Wednesday, March 26, 2014

Our current management of apparently aseptic shoulder arthroplasty failure

We are often asked about our approach to the revision of stiff, painful or loose shoulder arthroplasties without obvious evidence of infection (i.e. no fever, chills, swelling warmth, elevated sedimentation rate, elevated C reactive protein, elevated white blood cell count, draining sinus, etc). This approach is heavily influenced by two of our research studies as posted here and here. It is also informed by our current understanding of biofilms.

Based on these studies we assume that a painful/stiff arthroplasty that has not responded to reasonable attempts at rehabilitation or a shoulder arthroplasty with component loosening and / or osteolysis is infected with either Propionibacterium or coagulase negative Staph until proven otherwise. 

If the patient wishes to proceed with revision surgery after a detailed informed consent session, we plan a single stage exchange revision. At surgery, we harvest 5 non-fluid cultures (tissue or prosthesis explants) before prophylactic antibiotics are administered and send these specimens for Propionibacterium-specific cultures (aerobic, anaerobic and broth held for three weeks). If there is a high index of intraoperative suspicion (humeral membrane, osteolysis, male patient, component loosening, cloudy joint fluid) the patient is placed on a PICC line with Ceftriaxone+Vancomycin. We call this the 'red' protocol (see this link). If the index of suspicion is lower, we place the patient on oral Augmentin, the 'yellow' protocol (see this link).  If the cultures become positive, our infectious disease service makes modification in the regimen (for example, if someone on the 'yellow' protocol grows out Propionibacterium the patient will be converted to IV antibiotics (as in the 'red' protocol)). If there is no growth at three weeks, we will usually stop antibiotics unless the surgical suspicion is high. If cultures are positive, the patient is given a course of 6 to 12 months of oral antibiotic suppression.

The surgical procedure usually involves removing all components (to exclude the possibility of biofilms perpetuating the infection) and reimplanting the humeral component with impaction grafting using Vancomycin soaked allograft.

Here's a case from yesterday's OR schedule:

This patient had a total shoulder arthroplasty done in 1997. Recently it became painful with loss of function. X-rays showed glenoid component loosening and osteolysis.

At surgery the shoulder showed extensive chronic inflammation, glenoid loosening and humeral osteolysis that was not evident on the preoprerative films.

The glenoid and humeral components were removed, the hypertrophic tissue was resected and a new humeral component was inserted with impaction allograft after vigorous irrigation with 3 liters of Vancomycin - Cephtriaxone solution.

The patient will have a PICC line placed today. 
His rehabilitation is the same a that for a standard shoulder arthroplasty.

Today in clinic we saw a patient who had had this procedure a year ago and was pleased with the comfort and function of his shoulder.


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