Let's consider a case of an active male who had a ream and run procedure. His shoulder was somewhat stiff from the start. His stiffness did not resolve with therapy; he developed increasing pain. He had no fever, chills, or abnormal blood markers for infection.
Two years after his index procedure he had a single stage revision. At that time his synovial fluid showed 1000 neutrophils; two frozen section specimens had more than 10 cells per high-power field.
Postoperatively, he was placed on oral amoxicillin/clavulanate.
After surgery, eight tissue specimens each cultured positive for low levels of Cutibacterium.
So here are some clinically relevant questions:
(1) Were his pre-revision findings of stiffness and pain suggestive of a periprosthetic infection?
(2) Would a preoperative aspiration or arthroscopic biopsy have changed the management of this case?
(3) Were his surgical findings diagnostic of a periprosthetic infection?
(4) For this patient, how do the benefits and risks compare between a single stage and a two-stage revision?
(5) Postoperatively, while the culture results are pending (i.e. the organism is not yet unidentified), how do the benefits and risks compare between oral and intravenous antibiotics?
(6) Immediately after surgery (before culture results are available) what would be the antibiotic of choice?
(7) If the patient has ongoing pain and stiffness of the shoulder after his single stage revision, how will the surgeon know if there is a persisting infection?
A recent article, Periprosthetic Shoulder Infection management: one-stage should be the way - A systematic review and meta-analysis brought up more questions:
(8) "For this review, the rate of reinfection after a revision arthroplasty for a shoulder PJI was the main outcome assessed." How is a "reinfection" diagnosed? Does the definition require a re-operation to see if deep tissue specimens are culture positive (and for the same organism as was found in the index revision)? If a patient is doing poorly after a revision but does not have a re-operation, how does one know whether there is a "reinfection"?
(9) In this review, why is the complication rate for two-stage revision (21.26%) higher than that for one-stage revision (6.11%)? It may be that a shoulder having two procedures is more likely to have more complications than a shoulder having a single procedure.
(9) In this review, why is the complication rate for two-stage revision (21.26%) higher than that for one-stage revision (6.11%)? It may be that a shoulder having two procedures is more likely to have more complications than a shoulder having a single procedure.
(10) Why was the "reinfection rate" with a single stage (one stage) revision (1.14%) lower than that after a two-stage revision (8.81%). This gets to #7 above: how does a surgeon know if there is a "reinfection" if the shoulder is not re-operated with cultures taken at the time of re-operation. Since the complication rate was three times higher with the two-stage revisions, it seems likely that more of the two-stage revisions would have had re-operations and re-culturing.
(11) Does the organism cultured from the time of revision matter to the treatment and to the outcome? The isolated bacteria reported in the analyzed studies varied widely with respect to virulence, including Cutibacterium, Coagulase-negative Staph, Methicillin resistant Staph Aureus, E. Fecalis, Strep Viridans, and Pseudomonas. Reliable studies comparing the efficacy of different surgical and antibiotic regimens will require controlling for the infecting organism.
(12) What are the indications for a two-stage revision of a periprosthetic infection?
Comments: Some things we think we know
(1) Some perioprosthetic infections are obvious (pain, swelling, drainage, fever, chills, elevated serum inflammatory markers).
While the diagnosis of PJI may not difficult, it is still important to identify the causative organism.
(2) Many periprosthetic infections have a stealth presentation (unexplained onset of pain and stiffness after a "honeymoon" period of benign post-arthroplasty recovery).
These infections are typically caused by low virulence organisms, such as Cutibacterium. Often the diagnosis is made by obtaining specimens for culture at the time of a revision procedure performed for pain and stiffness. In that the results of these cultures are not finalized until weeks after the revision, the surgical and immediate postoperative antibiotic treatment must be decided without this information.
(3) Single stage revision with thorough debridement, prosthesis exchange and post-operative antibiotics can be effective treatment of shoulder periprosthetic infections caused by Cutibacterium. (see Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium).
(4) Two-stage revision is more morbid, has a higher complication rate and is more costly than a single stage revision, but can be considered in cases of obvious infection from a high virulence organism or when a prior single stage revision has failed.
(5) Postoperative intravenous antibiotics are more morbid, have a higher complication rate and are more costly than oral antibiotics, but can be considered in cases of obvious infection from a high virulence organism (see The Use and Adverse Effects of Oral and Intravenous Antibiotic Administration for Suspected Infection After Revision 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).
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).
