Management of infected shoulder arthroplasty: a comparison of treatment strategies
These authors retrospectively reviewed 47 of their surgically treated infected shoulder arthroplasties between 2006 and 2014. More than one in three of these patients were immunocompromised and more than one in four had diabetes
These authors retrospectively reviewed 47 of their surgically treated infected shoulder arthroplasties between 2006 and 2014. More than one in three of these patients were immunocompromised and more than one in four had diabetes
Many of these patients had substantial evidence of inflammation. One third of the patients had negative cultures.
27 underwent a 2-stage revision, and 20 were planned for a two-stage, but instead chose to retain the antibiotic spacer as definitive treatment.
A recurrent infection was recognized in 5 patients. A total of 20 procedure-related complications and 11 medical complications occurred in these patients
SST scores at followup ranged from 4.3±3.4 for those who retained their spacer, 5.2±4.0 for those revised to hemiarthroplasties and total shoulders, to 8.1 for those revised to a reverse total shoulder.
There were 2 deaths within 1 year of surgery. One patient died as a result of pneumonia complicated by sepsis 6 months after antibiotic spacer placement. The second patient died of suicide 9 months after the second-stage reimplantation. Another patient also attempted suicide shortly after discharge from the hospital after antibiotic spacer placement.
The authors point to the substantial psychosocial burden that management of a prosthetic infection can place on a patient. They suggest that a patient is showing or expressing symptoms of depression, mental health intervention may be indicated.
There were 2 deaths within 1 year of surgery. One patient died as a result of pneumonia complicated by sepsis 6 months after antibiotic spacer placement. The second patient died of suicide 9 months after the second-stage reimplantation. Another patient also attempted suicide shortly after discharge from the hospital after antibiotic spacer placement.
The authors point to the substantial psychosocial burden that management of a prosthetic infection can place on a patient. They suggest that a patient is showing or expressing symptoms of depression, mental health intervention may be indicated.
Comment: This study demonstrates a high degree of variability among the patients and in the treatment selected for them. The authors did not carryout a multivariate analysis of these retrospective data to see which factors were associated with better clinical outcomes or lower rates of recognized recurrence. As a result conclusions cannot be reached regarding which treatments are "superior" for managing these patients.
The cases in this report fall into the category we refer to as 'obvious' infections. It is important to distinguish between (a) the 'obvious' presentation of a shoulder infection with findings such as abnormal blood tests (WBC, ESR, C-reactive protein), erythema, fever, and/or wound drainage from (b) the 'stealth' presentation in which none of these findings are present in shoulder arthroplasties revised for pain, stiffness or component loosening combined with cultures positive for organisms such as Cutibacterium. For the "stealth: infections, we find that a single state revision is effective as detailed below
Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium
Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.
Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.
The culture-positive group were 89% male with a mean age of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement.
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These authors point out that cultures taken at the time of revision shoulder arthroplasty are often positive for Propionibacterium. They tested the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive.
Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.
After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.
The patient self-assessed functional outcomes for those shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group).
Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.
The culture-positive group were 89% male with a mean age of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement.
The control group were 39% male with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement.
Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive.
The authors concluded that the clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases.
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