We've had a number of requests for an update to our approach to revision shoulder arthroplasty, recognizing that the rate of infection in these cases is high. See prior related post here and a diagram of the red and yellow protocol here.
Considerations in revision arthroplasty
I. Obvious infection
Typical characteristics
Draining sinus
Classic signs (fevers, chills, erythema, elevated WBC, ESR, CRP)
Massive osteolysis
Gross purulence
Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Treat with explant of all components, vigorous debridement and irrigation, topical antibiotics, lightly fixed antibiotic spacer and IV antibiotics via PICC line X 6 weeks; initially ceftriaxone and Vancomycin. Antibiotics modified according to culture results. 6 months oral antibiotics after IV course complete. At 6 months can consider reimplantation of prosthesis
II. High suspicion for stealth infection – red protocol
Typical characteristics
Honeymoon period (onset of otherwise unexplained pain and stiffness after a period of usual post op course ranging from months to years)
Patient at increased risk: young active male patient with prior surgery
Rest pain
Loose components (especially early humeral loosening), osteolysis
Synovitis, >5 wbc/hpf, cloudy joint fluid, humeral membrane
Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Treat with explant of all components, vigorous debridement and irrigation, topical antibiotics, single stage exchange to impaction allografted hemiarthroplasty and IV antibiotics via PICC line X 6 weeks; initially ceftriaxone and Vancomycin. Antibiotics modified according to culture results. 6 months oral antibiotics after IV course complete. If cultures negative at 3 weeks consider discontinuing antibiotics.
III. Lower suspicion for stealth infection – yellow protocol
Typical characteristics
Female patient
No osteolysis
Pain only with activity
Suspect prosthesis failure is strictly mechanical
Prosthetic revision: Hold perioperative antibiotics until five tissue/explant cultures are obtained and submitted for Propionibacterium specific cultures. Prosthesis revision as indicated by surgical findings. Oral antibiotics (Doxycycline or Augmentin) for 3 weeks. Antibiotics modified according to culture results. If cultures are positive and if revision fails to produce a satisfactory clinical result, consider repeat surgery with red protocol or spacer.
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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
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