Saturday, December 31, 2022

Periprosthetic infection is one of the most frequent complications of reverse total shoulder arthroplasty - what is relationship of PJI to prior surgery?

Periprosthetic infection (PJI) is one of the most common and most serious reasons for failure of reverse total shoulder arthroplasty (RSA). When adjusted for age, sex, and indication, the risk of revision for  PJI after RSA (3.1%) is 2.4 times higher than after anatomic TSA. A possible contributing factor to this difference is the observation that patients having primary RSA are more likely to have had prior surgery than those having primary TSA.

Using the Danish Shoulder Arthroplasty Registry records of 2217 patients having RSA, the authors of Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty sought to determine the relationship between previous non-arthroplasty surgery and PJI after RSA performed for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis.

Patients were grouped as (1) having had a rotator cuff repair prior to their RSA, (2) having prior surgery other than cuff repair (such as subacromial decompression and/or AC joint resection), and (3) having no surgery prior to their RSA,

The fourteen-year cumulative rate of revision for different types of previous non-arthroplasty surgery are shown below. 
The cumulative RSA revision rate for shoulders with prior rotator cuff repair was 21.4% at 14 years. 
The cumulative rates for RSA after other types of prior non-arthroplasty surgery was 6.8% at 14 years. The cumulative rates for RSA with no prior surgery was 5.9% at 14 years.

PJI was defined as 3 of 5 tissue samples positive for the same bacteria or as definite or probable PJI evaluated based on criteria from the International Consensus Meeting.

Revision was performed in 88 shoulders (4.0%), of which almost half (40) had PJI.

There were 272 patients (12.3%) who had undergone previous rotator cuff repair, 11 (4.0%) of these had revision for PJI.

Fourteen-year cumulative rate of revision owing for periprosthetic joint infection (PJI)  for different types of previous non-arthroplasty surgery are shown below. 
The cumulative rate of revision for PJI for patients having prior rotator cuff repair was 14.1% at 14 years. 
The cumulative rate for others types of prior surgery was 2.1% at 14 years which was essentially the same as the cumulative rate for shoulders with no prior surgery was 2.7% at 14 years.

The bacteria identified at revision surgery were predominantly Cutibacterium - notably not only C. acnes.

It is of great interest and significance that the rate of revision for those shoulders with prior cuff repair continued to increase with time after RSA in contrast to the rates for shoulders having no prior surgery or prior surgery other than cuff repair. This finding points to the delayed onset of clinical manifestations of Cutibacterium infection noted by the authors of Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty

While the reasons for the increased risk of RSA PJI after cuff repair in comparison to procedures such as acromioclavicular arthroplasty and acromioplasty are not elucidated in this study, it is possible that the insertion of suture anchors and multiple non-dissolvable sutures may introduce bacteria into the shoulder - especially if the sutures have been in contact with the patient's skin.

Previous authors have noted the adverse effect of prior cuff repair on RSA outcomes. For example, in Failed Prior Rotator Cuff Repair Is Associated with Worse Clinical Outcomes After Reverse Total Shoulder Arthroplasty the authors sought to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared to RSA for CTA with prior RCR. The prior RCR group had a significantly higher complication rate (17.4%, n=15) than the primary RSA group (3.8%, n=4) (p=0.001).

At mean 36.3±26.1-month follow-up, the prior RCR group had statistically worse SST scores, ASES scores, and active forward elevation.

This study points out that prior cuff repair attempts can jeopardize the safety and outcome of reverse total shoulder. While not discussed in the manuscript, it seems likely that acromioplasty and section of the coracoacromial ligament - both often performed at the time of attempted cuff repair - may both contribute to instability and weaken the acromion, making it more susceptible to fracture. Prior surgery of any type may increase the risk of infection. Instability, fracture and infection can lead to revision of a failed reverse total shoulder.

Infection (including those that are not clinically obvious) is a cause of failure of cuff repair (see for example Mid- to Long-Term Outcomes After Deep Infections After Arthroscopic Rotator Cuff Repair and Postoperative deep shoulder infections following rotator cuff repair).

So, how might all of this change our practice? Here are some thoughts:
(1) a the time of cuff repair (and other surgical procedures) avoid contact of tagging and repair sutures with the patient's skin
(2) when evaluating a patient with a failed cuff repair, consider the possibility of an occult infection
(3) when performing a reverse total shoulder for a failed cuff repair consider
    (a) submitting deep specimens for culture for Cutibacterium
    (b) using extraordinary prophylactic measures, such as Betadine irrigation, topical antibiotics and post-operative antibiotics at least until the results of the intraoperative cultures are final at two weeks.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).