Resection arthroplasty - a salvage procedure - a study with 50% lost to followup

Functional outcomes after shoulder resection: the patient's perspective.

These authors present followup on 7 of 14 patients having resection arthroplasty for the treatment of failed arthroplasty.

Five of the 7 patients reported satisfaction with their resection arthroplasty, and 6 of the 7 patients would undergo the procedure again if given the choice.

Comment: From this study with 50% of the patients lost to followup, it is difficult to determine the effectiveness of this procedure. We have posted before on this procedure here and here. It is of note that most of the patients having this procedure had it to manage a periprosthetic infection. 

We very rarely use either resection or spacers in the management of Propionibacterium or coagulase negative Staph infections of the shoulder, relying instead on debridement and single stage conversion to a hemiarthroplasty fixed with impaction allografting and intravenous and topic antibiotic therapy. However, the management of the infected arthroplasty requires a high level of individualization of the treatment considering the bacteria, the quality of bone, the stability of the joint, and the desires of the patient.

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Resection arthroplasty

Resection arthroplasty for failed shoulder arthroplasty

The authors of this paper found 26 patients having had resection arthroplasty for failure of a primary arthroplasty. These patients demonstrated significant improvement in their pain score but not their function. What we found most interesting about this paper was that all but four of these resections were performed for intractable infection.
Patients having resection for reverse total shoulders had poorer function than those having resection for failed total shoulders or hemiarthroplasties.

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Resection arthroplasty

Resection arthroplasty for failed shoulder arthroplasty

This is a Level IV  review of 26 patients who underwent resection arthroplasty  at a mean follow-up of 41.8 months (range, 12-130 months) after a prior shoulder arthroplasty (total shoulder, hemiarthroplasty or reverse total shoulder). The procedures were performed at 5 different centers. The number of patients having resection arthroplasty at these centers but who were not available for follow-up is not known.

 At follow-up, the average VAS pain score was  3.2 ± 2.5 (0-10), the average Constant Score (for 21 of the shoulders) was  27.3 ± 12.5 (3-53), and the average forward elevation was 46.7 ±  29.1 degrees (0-100).

The most impressive aspect of this series was that 22 of the 26 resection arthroplasties were for arthroplasties that had become infected. The organisms responsible for the infections were not identified. Infection was not identified in the remaining four, however the protocol for culturing the shoulders was not explained. 

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Infections of the shoulder - resection - JSES Dec 2011

In a previous post we reviewed a report of the use of cement spacers in the management of deep shoulder infections. This series did not have a comparison group, that is the authors did not compare their results with a spacer (removal of all components followed by insertion of a cement spacer with antibiotics) to those with a primary exchange (removing all components and reinserting new ones) or to those with a resection arthroplasty (removing all prosthetic components without reinsertion).

Verhelst et al recently published a series of cases of resection arthroplasty comparing patients in which a spacer (containing gentamycin)  was used to those with a resection alone. This was not a controlled series so it cannot be assumed that the two patient populations were comparable prior to the revision surgery.  The initial surgeries ranged from acromioplasties and rotator cuff repairs to total and reverse shoulder arthroplasties. An average of 9 months elapsed between the initial surgery and the diagnosis of infection. The culture results were: 9 Staph aureus, 12 coagulase negative Staph, 4 Propionibacterium, and 2 Corynebacterium. No differences were observed in the results of the patients treated with and without spacers.  The authors believed infection was eradicated in 19 of the 21 cases.

Importantly, five of the ten patients treated with a spacer required a second procedure to reimplant a prosthesis at an average of 7 months after the spacer placement because of pain. Severe glenoid erosion occurred in those patients who received a stemmed spacer.  None of the patients having a resection had revision surgery. No significant differences in function were noted between the two groups.

The authors point out that preservation of the tuberosities is a key prognosticator of a good functional result.

The authors provide a thorough review of the literature on resection, primary exchange and two stage exchange.

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Our management of infections depends on the clinical presentation. Patients with draining sinuses, patients with local or systemic evidence of sepsis are likely to be managed with resection arthroplasty as suggested by Verhelst et al. Patients suspected of having low grade infections with organisms such as P. acnes are likely to be managed with a primary exchange using antibiotic-soaked allograft and prolonged antibiotic management in anticipation of a better functional outcome.

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