Routine cultures for seemingly aseptic revision shoulder arthroplasty: are they necessary?
These authors present a thoughtful review considering the value of obtaining intraoperative cultures for Priopionibacterium at the time of revision shoulder arthroplasty.
These authors present a thoughtful review considering the value of obtaining intraoperative cultures for Priopionibacterium at the time of revision shoulder arthroplasty.
It is important to recognize that that the presence of Propionibacterium in failed arthroplasties was essentially unrecognized before the mid 2000s (The complex characteristics of 282 unsatisfactory shoulder arthroplasties), so we are all pretty new at seeking how this new knowledge can be best put to work to help our patients.
They point out that the presence of Propionibacterium in a shoulder does not trigger the usual clinical or laboratory findings characteristically associated with an infection (redness, swelling, tenderness, elevated CBC, sed rate, C reactive protein, intraoperative histology, gram stains), probably because the body does not recognize this bacterium as 'foreign'. As a result, one simply cannot apply the commonly accepted definition of 'infection' to a primary or revision shoulder surgery with positive cultures for Propionibacterium.
We are in a position where more data are need to clarify the role of Propionibacterium in failures of shoulder surgery (arthroplasty, cuff surgery, fracture fixation). These data will come by correlating the clinical course of the patient with the results of a standardized approach to obtaining specimens, culturing the specimens, obtaining control cultures, and semi quantitatively reporting the results (Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty: A Study of 137 Culture-Positive Cases).
We conclude that rather than trying to ‘define prosthetic joint infection (PJI) of the shoulder', it is more straightforward to recognize three types of presentation:We are in a position where more data are need to clarify the role of Propionibacterium in failures of shoulder surgery (arthroplasty, cuff surgery, fracture fixation). These data will come by correlating the clinical course of the patient with the results of a standardized approach to obtaining specimens, culturing the specimens, obtaining control cultures, and semi quantitatively reporting the results (Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty: A Study of 137 Culture-Positive Cases).
(1) obvious: shoulders with positive cultures and clinical / laboratory evidence of infection (redness, drainage, draining sinus, elevated ESR, CRP, sed rate, alpha definsin, IL6, etc)
(2) stealth: shoulders with positive cultures and pain, stiffness, and or component loosening but no other obvious evidence of infection
(3) cryptic: shoulders without positive cultures but with clinical / laboratory evidence of infection (redness, drainage, draining sinus, elevated ESR, CRP, sed rate, alpha definsin, IL6, etc)
Attempts to combine 1, 2, and 3 into a single set of criteria for PJI disregard the complexity of the situation. On the other hand, studies that report the clinical, laboratory, and surgical findings, the semiquatitative culture results, the surgical and medical management and the clinical outcomes will inform our future efforts to optimize the care of our patients.
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