These authors evaluated outcomes after treatment of 28 shoulder periprosthetic joint infection (PJI) with a 3-stage revision protocol consisting of (1) débridement, explantation, and cement spacer placement, followed by parenteral antibiotics; (2) open biopsy and débridement; and (3) reimplantation if cultures were negative.
They used the Musculoskeletal Infection Society (MSIS) diagnostic criteria for lower extremity PJI, including sinus tract communicating with the prosthesis, pathogen isolated by culture from 2 separated tissue samples, or the constellation of clinical symptoms, purulence of the joint, laboratory data (peripheral white blood cell counts, erythrocyte sedimentation rate, C-reactive protection, and more than 5 neutrophils per high-power field in 5 high-power fields detected from histologic analysis of periprosthetic tissue.
Note the "usual suspects" for shoulder PJI: Propionibacterium and coagulase negative Staph.
Note the "usual suspects" for shoulder PJI: Propionibacterium and coagulase negative Staph.
Inspite of the use of a spacer at the first stage, cultures were positive for 6 patients (21.4%) at the second stage with open biopsy. These patients underwent additional débridement and open biopsy procedures. Three had isolated C acnes infection and the other three had mixed S epidermis and C acnes infections, which had the same organism as their first stage culture results. All had negative cultures after 1 additional open biopsy and underwent final implantation.
They identified no recurrent infections at a mean 32-month follow-up. The 21 shoulders with PJI revised to reverse total shoulder had no differences for functional and subjective outcomes compared with revised patients without shoulder PJI.
Comment: Evaluation and management of failed shoulder arthroplasties suspected of being infected is complex to be sure.
For example, in 7 patients all cultures were negative. These patients were included in their infection cohort because they met the definition proposed by MSIS for PJI on the basis of sinus tract formation, laboratory values, and intraoperative infected appearance. In these cases it is not clear how the second stage procedure to obtain culture is helpful in guiding treatment.
Each "stage" carries with it additional costs and risks of anesthetic and surgical complications, the risks of adverse reactions to antibiotics, as well as the risks of introducing new bacteria at each subsequent procedure. Thus, a rigorous cost/risk/benefit analysis is required to evaluate such a treatment algorithm.
The use of a cement spacer is a mixed blessing. On one hand, spacers can be difficult to stabilize in the humeral canal and on the other hand they can be difficult to remove. In this series the use of a spacer in the first stage failed to resolve the infection in over 20% of the cases. Not all patients having a spacer placed go on to the next stage. The surface of a spacer is abrasive and, if left in place, can lead to glenoid erosion. In this study, it would be important to know how many patients had stage one without stage two, and how many had stage two without stage three.
When treating Propionibacterium infections, it is impossible to know if the treatment has resulted in a "cure" because recurrences may present years after the surgical revision. Recurrences may present as painful stiffness so that the presence of the bacterium is only revealed by yet another surgery.
For most patients suspected of having shoulder PJI, we prefer a single stage revision as explained in this paper regarding 55 shoulders meeting the MSIS PJI criterion of ≥2 positive cultures for Propionibacterium:
Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium.
BACKGROUND: Revision shoulder arthroplasties are often culture-positive for Propionibacterium. This study tests the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive.
METHODS: Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. The patient self-assessed functional outcomes for shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group).
RESULTS: The culture-positive group had 89% male patients, with a mean age (and standard deviation) of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement. The control group had 39% male patients, with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement. Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive. Fourteen patients reported side effects to antibiotics.
CONCLUSIONS: Clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases.
See also:
One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis
These authors compared re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and two-stage revision surgery for shoulder PJI using a systematic review and meta-analysis. They searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or two-stage revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation.
Comment: Evaluation and management of failed shoulder arthroplasties suspected of being infected is complex to be sure.
For example, in 7 patients all cultures were negative. These patients were included in their infection cohort because they met the definition proposed by MSIS for PJI on the basis of sinus tract formation, laboratory values, and intraoperative infected appearance. In these cases it is not clear how the second stage procedure to obtain culture is helpful in guiding treatment.
Each "stage" carries with it additional costs and risks of anesthetic and surgical complications, the risks of adverse reactions to antibiotics, as well as the risks of introducing new bacteria at each subsequent procedure. Thus, a rigorous cost/risk/benefit analysis is required to evaluate such a treatment algorithm.
The use of a cement spacer is a mixed blessing. On one hand, spacers can be difficult to stabilize in the humeral canal and on the other hand they can be difficult to remove. In this series the use of a spacer in the first stage failed to resolve the infection in over 20% of the cases. Not all patients having a spacer placed go on to the next stage. The surface of a spacer is abrasive and, if left in place, can lead to glenoid erosion. In this study, it would be important to know how many patients had stage one without stage two, and how many had stage two without stage three.
When treating Propionibacterium infections, it is impossible to know if the treatment has resulted in a "cure" because recurrences may present years after the surgical revision. Recurrences may present as painful stiffness so that the presence of the bacterium is only revealed by yet another surgery.
For most patients suspected of having shoulder PJI, we prefer a single stage revision as explained in this paper regarding 55 shoulders meeting the MSIS PJI criterion of ≥2 positive cultures for Propionibacterium:
Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium.
BACKGROUND: Revision shoulder arthroplasties are often culture-positive for Propionibacterium. This study tests the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive.
METHODS: Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. The patient self-assessed functional outcomes for shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group).
RESULTS: The culture-positive group had 89% male patients, with a mean age (and standard deviation) of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement. The control group had 39% male patients, with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement. Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive. Fourteen patients reported side effects to antibiotics.
CONCLUSIONS: Clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases.
See also:
One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis
These authors compared re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and two-stage revision surgery for shoulder PJI using a systematic review and meta-analysis. They searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or two-stage revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation.
The re-infection rate (95% CI) in pooled analysis of eight one-stage studies (147 participants) was 5.3% (1.4–10.6). The corresponding rate for 27 two-stage studies (351 participants) was 11.5% (6.0–18.1).
Postoperative clinical measures of function and pain were not significantly different between the two revision strategies.
The pooled noninfection complication rate (95% CI) for one-stage and two-stage revision was 12.1% (6.1–19.5) and 18.9% (8.4–31.9) respectively.
They concluded that one-stage revision is at least equally as effective as the two-stage in controlling infection, maintaining joint function, and improving complications in shoulder PJI.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
How you can support progress in shoulder surgery
You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
