A respected colleague on the opposite side of the U.S., Andy Green, revised a patient of ours for a delayed Cutibacterium infection.
Here's the story.
A 39 year old with a prior history of a Nicola procedure and open capsulorrhaphy presented to us 18 years ago with anchor arthropathy and these x-rays
Our initial plan was a ream and run, but the decision was made instead to perform a total shoulder with a posterior capsulorrhaphy.
14 years after surgery, he presented with painful stiffness of his shoulders and these films showing wear and loosening of his glenoid component. He was offered a revision at that time, but he decided to live with it for a while.
One year later he presented to our colleague who found active forward elevation of 135 degrees, active external rotation of 40 right, internal rotation 3+, belly press positive and the x-rays below
At revision, synovial fluid showed 50 nucleated cells, moderate metalosis, proximal humeral osteolysis, well fixed humeral component, loose, worn glenoid, extensive glenoid osteolysis.
He had a single-stage revision to a hemiarthroplasty, glenoid smoothing, insertion of new humeral component with impaction allografting and Vancomycin. Discharged on oral Augmentin.
Synovial biopsy showed necrosis, severe degenerative changes, chronic lymphohistiocytic giant cell reaction, polarizable foreign body material.
Early post operative films are shown below.
Two years afterwards he was substantially improved with respect to comfort and function. His radiographs showed stable configuration of the implants.
(1) the occurrence of a Cutibacterium periprosthetic infection in a high risk patient (young age, male, prior surgery)
(2) the long delayed in the presentation of the Cutibacterium periprosthetic infection after the index shoulder arthroplasty (see Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty).
(3) the difficulty in distinguishing a Cutibacterium infection from detritic synovitis (see this link) at the time of surgery
(4) the importance of taking multiple specimens at surgery and submitting them for Cutibacterium- specific culturing.
(5) the utility of converting patients from oral (yellow protocol) to IV (red protocol) antibiotics if cultures are postive. See the links below:
10 points about Cutibacterium, periprosthetic infection, and revision for failed shoulder arthroplasty
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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link)
Shoulder arthritis - x-ray appearance (see this link)
The smooth and move for irreparable cuff tears (see this link)
The total shoulder arthroplasty (see this link).
The ream and run technique is shown in this link.
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
