Infections of shoulder joint replacements, periprosthetic infections of the shoulder = bacteria doing harm

Infections constitute one of the most serious complications of shoulder joint replacement. Because the slow-growing bacteria that typically cause these infections (Cutibacterium) originate from the skin of the patient, they do not do stimulate the usual host reaction characteristic of other infections (fever, chills, erythema, abnormal lab tests). The clinical presentation can be subtle, such as the unexplained onset of pain and stiffness months or years after the joint replacement.

An bacterial infection is the situation where bacteria are causing harm. Thus, if we find substantial loads of bacteria in a failed shoulder joint replacement it would seem reasonable to treat with surgical revision and antibiotic therapy.

But what if there is evidence of harm in a shoulder arthroplasty (e.g. draining sinus, elevated joint fluid or serum inflammatory markers) without the detection of bacteria by positive cultures? It would seem that this situation does not meet the criterion of "bacteria causing harm", even though some authors like to refer to this as a "culture negative infection". If cultures are negative, how do we know that bacteria are playing a role - how do we know if and what antibiotics are indicated?

Our hope is that active research will continue to refine clinical guidelines for the evaluation and management of the failed shoulder arthroplasty (rather than worrying about the nuances of defining "infection").

Here are the four questions that need to be answered by those actively investigating this critical clinical problem:

(1) When a previously well-functioning shoulder joint replacement because stiff, painful, or loose without an obvious explanation, what clinical, laboratory and imaging evaluations inform treatment?

(2) At the time of revision surgery, what information can be gathered (e.g. histology) that will inform treatment?

(3) What preoperative and intraoperative findings suggest the need for complete prosthesis exchange?

(4) What preoperative and intraoperative findings suggest the need for post-revision antibiotic treatment?


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