Sunday, October 18, 2020

Shoulder arthritis, why not just "scope" it before joint replacement?

 The Impact of Prior Ipsilateral Arthroscopy on Infection Rates After Shoulder Arthroplasty

These authors sought to determine whether prior ipsilateral shoulder arthroscopy is associated with an increased risk of postoperative infection following shoulder arthroplasty.

They identified patients who underwent shoulder arthroplasty, including hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse shoulder arthroplasty (RSA).

A total of 9,362 Medicare patients and 17,716 private-payer patients were included in the study. 

Of these, 486 (5.2%) Medicare patients and 685 (3.9%) private-payer patients underwent prior arthroscopy. 

In the Medicare database, prior arthroscopy was also associated with a post-arthroplasty infection rate of 3.9% as compared to 1.9% in the control group (OR 22 1.96, 95% CI 1.20 – 3.22, p = 0.003). 

In the private insurance cohort, prior shoulder arthroscopy was associated with a post-arthroplasty infection rate of 2.9% as 23 compared to 1.4% in the control group (OR: 1.85, 95% CI 1.13 – 3.03, p = 0.005).

They concluded that shoulder arthroscopy performed within two years before shoulder arthroplasty is associated with a higher infection rate in the first year after shoulder arthroplasty.

Comment: In this analysis, prior arthroscopy more than doubled the rate of periprosthetic joint infection (PJI). The value of arthroscopy (benefit/risk) for glenohumeral arthritis is not known.

Unfortunately, data were not presented on the type of bacteria causing the PJIs. This is important because a high percentage of shoulder PJIs are caused by Cutibacterium and the presence of a Cutibacterium PJI may not become evident until >1 year after surgery. 

Evidence is now available that enables surgeons to identify patients at increased risk for PJI. Prior arthroscopy is one of those. 

In patients at increased risk, increased efforts at prophylaxis can be considered: preoperative ceftriaxone and vancomycin, Betadine washes, topical antibiotics and perhaps a short course of postoperative oral antibiotics. 

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