"Can't I have a cortisone shot in my shoulder?"

Physicians and patients are often tempted to try injection of the shoulder to see if this gives pain relief. While intra articular injection of steroids (like cortisone) may be of at least temporary benefit in lessening symptoms, each injection does carry the risk of infection as emphasized in these posts
Can injection infect the shoulder with Propionibacterium?
Should the painful shoulder arthroplasty be injected with corticosteroids?
Are shoulder injections safe before shoulder joint replacement and arthroscopy?
Injection can increase the risk of infection in rotator cuff repairs
Rotator cuff repair - does injection increase the risk of infection?


The authors of Does Pre-Operative Corticosteroid Injection Increase the Risk of Periprosthetic Joint Infection After Reverse Shoulder Arthroplasty? investigated the association between the timing of corticosterioid injection (CSI) for osteoarthritis and the incidence of periprosthetic infection (PJI) of a reverse total shoulder arthroplasty using a national, all-payer database.
Their analysis demonstrated a significantly increased risk of PJI at 90 days and at one year after surgery in patients who received CSI within one month prior to RSA. While the authors state that no significant increase in PJI risk was noted for patients who received CSI more than one month before their RSA, a plot of their data suggests that the average rate of PJI remains higher for all patients having CSI prior to RSA in comparison to those not having prior CSI

Alcohol abuse, chronic kidney disease, and depression were also identified as risk factors for PJI.

The types of organisms causing PJI in this series are not specified.

Comment: The rate of PJI after RSA is high: at least one in 14 patients in this series. There is usually no rush in proceeding with these joint replacements. Infection is worth avoiding to every extent possible.

The reasons why injections increase the risk of PHI are not known. Is it
(1) contamination by the needle taking bacteria from the skin and inoculating the joint?
(2) does the injection activate bacteria that are already existing in the shoulder?
(3) does the steroid diminish host resistance to the ever present risk of infection, or
(4) some combination of these and other factors.

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

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Follow on facebook: https://www.facebook.com/frederick.matsen

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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).

Diagnosing the presence of Cutibacterium in shoulder arthroplasty: how many cultures need to be taken at revision shoulder arthroplasty?

Cutibacterium (formerly known as Propionibacterium) is the commonest organism causing shoulder periprosthetic infections (PJI). Evaluating failed arthroplasties for PJI is essential for guiding treatment. Diagnosing Cutibacterium PJI requires multiple deep tissue and explant samples, special culturing protocols and prolonged periods of observation. 

The topic of detecting Cutibacterium at revision arthroplasty was addressed by the authors of Origin of propionibacterium in surgical wounds and evidence-based approach for culturing propionibacterium from surgical sites who studied the presence of this organism on the skin and in the surgical wounds of patients who underwent revision arthroplasty for reasons other than clinically obvious infection. Specimens were cultured in broth and on aerobic and anaerobic media.

Propionibacterium grew in twenty-three of thirty cultures of specimens obtained preoperatively from the unprepared epidermis over the area where a skin incision was going to be made for a shoulder arthroplasty; males had a greater average degree of positivity than females. 

Twelve of twenty-one male subjects and zero of twenty female subjects who had cultures of dermal specimens obtained during revision shoulder arthroplasty had positive findings for Propionibacterium. 

Twelve of twenty male subjects and only one of twenty female subjects had positive deep cultures.. 

The positivity of dermal cultures for Propionibacterium was significantly associated with the positivity of deep cultures for this organism.

If Propionibacterium was present in deep tissues, it was likely that it would be recovered by culture if four different deep specimens were obtained and cultured for a minimum of seventeen days on three different media: aerobic, anaerobic, and broth.

Evaluating the presence of Cutibacterium in primary shoulder arthroplasty was explored by the authors of Minimal number of cultures needed to detect Cutibacterium Acnes in primary reverse shoulder arthroplasty. A prospective study

They studied 160 primary RSAs (128 females and 32 males, mean age 74 years), excluding patients with obvious infection or an invasive shoulder procedure in the prior 6 months. 

In 90 cases, 11 cultures were obtained.  10 cultures were obtained in the other 70 cases (culture #10 was a sterile sponge to detect false positives). To determine the minimum number of cultures needed to detect Cutibacterium

Two out of the 70 sterile sponges cultured turned out to be positive for Cutibacterium, giving a false positive rate of 2.8%.

There were 42 patients with positive cultures: 20/32 of the males (69%) and 22/128 of the females (17%).

When considering the the 23% of patients with positive deep tissue cultures, the sensitivity to detect Cutibacterium in relation to the number of specimens is shown in the chart below

Comment: The second study above demonstrates that Cutibacterium can be recovered from a subtantial percentage of patients having primary reverse total shoulder arthroplasty. This study of older predominantly female patients needs to be considered in light of the fact that younger male patients are substantially more likely to have positive deep cultures. 

It is not clear why cultures were obtained in these primary arthroplasties - was there a suspicion of infection?. It is not clear at what point in the procedure the specimens were obtained - the beginning, middle or end. And it not clear whether these patients had ipsilateral shoulder surgery prior to their reverse total shoulder. The post from earlier today (see this link) is of interest in that regard. 

While the number of positive cultures is of relevance, recent evidence indicates that the degree of positivity is of greater importance in interpreting the results of deep cultures for Cutibacterium. The authors of Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty A Study of 137 Culture-Positive Cases  reported on 137 revision shoulder arthroplasties from which a minimum of 4 specimens had been submitted for culture and at least 1 was positive for Propionibacterium. Standard microbiology procedures were used to assign a semiquantitative value (0.1, 1, 2, 3, or 4), called the Specimen Propi Value, to the amount of growth in each specimen. The sum of the Specimen Propi Values for each shoulder was defined as the Shoulder Propi Score, which was then divided by the total number of specimens to calculate the Average Shoulder Propi Score.

The number and percentage of positive specimen specific cultures of material obtained from the stem explant, head explant, glenoid explant, humeral membrane, collar membrane, other soft tissue, fluid per shoulder ranged from 1 to 6 and 14% to 100%. 

A high percentage of specimens (mean, 43%; median, 50%) from the culture-positive shoulders showed no growth. 

Only 32.6% of the fluid cultures were positive in comparison with 66.5% of the soft-tissue cultures and 55.6% of the cultures of explant specimens. 

The average Specimen Propi Value (and standard deviation) for fluid specimens (0.35 ± 0.89) was significantly lower than those for the soft-tissue (0.92 ± 1.50) and explant (0.66 ± 0.90) specimens (p < 0.001). 

The Shoulder Propi Score was significantly higher in men (3.56 ± 3.74) than in women (1.22 ± 3.11) (p < 0.001). Similarly, men had a significantly higher Average Shoulder Propi Score (0.53 ± 0.51) than women (0.19 ± 0.43) (p < 0.001).

This investigation suggests that Propionibacterium is unevenly distributed within culture-positive revised shoulders. As a result, the number of specimens and their source (explant, soft tissue, or fluid) have major influences on the culture results for a revised shoulder arthroplasty.

We have subsequently learned to identify patients at high risk for positive deep cultures at revision for failed arthroplasty: young male patients with highly positive preoperative cultures of the skin overlying the intended skin incision and having high serum levels of testosterone who develop shoulder pain and stiffness after an initial "honeymoon" period of good comfort and function. In  these patients multiple deep tissue and explant specimens are sent for culture while wound prophylaxis (Betadine lavage, topic antibiotics), prosthesis exchange, and antibiotic treatment are considered for managing a likely infection pending the results of the cultures.

When seeking Cutibcaterium at revision arthroplasty, out current practice is to take 5 deep tissue or explant specimens and culture them on aerobic, anaerobic and broth media for at least 14 days.

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).

Are the Cutibacterium present at the end of primary shoulder arthroplasty responsible for subsequent periprosthetic infection?

Are Cutibacterium acnes present at the end of primary shoulder prosthetic surgeries responsible for infection? 

Cutibacterium are commonly isolated both in superficial and deep tissues after primary shoulder arthroplasty although the clinical significance of these positive cultures is yet to be defined. 

Antibiotic prophylaxis and standard skin preparation are not universally effective in eradicating Cutibacterium in shoulder surgery. It is estimated that 20% of primary shoulder arthroplasties end with the presence of Cutibacterium both in superficial and in deep tissues.

Cutibacterium can create microcolonies and participate in the "race to the implant surface" with biofilm formation leading to arthroplasty failure months or years after.

These authors sought to investigate whether the Cutibacterium present at the end of a primary shoulder arthroplasty could be responsible for shoulder arthroplasty infection. In each of 156 patients 5 to 12 tissue samples were cultured for Cutibacterium. DNA was extracted from the Cutibacterium isolates and analyzed using whole genome sequencing (WGS). 

In twenty-seven patients (17%), Cutibacterium were present at the end of surgery. Patients were followed for a minimum of two years. None of the patients with negative cultures at the time of arthroplasty developed prosthetic joint infection.

Two of these patients developed a Cutibacterium periprosthetic shoulder infection at 6 and 4 months after the arthroplasty. Both were 75-year-olds and males, yielding an infection rate of 7.7% for male. In both patients, the only microorganism present in all cultures was the Cutibacterium. 

For the first patient, 12 cultures were obtained at the index surgery and eight of them turned to be

positive for Cutibacterium. At revision surgery, nine cultures were obtained and eight were positive for Cutibacterium. 

For the second patient, five cultures were obtained at the index surgery and only one turned to be positive for Cutibacterium. At revision surgery, seven cultures were obtained and four were positive

for Cutibacterium. 

In both patients, the same Cutibacterium strain was identified at the end of the primary surgery and during revision surgery for infection: WGS of Cutibacterium isolates from the revision surgeries were essentially identical to the isolates from the primary-surgery (99.89% similarity). 

The genomic proximity between primary-surgery and revision-surgery isolates of Cutibacterium suggests that periprosthetic shoulder infections result from preexisting bacteria in the host rather than from contamination after surgery or selection of resistant strains. 

Genotyping of multiple isolates at the time of implantation during shoulder surgery can be a means of

assessing the Cutibacterium burden inoculated at the time of surgery.

In the future, WGS will be useful in confirming whether infections are caused by a single pathogenic clone of Cutibacterium and in distinguishing infection, polyclonal infection, and contamination.

Comment: Two other interesting findings is this study are 

(1) the onset of the two infections were delayed four and six months after surgery and

(2) of the 27 patients who had positive cultures for Cutibacterium at the end of the arthroplasty surgery, only 2 were noted to have developed a periprosthetic infection. This suggests that the other 25 patients had sufficient host defenses to manage the presence of Cutibacterium in the wound without manifesting symptoms of infection.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

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

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (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).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Complications and recurrence of periprosthetic infections treated with two stage revision

 Midterm results of two-stage revision surgery for periprosthetic shoulder infection

These authors sought to determine the recurrent infection rate and clinical outcomes of two-stage revision for shoulder periprosthetic infection (PSI). 

A minimum of 5 white blood cells per high-powered field (40 times magnification) was considered diagnostic for infection.

They identified 17 patients ( Mean patient age was 64±7 years, and 65% of patients were male) that met this criterion for infection after shoulder arthroplasty who were treated with a two-stage revision and had a minimum followup of 5 years (range, 5-9 years). 

As shown below, among the 17 cases, Cutibacterium was recovered from tissue samples in 6, 5 cases had negative cultures, 2 had positive cultures for MSSA, 1 for MRSA, and 1 each for enterococcus, pseudomonas, and peptostreptococcus. 

The mean time from the involved arthroplasty to first stage revision was 40 months. 

All patients were revised to a reverse shoulder arthroplasty at the second-stage revision. 

All patients were treated with culture-specific antibiotics chosen in consultation with an infectious disease specialist, and treatment was individualized according to the virulence of the organism and  general health and immunity of the patient.

The decision to re-revise for reinfection was based on various factors, including chronic, recurrent pain, wound drainage, elevated ESR and CRP, loosening of humeral or glenoid components, elevated synovial cell counts on aspiration, and positive cultures at second-stage revision or subsequent aspiration. A recurrent infection was diagnosed in 3 (18%) of the 17 patients. The cumulative incidence of recurrence of infection was 0% at 1 year, 6% at 2 years, and 18% at 5 years. There were 6 (36%) other complications, including 4 periprosthetic fractures, 1 spacer fracture, and 1 dislocation. 

At latest followup, patients who did not have recurrent infection had a statistically and clinically meaningful improvement from preoperative to postoperative PROs, including VAS for pain, ASES score, SST score, and WOOS score, and active ROM, including abduction and forward flexion. 

Comment: This paper demonstrates the challenges in diagnosing and managing shoulder periprosthetic infections. Here are of few:

(1) It is recognized that Cutibacterium is the most common causative organism for shoulder PJI, yet the presentation of PJI from this organism is often subtle and delayed with non-specific symptoms of pain and stiffness. Many of these cases may escape diagnosis either because a revision is not performed or because adequate sampling and culturing of deep tissue and explant specimens is not performed at revision. The stealth presentation of Cutibacterium PJI also creates a problem when evaluating the outcome of treatment for PJI. While a failure can be diagnosed if multiple cultures from a re-revision are positive, it is difficult to define a successful revision (note that in this paper the incidence of diagnosed infection increased by 300% between the second and the fifth year after the first revision - when is the patient "out of the woods"?). 

(2) The post-revision treatment included "culture-specific antibiotics", however the outcome of cultures for Cutibacterium are not final until weeks after surgery; furthermore almost 1/3 of the cases had negative cultures. Thus the immediate postoperative antibiotic management cannot be based on culture results.

(3) It is not known how many patients planned for a two-stage revision did not proceed with the second stage. In this report three patients had a "permanent" spacer placed.

(4) While all the patients in this series were treated with two-stage revision to reverse total shoulder, the simpler and safer single stage revision to a hemiarthroplasty has been demonstrated to be effective in those cases of Cutibacterium PJI without a draining sinus (see this link and this link).

(5) What about "culture negative 'infections'"? The one case example presented in this paper showed high placement of the humeral component with rocking horse loosening of the glenoid component (see below).  

The culture results for this case are not presented. If this case was "culture negative" it might have been a case of detritic synovitis rather than infection, as described below.

Detritic synovitis can mimic a Propionibacterium periprosthetic infection This paper illustrates that the clinical findings of detritic synovitis (the macrophage reaction to polyethylene, cement or metal debris) complicating a total shoulder arthroplasty can strongly resemble those of a ‘stealth’ periprosthetic shoulder infection with a low-virulence organism such as Cutibacterium, including a clinical presentation long after the index procedure. At present, the important differentiation between these two etiologies can only be ascertained by awaiting the results of cultures obtained at the time of revision surgery. The surgical and antibiotic treatment decisions must be made before the culture results become available.

A 76-year-old right hand dominant man presented with right shoulder pain and decreased range of motion. He had a history of bilateral total shoulder arthroplasties, his left 15 years prior and his right 14 years prior to his visit with us. Following his index surgeries he initially did well with full painless range of motion and was able to return to full activities. Eleven years after his right arthroplasty he experienced the insidious onset of worsening shoulder pain and stiffness with no known injury. He also noted painful catching and locking in his shoulder joint with certain shoulder movements. His symptoms were unresponsive to non-operative treatment, including exercises, anti-inflammatory medications and a corticosteroid injection. His left shoulder had some stiffness but was otherwise asymptomatic. The CBC, sedimentation rate and C-reactive protein were all normal.

Physical examination demonstrated a well-healed surgical scar with no erythema, drainage or evidence of infection. Both active and passive ranges of motion were decreased. There was palpable crepitus on range of motion. Rotator cuff strength was intact, as was neurologic function of the affected extremity. Radiographs demonstrated a thinned glenoid component with surrounding osteolysis, appearing grossly loose. The humeral component was well positioned with surrounding osteolysis of the medial and lateral proximal humeral bone. There were no radiolucencies around the distal stem and the prosthesis did not appear grossly loose.

                           

The patient was advised to have a revision shoulder arthroplasty to manage his symptoms and loose glenoid component. Because of the high index of suspicion of an infection, the plan included a one-stage revision to hemiarthroplasty followed by a course of intravenous antibiotic therapy until culture results were finalized. At the time of revision surgery, perioperative antibiotics were held until tissue cultures were obtained. There was abundant scar tissue surrounding the shoulder. A synovial fluid aspiration prior to capsulotomy showed grossly cloudy fluid with a negative gram stain, with no polymorphonuclear cells or organisms seen.  

There was diffuse membranous tissue around both the humeral and glenoid components.  There was osteolysis of the proximal humerus, but the humeral component was securely fixed ; it was removed without complication.  The glenoid component was grossly loose and easily removed.  There was significant wear of the glenoid polyethylene and osteolysis of the underlying glenoid bone.  The rotator cuff was intact.

 A total of 8 samples for culture were taken from various locations within the glenohumeral joint, including the glenoid membrane, collar membrane between the modular humeral head and stem, humeral canal membrane, bursa, glenoid explant, and stem explant.  Due to preoperative and intraoperative concerns of infection, including cloudy fluid, abundant membrane, glenoid loosening and osteolysis, the patient was treated with a one-stage revision consisting of removal of the loose glenoid and single stage exchange of the humeral component using Vancomycin soaked cancellous allograft to secure the stem by impaction grafting.  The remaining glenoid bone was smoothed, no bone graft was added, and no glenoid component was reimplanted.  Cultures were grown on four types of media: blood agar, chocolate agar, Brucella agar and brain-heart infusion broth as previously published. Postoperatively the patient was placed on IV Ceftriaxone 2g daily and Vancomycin 1g daily via PICC line.  The Vancomycin was discontinued after 2 days when the cultures failed to grow MecA CoNS.  All cultures were negative at 21 days at which time all antibiotics were discontinued.  Permanent pathology of the deep tissues identified fibrotic tissue with chronic inflammation, the absence of neutrophils, and a foreign body giant cell reaction consistent with detritic synovitis

After surgery, he was placed on the standard post arthroplasty rehabilitation program focusing on range of motion in the first six weeks, followed by progressive anterior deltoid strengthening. At his six-month follow up visit, the patient was recovering well with no complaints of pain. His Simple Shoulder Test had improved from 5 out of 12 prior to his revision to 10 of 12, and radiographs showed a well-fixed humeral component.

   

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

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 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).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

Antibiotic protocol after revision shoulder arthroplasty

The Journal of Bone and Joint Surgery has provided this useful summary of a recent article on antibiotics after revision arthroplasty (see this link).

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

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

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