A 52 year old man presented with pain and stiffness of his right shoulder. X-rays at that time are shown below.

Because of his active lifestyle, the patient wished to avoid the risks and limitations associated with a polyethylene glenoid component; he opted instead for a ream and run procedure. The 6 week postoperative films are shown below.

A year post surgery he had excellent comfort and function of the shoulder with these x-rays

However, two years after surgery, his shoulder became stiff and painful without apparent cause. He had no fever, swelling, or redness. His peripheral white count and sed rate were normal.

His x-rays at that time showed only slight glenoid irregularity.

A swab of his unprepared skin over the shoulder area revealed 3+ Cutibacterium. A single stage revision was performed including complete prosthesis exchange, soft tissue debridement, extensive lavage, and topical Vancomycin.

There was no synovitis seen at surgery. Histology showed reactive fibrous tissue with focal chronic inflammation. No neutrophils were identified.

Because of the high suspicion for Cutibacterium infection based on the history and the skin surface culture, the patient was placed on a six week course of intravenous ceftriaxone and rifampin starting immediately after surgery before the intraoperative culture results were known.

By three weeks after surgery, the semiquantitative intraoperative cultures revealed a major Cutibacterium periprosthetic infection:

Collar membrane 0.1+

Collar membrane 1+

Humeral head explant 1+

Humeral stem explant 2 +

Capsule 1+

Glenoid membrane 1+

Glenoid membrane 2 +

Humeral membrane 2 +

After the intravenous antibiotics, the patient received a 6 month course of oral augmentin.

Seven years after his revision he returned for followup. He had full comfortable motion of his shoulder and had returned to unlimited use of his shoulder including construction.

His x-rays 7 years after revision are shown below.

Comment: This case illustrates the challenge of making the diagnosis of Cutibacterium periprosthetic infection before or at surgery and thus the need to determine postoperative antibiotic treatment before the results of intraoperative cultures are available.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Thursday, April 21, 2022

Single stage revision for massive Cutibacterium periprosthetic infection.