Shoulder infections - 20 things to know.

Infection can be a major complication for patients having shoulder surgery. 

Posts on this shoulder blog have provided evidence that:

(1) Cutibacterium - commensal bacteria commonly found in the dermis of normal skin - are the most common organism causing periprosthetic infections (PJI) of the shoulder. By contrast infections of total hip and total knee replacements are usually caused by other types of bacteria. 

(2) Cutibacterium are often isolated from specimens obtained at revision for a failed arthroplasty, even in the absence of a preoperative suspicion of PJI.

(3) The risk of Cutibacterium PJI is increased in young, healthy male patients having had prior surgery, patients having high loads of Cutibacterium on their skin surface, in patients taking supplemental testosterone, and those with recent steroid injections of the shoulder.

(4) These organisms are released into the surgical wound from the dermis when the skin incision is made

(5) Cutibacterium cannot be eliminated from the dermis by presurgical skin treatment, preoperative antibiotics, or surgical skin preparation

(6) While Betadine or antibiotic irrigation solutions and in-wound antibiotics may be helpful in reducing the load of bacteria in the surgical field, the evidence that they reduce the rate of infection is not robust.

(7) Cutibacterium tend to form an adherent biofilm, especially on titanium-alloy stems; thus, complete prosthesis exchange after debridement may be necessary to resolve an infection.

(8) Some infections are obvious (redness, swelling, tenderness, elevated serum and synovial fluid inflammatory markers); however, Cutibacterium infections typically have a stealth presentation with the otherwise unexplained onset of pain and stiffness months after the index arthroplasty.

(9) Joint fluid aspiration can be helpful if the fluid is culture positive, but negative cultures do not rule out infection.

(10) At the time of revision surgery at least 5 deep specimens (tissue / explants) need to be submitted for culture in order to optimize the identification of a PJI.

(11) Specimens taken to detect Cutibacterium must be cultured on aerobic and anaerobic media and observed for at least two weeks.

(12) Because the results of these cultures are not finalized for weeks after surgery, patients are placed on antibiotics after revision surgery until the culture results are known.

(13) In rare cases if an infection is diagnosed soon after the primary arthroplasty, consideration can be given to debridement and irrigation with retention of the implants and antibiotic therapy after surgery. This may be an option for patients with cemented implants and patients who may not be sufficiently healthy for a major revision.

(14) In cases with a stealth presentation of pain and stiffness after a "honeymoon" period of routine post-arthroplasty recovery, consideration is often given to a single stage exchange with vigorous debridement and postoperative antibiotics until the culture results are finalized.

(15) In cases of obvious infection (redness, tenderness, swelling, drainage, elevated inflammatory markers, or wound drainage) and in cases of failed single stage revision, a two-stage revision can be considered (stage 1: implant removal, cultures, irrigation, implantation of an antibiotic-containing spacer, post operative antibiotics; when evidence of infection no longer present=>stage 2: repeat debridement, cultures, definitive implant insertion, and postoperative antibiotics).

(16) Two stage revisions are more costly and complication-prone than single stage revisions

(17) With either single stage or the second of a two-stage, it is possible that a re-revision may be necessary - this possibility should be considered in selecting how the implants are fixed in the bone.

(20) With respect to post operative antibiotics: (a) in most cases, oral antibiotics seem to be as cost-effective as IV antibiotics and (b) at least six weeks of antibiotics are recommended if >2 of the deep specimens are culture positive for the same organism. Prolonged antibiotic therapy is considered in cases where recurrent infection is more likely.

Use search box (upper right of this page) to find more posts on these topics

 
Here are a few recent articles that may be of interest.

Prevention

Does preoperative corticosteroid injection increase the risk of periprosthetic joint infection after reverse shoulder arthroplasty? reported a significantly increased risk of PJI in patients who received corticosteroid injections (CJI) within 1 month of reverse total shoulder, but not those who received CSI more than 1 month before RSA. Alcohol abuse, chronic kidney disease, and depression were also identified as factors increasing the risk of PJI.

The authors of Effect of supplemental testosterone use on shoulder arthroplasty infection rates concluded that testosterone use within 6 months of shoulder arthroplasty may be associated with higher rates of prosthesis joint infection. 

Photodynamic therapy for Cutibacterium acnes decolonization of the shoulder dermis found that the use of photodynamic therapy did not significantly reduce dermal colonization of Cutibacterium (as determined by punch biopsy cultures) as compared to standard skin preparation. The overall positive culture rate was 54%. All positive cultures identified Cutibacterium except for one.

Effect of Making Skin Incision with Electrocautery on Positive Cutibacterium acnes Culture Rates in Shoulder Arthroplasty: A Prospective Randomized Clinical Trial discovered that cultures obtained from the incised dermal edge immediately after skin incision were less likely to be positive if electrocautery was used in making the skin incision. However, there was no significant difference in the positive culture rate in samples from gloves and forceps taken immediately prior to humeral component implantation. Thus, use of cautery did not reduce the rate of wound innoculation.

Betadine and topical vancomycin may be of value in reducing the rate of periprosthetic infection.[Vancomycin powder embedded in collagen sponge decreases the rate of prosthetic shoulder infection] [Dilute povidone-iodine irrigation reduces the rate of periprosthetic joint infection following hip and knee arthroplasty: an analysis of 31,331 cases][A systematic review and meta-analysis comparing intrawound vancomycin powder and povidone iodine lavage in the prevention of periprosthetic joint infection of hip and knee arthroplasties][Systematic review and meta-analysis of intrawound vancomycin in total hip and total knee arthroplasty: a continued call for a prospective randomized trial.]

Bariatric surgery performed with the goal of reducing body mass is associated with higher risks of PJI, implant failure, and dislocation, especially if the arthroplasty is performed within two years of the bariatric surgery. [Prior bariatric surgery is associated with an increased rate of complications after primary shoulder arthroplasty independent of body mass index] [Does bariatric surgery prior to primary total knee arthroplasty improve outcomes?][Does Bariatric Surgery Prior to Primary Total Hip Arthroplasty Really Improve Outcomes?]

Diagnosis

The Incidence of Subclinical Infection in Patients Undergoing Revision Shoulder Stabilization Surgery: A Retrospective Chart Review twenty-nine (27%) of 107 patients having revision surgery had positive cultures. Twenty-six patients had positive Cutibacterium cultures; these cultures took an average of 10.65 days to turn positive. The authors suggest that surgeons consider infection as a reason for lack of clinical improvement and possibly needing revision surgery after shoulder stabilization. 

In The role of sonication in the diagnosis of periprosthetic joint infection in total shoulder arthroplasty the standard synovial fluid cultures combined with intraoperative periprosthetic tissue cultures had a sensitivity of 95%, specificity of 95% and total accuracy of 95%. Sonication cultures had a sensitivity of 91%, specificity of 68% and total accuracy of 80%. 

Treatment

Outcomes after Debridement, Antibiotics, and Implant Retention for Prosthetic Joint Infection in Shoulder Arthroplasty found that 29.4% of thee patients were diagnosed as having recurrent infection on chart review.

High infection control rate after systematic one-stage procedure for shoulder arthroplasty chronic infection found that 36/40 patients had no recurrence of infection after the one stage revision. Cutibacterium was the most frequent pathogen isolated, found in 67.5% (27/40) of the patients. The infection was polymicrobial in 40% (16/40) of the cases.

One-stage revision for infected shoulder arthroplasty: prospective, observational study of 37 patients found that 95% did not have evidence of recurrent infection. The most commonly isolated pathogen was Cutibacterium acnes (68%), isolated alone (15 patients, 41%) or as polymicrobial infections (10 patients, 27%). 

Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis found that when implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.

Comment: It is apparent that the experience in the diagnosis and treatment hip and knee PJI cannot be directly applied to the shoulder because of the difference in causative bacteria. 

The diagnosis of shoulder PJI is complicated by the relative frequency of Cutibacterium as the infecting bacteria. Another confunder is the difficulty in differentiating between osteolysis due to particles from polyethylene failure and osteolysis fron PJI. See Loose glenoid component - is the shoulder infected?

Determing the success rates for different treatments of periprosthetic shoulder infections is difficult to assess. Many of the publications reporting different therapeutic approaches lack appropriate controls and clear measures of treatment effectiveness.

 Often shoulders continue to be painful and stiff after a revision procedure. Because clinical symptoms, signs and lab tests are insensitive to the presence of Cutibacterium, the diagnosis of recurrent infection may be overlooked unless a re-revision with intraoperative cultures is performed. The lack of a re-revision procedure is not proof that an infection has been resolved. Alternatively, re-revision may be indicated for non-infectious issues and does not necessarily indicate failure of the treatment of infection. 

Considering all of the above, an approach to the management of the failed arthroplasty is to consider the possibility of infection unless another cause of failure is evident.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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).

Povidone-iodine irrigation in shoulder surgery - is it safe? is it effective in reducing the load of Cutibacterium?

Subcutaneous tissue disinfection significantly reduces C. acnes burden in primary open shoulder surgery

These authors used a 2-arm randomized, single blinded clinical trial to investigate the effectiveness of treating the subcutaneous tissue with povisdone-iodine (Betadine) in reducing the Cutibacterium culture rate in primary open shoulder surgery performed through a deltopectoral approach. 108 patients were enrolled in two groups (70 treatment vs 38 control).

The procedures included 32 open reductions and internal fixations, 67 total shoulder prostheses, and 9 shoulder stabilizations using an open Latarjet procedure.

A skin swab was taken for culture prior to standard surgical skin preparation. 

After exposure of the deltoid fascia, the treatment group received preparation of the subcutaneous layer with povidone-iodine solution. 

Once the proximal humerus was completely exposed, 5 swabs from different sites were taken for culture. 

The subcutaneous Betadine treatment significantly reduced the positive culture rate of the operating field for all bacteria combined (p = 0.036) and specifically for Cutibacterium (p = 0.013). 

The reduction of positive swabs for Cutibacterium was significant for the surgeon's gloves (p = 0.041) as well as for the retractors (p = 0.007).

37% of the control group and 19% of the treatment group showed at least 1 positive culture (any bacteria) for the deep cultures (RR=0.50, p = 0.036).

26% of the control group and 9% in the intervention group were deep culture positive for Cutibacterium (RR=0.33, p = 0.013)

The percentages of the different bacteria in the cultures in the control group

showed a greater prevalence of Cutibacterium (acnes and avidum) than in the treatment group

The percentage of Cutibacterium positive swabs was lower for the treatment group for all cultures except the "outside scalpel blade, which was used prior to the treatment with Betadine. 

Comment: While this study appears to provide some support for the use of povidone-iodine in shoulder surgery, further clinical research is needed to define the benefit and the risks of this treatment. See, for example, these two articles from the hip and knee arthroplasty literature.

Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty An Analysis of 11,738 Cases

These authors identified 5,534 primary THA and 6,204 primary TKA procedures. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% Betadine prior to closure. Betadine irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases.

The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score.

Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty An Analysis of 2,884 Cases 

These authors assessed the effectiveness of Betadine irrigation in reducing infection following revision total hips (THA) and and total knees (TKA).  Betadine lavage was employed in 27% of the revision THA cases and 34% of the revision TKA cases

After adjusting for baseline differences between the groups using the propensity-score weighted models, they found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received Betadine lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA. 

They noted a trend toward higher rates for reoperation for infection among patients who received PI irrigation.

===

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

===
How you can support research in shoulder surgery Click on this link.

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Do antibiotics in irrigation fluid actually kill bacteria and do they kill host cells?

Polymyxin and Bacitracin in the Irrigation Solution Provide No Benefit for Bacterial Killing in Vitro

These authors compares the antimicrobial efficacy and cytotoxicity of an irrigation solution containing polymyxin-bacitracin with other commonly used irrigation solutions in vitro.

They exposed Staphylococcus aureus and Escherichia coli to irrigation solutions containing topical antibiotics (500,000-U/L polymyxin and 50,000-U/L bacitracin; 1-g/L vancomycin; or 80-mg/L gentamicin), as well as commonly used irrigation solutions (saline solution 0.9%; povidone-iodine 0.3%; chlorhexidine 0.05%; Castile soap 0.45%; and sodium hypochlorite 0.125%). Following 1 and 3 minutes of exposure, surviving bacteria were manually counted. Failure to eradicate all bacteria in any of the 3 replicates was considered not effective for that respective solution. 

Cytotoxicity analysis in human fibroblasts, osteoblasts, and chondrocytes exposed to the irrigation solutions was performed by visualization of cell structure and was quantified by lactate dehydrogenase (LDH) activity. Efficacy and cytotoxicity were assessed in triplicate experiments, with generalized linear mixed models.

Polymyxin-bacitracin, saline solution, and Castile soap at both exposure times were not effective at eradicating S. aureus or E. coli. In contrast, povidone-iodine, chlorhexidine, and sodiumhypochlorite irrigation were effective against both S. aureus and E. coli. Vancomycin irrigation was effective against S. aureus but not against E. coli, whereas gentamicin irrigation showed partial efficacy against E. coli but none against S. aureus. 

Within fibroblasts, the greatest cytotoxicity was seen with chlorhexidine (mean 49.38%), followed by Castile soap (33.57%) and polymyxin-bacitracin (8.90%). Povidone-iodine showed the least cytotoxicity of the efficacious solutions (5.00%). Similar trends were seen at both exposure times and across fibroblasts, osteoblasts, and chondrocytes.

Conclusions: Irrigation with polymyxin-bacitracin was ineffective at eradicating these bacteria and were inferior to povidone-iodine. On the other hand, Chlorhexidine lavage conferred the greatest in vitro cytotoxicity.

The authors conclude that the addition of polymyxin-bacitracin to saline solution irrigation has little value and suggest that Povidone-iodine (Betadine) may be a more effective and safer option.

Comment: While this is not an in vivo study and while it does not test the effects of the different irrigating solutions against the organisms commonly causing shoulder periprosthetic infections (Cutibacterium, coagulase-negative Staph), these results are of interest to shoulder surgeons. First it points out that the effectiveness of various irrigation solutions cannot be assumed, but rather it needs to be tested against the organisms we commonly encounter. Secondly, it points out that irrigation solutions may have harmful effects on the cells of the patient. We note that the use of some of the irrigation solutions being marketed for the use in shoulder cases(see this link) may be called int o question by this article.

=====
To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link. Also see the essentials of the ream and run.

Prevention of infection after joint replacement - is Betadine lavage effective

We note that some shoulder arthroplasty surgeons use Betadine (Povidone Iodine, PI) lavage in an attempt to reduce the risk of infection. Two recent studies of patients having hip and knee arthroplasties fail to support this practice.

Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty An Analysis of 11,738 Cases

These authors identified 5,534 primary THA and 6,204 primary TKA procedures. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% Betadine prior to closure. Betadine irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases.

The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score.


Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty An Analysis of 2,884 Cases

These authors assessed the effectiveness of Betadine irrigation in reducing infection following revision total hips (THA) and and total knees (TKA).  Betadine lavage was employed in 27% of the revision THA cases and 34% of the revision TKA cases

After adjusting for baseline differences between the groups using the propensity-score weighted models, they found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received Betadine lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA.

They noted a trend toward higher rates for reoperation for infection among patients who received PI irrigation.

Comment: These studies do not provide support for the use of Betadine lavage in the prevention of revision for infection in primary or revision total hip and knee arthroplasty. In the discussion they provide evidence of the potential cytotoxic effects of Betadine lavage.

The authors do not provide information on the bacteria associated with reoperation for infection in these cases. 

While it is recognized that different bacteria are commonly associated with periprosthetic infections of the shoulder, this articles may prompt reconsideration of the use of Betadine lavage.
===

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'