Monday, August 29, 2016

Is it safe to do a shoulder arthroplasty in a patient with prior lower extremity periprosthetic infection?

Safety and efficacy of shoulder arthroplasty following lower extremity periprosthetic joint infection

These authors present 33 shoulders having shoulder arthroplasty 0.7-13.1 (mean 4.7) years after successful treatment of an infected lower extremity arthroplasty. Nine of the patients were receiving chronic antibiotic suppression at the time of their shoulder arthroplasty. Two patients had revision surgery: one for aseptic glenoid loosening and one for infection after a periprosthetic fracture.

Comment: The patients in this series had at least 3 intraoperative culture specimens obtained at the time of their hip or knee resection revision reimplantation surgery. Six patients grew methicillin-resistant Staphylococcus Aureus, 8 methicillin-sensitive S. Aureus, 11 coagulase negative staphylococcus, 2 Enterococcus faecalis, 1 viridans streptococcus, and 1 Propionibacterium acnes. It is of note that lower extremity bacteria represent a somewhat different set of infecting organisms than the dominance of Propionibacterium and coagulase negative staphylococcus commonly seen in infected shoulder arthroplasties. It is also of note that four patients were considered to have 'culture-negative' infections – obviously a tricky diagnosis to make.

There are at least two ways that a prior infection in a lower extremity arthroplasty might increase the risk of an upper extremity arthroplasty infection:

(1) by hematogenous spread from residual bacteria in the lower extremity arthroplasty (this would seem unlikely if the lower extremity arthroplasty was successfully treated)


(2) by indicating that the patient’s general resistance to infection might be compromised (these patients did have some possible risk factors for periprosthetic infection: BMI average 33, diabetes in 15%, smoking in 15%, ASA class average 2.5, and Charlton Comorbidity Index average 4.3).

Before proceeding with an elective shoulder arthroplasty in a patient with prior lower extremity periprosthetic infection, both the status of the previously infected hip or knee and the patient's resistance to infection need to be considered by the surgeon and the patient.