A 45 year old right handed active man had a Simple Shoulder Test score of 4/12. His x-rays revealed severe capsulorrhaphy arthropathy with posterior dislocation of right shoulder after a Putti Platt procedure for shoulder instability performed many years earlier.

At surgery he was found to have massive humeral and glenoid deformity with severe posterior glenoid erosion and malformation of the humeral head with posterior capsular laxity and anterior capsular contracture. His surgery was a humeral hemiarthroplasty with subscapularis lengthening. His post operative film is shown here.

However, the humeral head again became posteriorly unstable. A year later he had an open reduction of the posteriorly dislocated shoulder with anterior release, prosthetic head removal, posterior cortical iliac autograft of the glenoid with screw fixation, posterior soft tissue reconstruction, and reinsertion of hemiarthroplasty head. However, on testing the range of motion of the shoulder at surgery, the securely fixed bone graft fragmented requiring removal of the graft and screws and insertion of a reverse total shoulder. His postoperative film is shown here.

Three years later he represented with pain in his shoulder that started with golfing. He had no clinical evidence of infection. His x-rays showed humeral osteolysis and subsidence

He then had a single exchange revision of reverse total shoulder arthroplasty to a long stemmed humeral component and a new glenoid component at which time six cultures were obtained before antibiotics were administered. At this procedure there was a substantial amount of membrane and granulomatous tissue from the glenoid and from the humeral medullary canal. There was no cloudy fluid and no purulence.

His histology showed gram-positive rods and up to 40 white blood cells per high power field on frozen section. The patient’s final pathology eventually returned “synovial tissue with multiple foci of dense neutrophilic infiltrates (greater than five neutrophils per high power microscopic field using a 40 X objective in at least five separate microscopic fields) in a background of prominent plasmacytic inflammation and hemosiderin-laden macrophages.” He was placed on a six-week course of IV vancomycin and rifampin, which was changed to ceftriaxone to better cover Propionibacterium after the culture results were final at 3 weeks.

His culture results were as follows:
Glenoid Membrane No. 1: 2+ Propionibacterium
Glenoid Membrane No. 2: 1+ Propionibacterium
Fluid Right Glenoid: 1+ Propionibacterium
Humeral Membrane No.1: 1 colony Propionibacterium
Humeral Membrane No. 2: 1+ Propionibacterium
Humeral Membrane No. 3 One colony Propionibacterium

He remained on oral Augmentin for a year.

Six years after his most recent revision he was playing tennis (tossing the ball with his right hand serving with his left), skiing gentle slopes, and running for fitness. His x-rays at 6 years showed stable component fixation.

At 14 years after his revision, he returned for followup, reporting a comfortable shoulder that allowed him to play tennis and golf. His films at 14 years are shown below.

Comment: This case reveals the challenges of severe capsulorrhaphy arthropathy with posterior instability as well as the substantially delayed insidious presentation of osteolysis associated with Propionibacterium (Cutibacterium).

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