Wednesday, April 4, 2018

Revision shoulder arthroplasty and infection - reflections

We want to be sure that we’re asking the right question – one that will help surgeons deliver the best care to their patients rather than striving for an academic definition of infection (which can be as difficult as defining art or race). If we want a definition of ‘infection’ shouldn’t it be something like “bacteria doing harm”? And if that is the definition, does a draining sinus without positive cultures qualify?

Instead of going down that road, we are drawn to the concept of the "tipping point”. While on one hand the bacterial load and the host response each exist on a continuum, our treatment responses are categorical – either we remove the implants or we don’t, either we treat with antibiotics we don’t.

So what we need to learn is what should trigger the different treatment responses for a failed shoulder arthroplasty, which might be categorized as follows:

(1) incision and drainage followed by antibiotic treatment
(2) prosthesis removal and exchange followed by antibiotic treatment
(3) prosthesis removal and spacer insertion followed by antibiotic treatment
(4 )prosthesis removal followed by antibiotic treatment (resection arthroplasty)
(5) prosthesis revision without antibiotic treatment
(6) surgical revision without prosthesis revision (I.e. soft tissue procedures)

Note that the decision among these needs to be made at the time of surgery, not after cultures are finalized.

What surgeons need to know are the indications for 1-6.

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