Tuesday, February 5, 2019

Can injection infect the shoulder with Propionibacterium?

The colonisation of the glenohumeral joint by Propionibacterium acnes is not associated with frozen shoulder but is more likely to occur after an injection into the joint

These authors investigated the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of 46 patients undergoing shoulder surgery for frozen shoulder or instability. Patients were asked if they have ever had an injection into the shoulder to be operated on, including an injection of contrast for MR arthrogram.

25 patients (53%) had P. acnes in one or more tissue samples and 35 (74%) had other bacterial species. The same microbe was found in the subcutaneous fat and the capsule in 13 patients (28%). 

Male gender was significantly associated with an increased capsular colonisation of P. acnes (odds ratio (OR) 12.38, 95% confidence interval (CI) 1.43 to 106.77, p = 0.02). 

A pre-operative glenohumeral intra-articular injection - either as treatment for a frozen shoulder or for the injection of contrast in patients with instability - was significantly associated with capsular P. acnes colonisation (OR 5.63, 95% CI 1.07 to 29.61, p = 0.04. 

Positive fat colonisation with P. acnes was significantly associated with capsular P. acnes (OR 363, 95% CI 20.90 to 6304.19, p < 0.01). 

Patients who had a pre-operative glenohumeral injection who were found intra-operatively to have fat colonisation with P. acnes had a statistically significant association with colonisation of their capsule with P. acnes (OR 165, 95% CI 13.51 to 2015.24, p < 0.01).

These authors concluded that there was a statistically significant association between subcutaneous skin P. acnes culture and P. acnes capsular culture, especially when the patient has undergone a previous injection. 

Comment: This paper provides additional evidence that any invasion of the joint, even an injection, may introduce Propionibacterium into the shoulder. This paper does not provide data on how long prior to the surgery the injections were performed. There is a common believe that shoulder arthroplasty shoulder not be performed within three months of an injection. However, there is no evidence that Propionibacterium introduced by an infection would have been eliminated by host defenses in that period of time. Thus we must ask, does the risk of shoulder colonization after injection decrease with time after injection, or is it long standing?

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