Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty

These authors point out that there is an increased risk of periprosthetic joint infection in patients treated with reverse shoulder arthroplasty compared with patients treated with anatomic total shoulder arthroplasty.

Using the Danish Shoulder Arthroplasty Registry they found 2,217 patients having reverse shoulder arthroplasty for cuff tear arthropathy, massive irreparable rotator cuff tears or osteoarthritis between 2006 and 2019. They sought to determine whether previous non-arthroplasty surgery was a risk factor for revision for periprosthetic joint infection after reverse shoulder arthroplasty.

Periprosthetic joint infection (PJI) was defined as at least 3 out of 5 tissue samples positive for the same bacteria or as definite or probable periprosthetic joint infection according to the International Consensus Meeting.

Revision was performed in 88 (4.0%) shoulders of which 40 (1.8%) were due to periprosthetic joint infection. In this series PJI was the most common indication for revision

There were 272 (12.3%) patients who had previous rotator cuff repair of which 11 (4.0%) were revised due to periprosthetic joint infection.

The 14-year cumulative rate of revision due to periprosthetic joint infection was 14.1% for patients with previous rotator cuff repair and 2.7% for patients without previous surgery.

The adjusted hazard ratio for revision due to periprosthetic joint infection (PJI) for patients with previous rotator cuff repair was 2.2 compared to patients without previous surgery. Interestingly, the hazard ratio for infection was not significantly increased for patients having non-rotator cuff surgery, such as acromiplasty or acromioclavicular joint surgery. Male sex was even more strongly associated with PJI than prior cuff repair.

The rate of revision for PJI continued to increase with time after surgery.

The predominant organism species was Cutibacterum, notably not always Cutibacterium acnes

Comment: Because of the seriousness of periprosthetic infection after reverse total shoulder and the difficulties in its management, it is worthwhile to identify patients at increased risk. The association of male sex and prior cuff surgery with periprosthetic infection after reverse total shoulder has been noted previously (see Complications and revision of reverse total shoulder arthroplasty and Reverse shoulder arthroplasty: perioperative considerations and complications).

Patients at increased risk for infection may benefit from (1) preoperative education regarding the risk, (2) obtaining deep specimens (including sutures) for Cutibacterium cultures at the time of reverse total shoulder arthroplasty, (3) extraordinary intraoperative prophylaxis, such as Betadine lavage, and topical antibiotics, (4) a course of postoperative oral antibiotics, and (5) observation of the postoperative course for an extended period after surgery.

Any surgery prior to arthroplasty carries the potential risk of introducing Cutibacterium into the wound. In cuff repair as in shoulder arthroplasty, braided sutures may come in contact with the skin surface or dermis allowing them to become inoculated with skin organisms as suggested in Microbial colonization of subscapularis tagging sutures in shoulder arthroplasty: a prospective, controlled study. While clinically evident infection after rotator cuff repair is reported to occur in about one out of one hundred cases (see Postoperative deep shoulder infections following rotator cuff repair), a substantially higher percent of cuff repairs may harbor sutures inoculated with Cutibacterium increasing the risk of PJI after subsequent reverse total shoulder arthroplasty.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.