Revising the shoulder with a periprosthetic infection: how important is it to remove everything?

For most cases of shoulder periprosthetic infection, the single stage with complete implant exchange is the "go to" procedure.

However, in some patients with complex periprothetic infections in which complete implant exchange is difficult and risky, surgeons have competing priorities: 1. trying to cure the patient's infection or 2. trying to preserve the comfort and function of the patient's shoulder. The interesting thing about #1 is that no matter how hard we try, we can never be sure that we have removed every last bug from the shoulder and have eliminated the possibility of a recurrence down the line. 

Vigorous attempts to stamp out infection may involve removal of all implants and cement, but these attempts may permanently compromise the comfort and function of the patient's shoulder. Imagine an elderly person with fragile bone and a well cemented implant who has developed drainage from her shoulder, which otherwise is functional and painless. Is she better served by complete explantation or by a washout, culture-specific antibiotics and - should she continue to drain - offering her the option of retaining her implants and managing the drainage with dressings?

The authors of Does retained cement or hardware during 2-stage revision shoulder arthroplasty for infection increase the risk of recurrent infection? sought to determine if incomplete removal of cement and hardware adversely affected the results of revision for infection.

Specifically they compared the rates of repeat infection at two years after 2-stage revision for prosthetic joint infection in 37 patients who had retained cement or hardware compared to those who had complete removal.

Repeat infection was defined as either ≥2 positive cultures at the time of the second-stage with the same organism that was cultured during the first-stage or repeat surgery for infection after the two-stage revision. 

 Six patients had retained cement and 1 patient had 2 retained broken glenoid baseplate screws after first-stage revision.  30 patients had no retained hardware.

10 cases had recurrent infection:

Patient demographics were not significantly associated with recurrent infection.

Of the 10 cases of recurrent infection, 1 case had retained cement/hardware while 9 had no retained cement/hardware.

Thus 1 of 7 (14%) with retained cement/hardware had a recurrent infection while 9 of 30 (30%) with no retained cement/hardware had a recurrent infection. Retained cement or hardware was not significantly associated with a repeat risk of infection.

The authors suggested that surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications. 

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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). 

Periprosthetic infections and tranexamic acid

 Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty

These authors point out that revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. They hypothesized that the administration of tranexamic acid (TXA) during revision arthroplasty is protective against subsequent PJI.

They identified 1,731 patients who underwent aseptic revision; of these patients, 83 (4.8%) developed

PJI. 

Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%. 

In their multivariate analysis, 

(1) preoperative anemia was independently associated with over a 2-fold increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003).

(2) antibiotic administration was independently associated with a reduced risk of PJI (OR, 0.25 [95% confidence interval (CI), 0.07 to 1.02]; p = 0.034). 

(3) female sex was independently associated with a reduced risk of PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016). 

(4) TXA administration was independently associated with a reduced risk of PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030). 

Comment: It has not been suggested that tranexamic acid has antibiotic properties; instead the authors suggest, "It would stand to reason that, if one could limit blood loss and avoid the need for allogeneic blood transfusion, a reduction in infection may be possible." The question that remains to be answered is whether - in addition to the presence of preoperative anemia - blood loss and/or transfusion are indeed major risk factors for PJI. 

There are some data that may be missing from the univariate analysis table as indicated below, especially the data related to blood loss and units of blood received (see yellow highlights). 

If the data show that blood loss (rather than the use or non-use of TXA) drives the rate of periprosthetic infection, it may be the case that other anti-blood-loss steps (topical thrombin, careful coagulation, controlling intraoperative blood pressure) may be comparably effective in reducing PJI. Further studies are need to determine: (1) is PJI related to the amount of blood loss into the wound, to the amount of external blood loss (drains and soaked dressing), or to the resulting drop in the number of circulating red blood cells? (2) which has the stronger association with PJI, the estimated blood loss or the units of blood received? (3) should antibiotics be routinely administered in apparently "aseptic" revisions? and (4) is management of preoperative anemia effective in reducing PJI?

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Infected shoulder arthroplasty - over half of patients having revisions experienced complications, suicide

Management of infected shoulder arthroplasty: a comparison of treatment strategies

These authors reviewed 47 patients having revision for periprosthetic infections of the shoulder: 27 underwent a 2-stage revision, and 20 were treated with an antibiotic spacer as definitive treatment.

A recurrent infection was recognized in 3 patients in the antibiotic spacer group and 2 patients in the 2-stage revision group.

A total of 20 procedure-related complications (43%)  and 11 medical complications (23%) occurred among the 47 patients. All 3 reoperations in the spacer group were due to recurrent infections. Of the 4 reoperations in the 2-stage group, 2 were due to recurrent infections; the other reoperations were due to a woundhealing complication and humeral stem loosening after reimplantation of the final shoulder arthroplasty.  Adverse reactions to IV vancomycin developed in 1 patient from each study group. In the patient in the 2-stage group, Stevens-Johnson syndrome developed, requiring admission to the hospital. In the other patient, an allergic response to the medication developed after 2 weeks of treatment, requiring a change in medication. Additional complications in the spacer group included deep vein thrombosis, myocardial infarction, hip fracture, acute renal failure, and a suicide attempt from an opioid overdose. Two deaths occurred within the first year of surgery. One death occurred as a result of a suicide approximately 9 months after the second-stage reimplantation. The other death occurred owing to sepsis from pneumonia; the patient had undergone antibiotic spacer placement approximately 5 months earlier.

Comment: This article points to the high complication rate associated with surgery in managing an infected shoulder arthroplasty. Of interest, 38% of the patients planned for a two-stage revision refused to proceed with the second stage.

This paper did not distinguish the treatment and outcomes of low virulence organisms (Cutibacterium and coagulase negative Staph (CoNS)), from those with high virulence organisms (Staph aureus and gram negatives). As pointed out in the article below, we have found that periprosthetic infections with Cutibacterium can be satisfactorily treated with a single stage revision - a safer procedure than using a spacer and a two-stage revision. We suggest that future studies should evaluate the management of periprosthetic infections from Cutibacterium and CoNS separately from the management of more virulent organisms. 

Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium

These authors point out that cultures taken at the time of revision shoulder arthroplasty are often positive for Propionibacterium.  They tested 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.

Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.

Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.

After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.

The patient self-assessed functional outcomes for those 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).

Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.

The culture-positive group were 89% male with a mean age 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 were 39% male 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. 

The authors concluded that the 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. 

Fourteen patients reported side effects to antibiotics, indication that patients should be educated with regard to potential antibiotic side effects.

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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.

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'

Single stage exchange for periprosthetic infection

Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium

These authors point out that cultures taken at the time of revision shoulder arthroplasty are often positive for Propionibacterium.  They tested 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.

Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.

Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.

After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.

The patient self-assessed functional outcomes for those 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).

Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.

The culture-positive group were 89% male with a mean age 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 were 39% male 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. 

The authors concluded that the 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. 

Fourteen patients reported side effects to antibiotics, indication that patients should be educated with regard to potential antibiotic side effects.

Another article,  One-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm, reported a retrospective study of a smaller series of 14 shoulders (average age 71, half men (note the older age and greater % women than the prior study) having a single stage exchange of septic shoulder arthroplasties that had an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile prior to revision surgery. If no microorganism was isolated or the underlying pathogen was a difficult-to-treat microorganism (not accessible for biofilm active antibiotics, enterococci, and fungi), 2-stage exchange was performed. 

For patients in whom septic shoulder arthroplasty was suspected, a diagnostic algorithm was followed to exclude or prove infection prior to revision surgery. The presumably infected shoulder was aspirated under aseptic conditions prior to revision surgery. Two weeks prior to aspiration, antibiotic treatment was suspended and all cultures were incubated for 14 days. In 12 patients, the underlying microorganism was identified in the synovial fluid obtained by aspiration. In 2 patients showing signs of infection with elevated serum C-reactive protein levels and synovial (WBC) counts, no microorganism grew in the synovial fluid. Consequently, they had to undergo an open biopsy, wherein infection was defined as a positive culture on at least 2 of the 5 resected tissue samples. If no microorganism was isolated prior to exchange surgery or the underlying pathogen was a difficult to-treat microorganism (not accessible for biofilm-active antibiotics, enterococci, and fungi, 2-stage exchange had to be performed.

The requirement for 1-stage exchange was an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile. Prior to surgery, we received a prescription from our microbiologist for local and systemic antibiotic therapy based on the antibiotic susceptibility profile of the isolated microorganism. The aim of the surgical procedure was to remove the infected prosthesis, followed by extensive débridement and insertion of a new prosthesis.

The mean follow-up period was 5.8 years. The most and second most commonly detected microorganisms were Cutibacterium acnes (formerly Propionibacterium acnes), and Staphylococcus epidermidis, respectively. 

At 1-stage exchange, patients received local and systemic antibiotics based on the susceptibility profile of the microorganism. 

Twelve patients with insufficient rotator cuffs received reverse shoulder arthroplasty, whereas 2 patients with intact rotator cuffs underwent anatomic total shoulder arthroplasty. The infection-free survival rate at 1 and 5 years was 100% and 93% (95% confidence interval [CI], 59%-99%), respectively, with 1 recurrence of infection 22 months after 1-stage exchange. Another patient with limited range of motion underwent revision 6 months postoperatively, leading to a revision-free survival rate of 93% (95% CI, 59%-99%) and 86% (95% CI, 54%-96%) at 1 and 5 years, respectively. The mean preoperative Constant score was 27 and the mean followup Constant score was 65 (range, 44-95); this calculates to an improvement of 52% of the maximal possible improvement.

Comment: While a two-stage revision may be indicated for the 'obvious' infections, these articles suggests that a single stage revision may be sufficient for the management of 'stealth' presentations.

It is important to distinguish between (a) the 'obvious' presentation of a shoulder infection with findings such as abnormal blood tests (WBC, ESR, C-reactive protein), erythema, fever, and/or wound drainage from (b) the 'stealth' presentation in which none of these findings are present in shoulder arthroplasties revised for pain, stiffness or component loosening combined with cultures positive for organisms such as Propionibacterium. While in the past some have referred to the second group of  cases as "unexpected positive cultures in revision shoulder arthroplasty", it is now preferable simply to report the clinical findings (i.e. is there obvious clinical evidence of infection?), the number of specimens, and the culture results. Furthermore, since it is not currently possible to distinguish "true infections", "contamination", "false-positive cultures", "non-pathogenic Propionibacterium growth", it is preferable to avoid these terms and, again, reporting the clinical findings, the number of specimens, and the culture results.

=====

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'

Revision shoulder arthroplasty - can we predict if bacteria are present?

Preoperative skin cultures are predictive of Propionibacterium load in deep cultures obtained at revision shoulder arthroplasty


Propionibacterium-specific cultures are commonly positive in revisedshoulders without obvious signs of infection. To help identify patients at risk for these “stealth” presentations of positive Propionibacterium cultures, these authors assessed the value of a preoperative skin culture in predicting the results of deep cultures obtained at the time of revision shoulder arthroplasty in patients without clinical evidence of infection. They enrolled 60 patients undergoing revision for a failed prior shoulder arthroplasty that showed no clinical evidence of infection. A preoperative culture of the skin surface was taken before skin preparation. At surgery, multiple (mean 5.9 ± standard deviation 1.6) deep tissue and explant cultures were harvested from the shoulder. Each culture was semiquantitatively reported as the specimen Propionibacterium value (SpPV). All SpPVs from the deep specimens from each patient were summed as the total shoulder Propionibacterium score (ShPS). The averaged ShPS was the total ShPS divided by the number of deep specimens harvested.

A multivariate analysis demonstrated that the preoperative skin SpPV was predictive of the Propionibacterium load in the revised shoulders as indicated by the total ShPS (P = .004) and averaged ShPS (P = .003).

In this series of patients, a preoperative culture of the unprepared skin, along with patient sex and age,  was strongly predictive of the Propionibacterium load in revised shoulder arthroplasties without clinical evidence of infection. This result suggests that the results of skin cultures taken before revision surgery may help inform operative management with respect to the need for prosthesis exchange and extended postoperative antibiotic treatment. 

Comment: This paper should be viewed along with a prior one using similar methods to correlate preoperative skin surface cultures with dermal wound cultures in patients undergoing primary shoulder arthroplasty:

Preoperative Skin-Surface Cultures Can Help to Predict the Presence of Propionibacterium in Shoulder Arthroplasty Wounds

These authors point out that propionibacterium species are commonly cultured from specimens harvested at the time of revision shoulder arthroplasty. These bacteria reside in normal sebaceous glands, out of reach of surgical skin preparation. The arthroplasty incision transects these structures, which allows Propionibacterium to inoculate the wound and to potentially lead to the formation of a biofilm on the inserted implant.

To help identify patients who are at increased risk for wound inoculation, they investigated whether preoperative cultures of the specimens from the unprepared skin surface were predictive of the results of intraoperative cultures of dermal wound-edge specimens obtained immediately after incision of he surgically prepared skin.

Sixty-six patients (mean age, 66.1 ± 9.4 years [range, 37 to 82 years]; 73% male) undergoing primary shoulder arthroplasty had preoperative cultures of the unprepared skin surface and intraoperative cultures of the freshly incised dermis using special culture swabs.

For the first 50 patients, a control swab was opened to air during the same time that the dermal specimen was obtained.

The results for female and male patients were characterized as the Specimen Propionibacterium Value (SpPV) (see this link). Here are some examples of the semiquantitative laboratory reports they used in the SpPV determination.

They then determined the degree to which the results of cultures of the skin surface specimens were predictive of the results of culture of the dermal specimens.

The skin-surface SpPV was ≥ 1 in 3 (17%) of the 18 female patients and 34 (71%) of the 48 male patients (p <0.001). The dermal SpPV was  ≥ 1 in 0 (0%) of the 18 female patients and 19 (40%) of the 48 male patients (p < 0.001).

None of the control samples had an SpPV of  ≥ 1  The predictive characteristics of a skin-surface SpPV of  ≥ 1 for a dermal SpPV of  ≥ 1 were as follows: sensitivity, 1.00 (95% confidence interval [CI], 0.82 to 1.00); specificity, 0.62 (95% CI, 0.46 to 0.75); positive predictive value, 0.51 (95% CI, 0.34 to 0.68); and negative predictive value, 1.00 (95% CI, 0.88 to 1.00).

A preoperative culture of the unprepared skin surface can help to predict whether the freshly incised dermal edge is likely to be positive for Propionibacterium. This test may help to identify patients who may merit more aggressive topical and systemic antibiotic prophylaxis.

This study shows that surgeons have the opportunity to use preoperative skin cultures to determine the likelihood that the shoulder arthroplasty wound will be culture-positive for Propionibacterium.

Comment: This study is important for at least four reasons: (1) when the skin is incised for a shoulder arthroplasty, the freshly cut dermal edge is often culture positive for Propionibacterium in spite of IV antibiotics and surgical skin preparation, (2) it is important that each surgeon know his/her rate of positive control cultures to better inform the interpretation of deep wound cultures, (3) the semiquantitative results of cultures appear to be more useful than simply reporting a culture as 'positive or negative', and (4) cultures of the unprepared skin surface can be predictive of the results of cultures of the freshly incised dermis.

The results of preoperative cultures of specimens from the unprepared skin surface may be helpful for anticipating the risk of positive intraoperative dermal wound-edge cultures that may, in turn, have a bearing on the risk of prosthetic bacterial colonization. This simple test may help to identify patients who may or may not merit more aggressive topical and systemic antibiotic prophylaxis
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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Two stage revision shoulder arthroplasty – how often do we get to stage 2?

A paper entitled "STAGE 1 SHOULDER ARTHROPLASTY: RISK FACTORS FOR REPEAT STAGE 1, SPACER RETENTION AND MORTALITY" was presented at the 2017 open meeting of the American Shoulder and Elbow Surgeons (see this link).

These authors sought to provide the perspective from a national Medicare database on the the outcomes at one year following stage 1 shoulder arthroplasty revision for patients who underwent removal of an infected shoulder prosthesis and placement of an antibiotic spacer.

975 patients who underwent shoulder arthroplasty prosthesis removal and cement spacer placement for infection met all inclusion and exclusion criteria. Within 1 year postoperatively, 21 patients died (2.2%), 70 patients had a repeat stage I procedure (7.2%), 55 patients had a girdlestone-type procedure (5.6%), 349 patients retained their spacers (35.8%) and the remaining 480 patients had a shoulder arthroplasty re-implanted (49.2%)

Independent risk factors for death within 1 year following stage 1 revision included older age, alcohol use, coronary artery disease (CAD) and hemodialysis

Independent risk factors for repeat Stage 1 revision include younger age, morbid obesity, diabetes mellitus and coronary artery disease. 

Independent risk factors for no re-implantation within one year include female gender, older age, tobacco use, alcohol use and inflammatory arthritis.

Only half of patients underwent re-implantation. 

One third of patients retained their spacer and just less than 10% repeated a stage 1 procedure.

Comment: We surely look forward to the publication of the full paper that would include the details of the type of infection and the condition of the shoulder. However, this abstract does indicate that a two stage revision is not always completed, leaving the patient with either a spacer or a resection arthroplasty.


======

The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Infected shoulder replacements - how should they be treated?

Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty

These authors report their results with two-stage implantation for deep periprosthetic infections in 35 shoulders (10 hemiarthroplasties, 24 anatomic total shoulder arthroplasties,1 reverse total shoulder arthroplasty).

Preoperative testing showed leukocytosis in 1 patient, elevated C-reactive protein concentration in 67%, elevated erythrocyte sedimentation rate in 61%, and positive preoperative aspiration in 69%.

At most recent follow-up (4.1 years) the patient had significant improvements in pain (from 4.4 to 2 on a 5-point scale; P < .0001), mean forward elevation (64°-118°; P < .0001), and mean external rotation (14°-41°; P < .0001).

Persistent infection, defined as positive cultures in samples obtained at the time of reimplantation, was identified in 5 shoulders (15%); 50% of persistent infections grew Propionibacterium acnes.

Reoperations for infection included irrigation and débridement (1), a second 2-stage reimplantation (2), and resection arthroplasty (1); 2 additional patients were treated with chronic suppression. Reoperation for aseptic glenoid loosening was performed in 2 additional shoulders.

There was an overall rate of unsatisfactory results approaching 40%.

Comment: Reports of treatment of periprosthetic infections are complicated by (1) the lack of a useful definition of "periprosthetic infection" that includes both obvious presentations (drainage, erythema, elevated white blood counts, sedimentation rate, C-reactive protein) and stealth presentation (no clinical or blood lab evidence of infection, but substantially positive cultures of deep tissues obtained at revision arthroplasty) and (2) the well documented observation that clinical manifestations of infection can present years after a shoulder arthroplasty (so that the 'success' of treatment can be difficult to determine).

Because of the added morbidity of a two-stage approach to a suspected infection, we reserve the two-stage for cases of obvious infection that present, for example, with wound drainage, elevated serum markers of systemic inflammation (CBC, Sed Rate, C-repactive protein), and bacteria other than Propionibacterium and coagulase negative staph. In the remaining cases we prefer a single-stage revision as reported here:

Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium

These authors point out that cultures taken at the tim of revision shoulder arthroplasty are often positive for Propionibacterium.  They tested 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.

Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.

Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.

After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.

The patient self-assessed functional outcomes for those 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).

Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.

The culture-positive group were 89% male with a mean age 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 were 39% male 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. 

The authors concluded that the 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. 

Fourteen patients reported side effects to antibiotics, indication that patients should be educated with regard to potential antibiotic side effects.

While a two-stage revision may be indicated for the 'obvious' infections, this article suggests that a single stage revision may be sufficient for the management of 'stealth' presentations.

This article carefully distinguishes between (a) the 'obvious' presentation of a shoulder infection with findings such as abnormal blood tests (WBC, ESR, C-reactive protein), erythema, fever, and/or wound drainage from (b) the 'stealth' presentation in which none of these findings are present in shoulder arthroplasties revised for pain, stiffness or component loosening combined with cultures positive for organisms such as Propionibacterium. While in the past some have referred to the second group of  cases as "unexpected positive cultures in revision shoulder arthroplasty", it is now preferable simply to report the clinical findings (i.e. is there obvious clinical evidence of infection?), the number of specimens, and the culture results. Furthermore, since it is not currently possible to distinguish "true infections", "contamination", "false-positive cultures", "non-pathogenic Propionibacterium growth", it is preferable to avoid these terms and, again, reporting the clinical findings, the number of specimens, and the culture results.

Again it is important to recognize that each report regarding periprosthetic infections needs to grapple with the question "What is an infection of a shoulder joint replacement?" as discussed here:

What is a "periprosthetic shoulder infection"? A systematic review of two decades of publications.

These authors point out that while as many as 50% of revision shoulder arthroplasties are culture positive, a consistent, clinically useful definition of a "periprosthetic shoulder infection" is lacking. They conducted a systematic review of the published literature with respect to (1) the definition of a "periprosthetic shoulder infection", (2) the pre-operative evaluation for possible infection, and (3) the harvesting and culturing of specimens at the time of surgical revision.

They found a remarkable lack of consistency in the way different authors defined an 'infection', in the way authors evaluated patients with possible infections before surgery and in the way authors obtained and analyzed specimens obtained for culture harvested at the time of the surgical revision of failed shoulder joint replacements.

This inconsistency makes it very difficult to compare different treatment approaches to failed shoulder joint replacements, recognizing that some of them will have substantial bacteria in the joint, the presence of which may go unrecognized until the culture results are finalized at 2 to 3 weeks after surgery.

Comment: It is critically important not to combine, confuse or commingle data from "obvious infections" (i.e. those with swelling, redness, drainage, fever, chills, elevated serum markers of inflammation) where the diagnosis of infection is apparent with cases of "stealth" presentation (i.e. the unexplained onset of pain and stiffness of the shoulder after a 'honeymoon' of good function in which specimens obtained at revision surgery are strongly positive for organisms such as Propionibacterium).

Here's an example of a stealth presentation:

A 50 year old patient presented desiring a ream and run arthroplasty for severe glenohumeral arthritis





After surgery, the shoulder progressively regained comfort and function. Subsequently, however it started to become stiff and painful without obvious explanation. Eight years after his shoulder arthroplasty, the patient returned to the office with no clinical, laboratory, or radiographic evidence of infection.





A single stage revision was performed (soft tissue releases, prothesis exchange) without any evidence of inflammation, joint fluid, loosening, or osteolysis. Five explant and tissue cultures were sent. The patient was discharge on the yellow protocol (Augmentin) until the results of the cultures were final.

The culture results were
Humeral head explant: 3+ Propionibacterium
Humeral stem explant: no growth
Collar membrane: 1+ Propionibacterium
Humeral periosteum: 1+ Propionibacterium
Joint capsule: no growth

At this point the red protocol (IV ceftriaxone) was started and continued for 6 weeks followed by a 6 month course of Augmentin. The patient has a comfortable shoulder and has regained most of the lost shoulder motion.

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Infection of shoulder joint replacement

Surgical management of periprosthetic shoulder infections

These authors reviewed patients having either a 1-stage partial component exchange (15 cases), a 1-stage complete removal and reimplantation (45 cases) or a 2-stage revision arthroplasty (19 cases) for periprosthetic joint infection.

Recurrence of infection was determined  by postoperative clinical signs of infection (elevated laboratory studies, drainage, swelling, and erythema) or by a reoperation for infection after the index (1-stage or 2-stage) procedure at a minimum of 1 year after the procedure.

At a minimum of 1 year followup, re-operation for infection was performed in

4 of 15 partial component exchanges,

2 of 45 complete single stage exchanges

and

4 of 19 2-stage procedures 

Reinfection rates were highest in patients whose cultures grew Staphylococcus aureus or coagulase negative Staphylococcus species and in those treated with a partial component exchange.

Comment: It is of interest that 

(1) less than half of the cases had evidence of what we refer to as an 'obvious' infection (local or systemic signs, abnormal laboratory tests).

(2) of the 29 planned 2-stage procedures, 10 elected not to undergo the second stage

(3) 21 (24%) of these shoulders diagnosed as having infection had negative cultures at surgery, but had positive pathology for acute inflammation. 

(4)  Propionibacterium acnes was the most commonly isolated organism (26 of 89 [29%]) and coagulase-negative Staphylococcus  species (CoNS) was  was the second most common (24 of 89 [27%]

(5) the criteria for determining recurrence of infection may not be sensitive to a 'stealth' presentation as discussed in the posts below.

Failed shoulder joint replacement: single stage revision when cultures are positive for Propionibacterium

Periprosthetic shoulder infections: single or two-stage revision?

Shoulder arthroplasty infections - how should they be treated?

While obvious periprosthetic infections are obvious, the evaluation and management of 'stealth' infections is challenging. Our approach to most cases of failed shoulder arthroplasty is to perform a single stage exchange to a stemmed hemiarthoplasty fixed with Vancomycin-soaked allograft, recognizing that the presence of bacteria in the joint cannot be reliably determined at the time of surgery.