Saturday, September 8, 2018

Management of the possibly infected shoulder joint replacement - the red and yellow protocols

We've had a number of requests for an update to our approach to revision shoulder arthroplasty, recognizing that the rate of infection in these cases is high. See prior related post here and a diagram of the protocol here.


Considerations in revision arthroplasty

I. Obvious infection
Typical characteristics
Draining sinus
Classic signs (fevers, chills, erythema, elevated WBC, ESR, CRP)
Massive osteolysis
Gross purulence

Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Treat with explant of all components, vigorous debridement and irrigation, topical antibiotics, lightly fixed antibiotic spacer and IV antibiotics via PICC line X 6 weeks; initially ceftriaxone and Vancomycin. Antibiotics modified according to culture results. 6 months oral antibiotics after IV course complete. At 6 months can consider reimplantation of prosthesis               

II. High suspicion for stealth infection – red protocol
                   Typical characteristics
Honeymoon period (onset of otherwise unexplained pain and stiffness after a period of usual post op course ranging from months to years)
                                      Patient at increased risk: young active male patient with prior surgery
                                      Rest pain
                                      Loose components (especially early humeral loosening), osteolysis
                                      Synovitis, >5 wbc/hpf, cloudy joint fluid, humeral membrane

Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Treat with explant of all components, vigorous debridement and irrigation, topical antibiotics, single stage exchange to impaction allografted hemiarthroplasty and IV antibiotics via PICC line X 6 weeks; initially ceftriaxone and Vancomycin. Antibiotics modified according to culture results. 6 months oral antibiotics after IV course complete. If cultures negative at 3 weeks consider discontinuing antibiotics.

III. Lower suspicion for stealth infection – yellow protocol
                   Typical characteristics                   
Female patient
                                      No osteolysis
                                      Pain only with activity
                                      Suspect prosthesis failure is strictly mechanical

Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Prosthesis revision as indicated by surgical findings. Oral antibiotics (Doxycycline or Augmentin) for 3 weeks. Antibiotics modified according to culture results. If cultures are positive and if revision fails to produce a satisfactory clinical result, consider repeat surgery with red protocol or spacer.

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