UW Shoulder and Elbow Academy: Possibly infected shoulder arthroplasty: the red and yellow protocol

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 ( a diagram of the red and yellow protocol is below)

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 ( a diagram of the red and yellow protocol is below)

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.