Tuesday, January 10, 2017

Periprosthetic shoulder infections: single or two-stage revision?

Two-stage revision for infected shoulder arthroplasty

These authors identified 19 patients (14 men)  who were treated with a 2-stage revision after presenting with a periprosthetic infection of the shoulder. The average time from the index arthroplasty to treatment was 40 months, 8 of 13 positive cultures were Propionibacterium acnes, and 9 of 19 patients had multiple shoulder operations before presenting with infection.

The incidence of recurrent infection was 26%. The rate of non-infection complications was 16%, for a total complication rate of 42%. Two patients had component loosening, one had a fracture and five had recurrent infections. 

Comment: This series combines 'obvious'  presentations (fever, drainage, erythema, abscess) with 'stealth' presentations (recurrent dislocation, cuff tear arthropathy, progressive radiolucency) as seen from the data below.
It is important to separate these two types of presentation in that the problems and risks associated with two stage revisions (failure and complications) can often be avoided using a single stage revision for 'stealth' presentations. We reserve two stage revisions for infection with 'obvious' presentation. 

Surgeons interested in this important topic should visit these related posts

Managing periprosthetic infections: Is there a place for spacers and the two-stage?
Periprosthetic shoulder arthroplasty infection - management with exchange arthroplasty
Periprosthetic joint infection - challenges of definition, diagnosis and treatment
Failed shoulder joint replacement: single stage revision when cultures are positive for Propionibacterium

We find that the evidence supports single stage revision for cases with 'stealth' presentation of periprosthetic infection.