procedures performed was dictated by clinical assessment at the time of surgery as determined by the surgeon, but the minimum number of irrigation and debridement procedures for actively infected patients was 2.

Patients with a remote history of infection in the operative shoulder and negative joint aspiration cultures underwent an arthroscopic biopsy. A minimum of 5 separate biopsy specimens were sent for aerobic, anaerobic, fungal, and AFB cultures. A positive culture following arthroscopic biopsy required at least 2 open irrigation and debridement procedures with antibiotic spacer placement and 6 weeks of antibiotics prior to RSA.

All patients had rotator cuff deficiency and end-stage arthritis.

At an average follow-up of 4.4 years, no patient had a clinically detectable recurrence of infection. Significant improvements were noted in clinical outcome scores.

Comment: It is of interest that most of the infections followed cuff repairs as shown in the table. We do not know the culture protocols for the 'outside hospitals' and data were unavailable on the organism causing the infection in five cases. What is notably absent from this series of cases is evidence of Propionibacterium, now recognized to be perhaps the most common organism recovered from cases of failed cuff surgery - perhaps due to insufficient culture protocols at the outside hospitals. This leads us to realize that while these patients had no clinically detectable evidence of infection at followup, sometimes this evidence presents many years after the arthroplasty.

We are cautious in surgical reconstruction for patients with post-infectious arthritis, recognizing that one can never be sure that the infection has been resolved. We reserve a reverse total shoulder for those patients with pseudoparalysis (inability to actively elevate more than 90 degrees) or instability. We often manage patients with postinfectious arthritis without instabilty or pseudoparalysis with either a more conservative anatomic hemiarthroplasty or a CTA arthroplasty inserted using impaction grafting with Vancomycin-soaked allograft, taking at least five cultures at the time of the procedure. In the event of recurrent infection, revision of these arthroplasties is more straightforward. This approach avoids the step of using a 'spacer' if the sterility of the shoulder is uncertain.


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