Monday, February 6, 2017

Surgical treatment of the infected shoulder arthroplasty

Surgical treatment of infected shoulder arthroplasty. A systematic review

These authors conducted a literature review of 15 Level IV studies published between 1996 to 2016 searching for the relationship between evidence of persistent infection and the mode of treatment.

They identified 287 patients (146 males/141 females) having a mean follow-up of 50.4 (range 32–99.6) months.

The most frequent indication for the primary arthroplasty was glenohumeral osteoarthritis and proximal humerus fracture. The type of implant used initially was available only for 170 of the

287 patients (64 hemi-arthroplasty, 29 total shoulder arthroplasty, 73 reverse shoulder arthroplasty, and four tumor resection implants). The most frequently cultured pathogens were Staphylococcus epidermidis and Propionibacterium.

The graph below compares the percent of patients without evidence of persistent infection and the final Constant score for the different treatment methods. The mean values for the combined data for all treatment groups are indicated by the “O”.

The authors found a high rate of complications with two stage revisions, including periprosthetic fracture, instability, tuberosity fracture, and non-union.

Comment: The authors point to the heterogeneity and low quality of the included studies, making it impossible rigorously compare the different studies and the patients within those studies. The surgeon’s choice in each individual case is likely to have been influenced by that surgeon’s experience, ability and resources, the characteristics of the patient (age, comorbidities,prorities), and the characteristics of the shoulder (acute vs. chronic evidence of infection, degree of soft tissue and bone destruction, manifestations of infection, the bacterium responsible).

Nevertheless, these data seem to suggest that in selected patients a single stage revision can yield a relatively high apparent cure rate and a relatively high degree of comfort and function as reflected by the Constant score.

In our practice we prefer the use of a single stage revision with topical Vancomycin and immediate IV antibiotic therapy in cases of suspected infection because it often avoids the risks of a second procedure and because it often shortens the total time of treatment.

In contrast to the recommendations of these authors, we try to avoid the use of cement in the revision in case a subsequent procedure is required. Instead we attempt to fix the revision prosthesis with Vancomycin-soaked allograft.

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