Cutibacterium periprosthetic infection of the shoulder in a young man - an instructive honeymoon

An active 34 year old man presented with pain and limited function of his right shoulder and the x-rays shown below.
 

Because he wished to avoid the risks and limitations of a plastic glenoid component, elected to proceed with a ream and run procedure. 

After which he returned to full comfortable function for 13 years.

However at 14 years after his ream and run, he presented with a 9 month history of unexplained pain and stiffness of his shoulder.  His x-rays at that time were unremarkable, showing no evidence of glenoid wear, erosion, loosening or adaptive changes.

His shoulder was stiff, but not tender or swollen. His white cell count and differential, sedimentation rate, and C reactive protein were all normal. A joint aspiration was not attempted.

He elected a revision surgery with soft issue releases and head exchange. The stem was well fixed; the exposed part of the stem was scrubbed with a wire brush, but not exchanged. There was minimal joint fluid. A frozen section showed only giant cell reaction and fibrous tissue without neutrophils. Deep tissue specimens and the head explant were sent for aerobic and anaerobic culture. The wound was throughly debrided and irrigated with Betadine and saline; topical vancomycin was applied.  After his revision, he was placed on oral Doxycycline.

 

Three weeks after surgery, his culture results were finalized, documenting a periprosthetic infection:

Joint fluid: No growth

Head explant: 1+ Cutibacterium

Collar membrane: 1+ Cutibacterium

Humeral bone: 1+ Cutibacterium

Biceps tendon: 1+ Cutibacterium

His oral Doxycycline was extended for a total of 12 weeks.

He subsequently made an excellent recovery of comfort and function. 

Comment: This case is of interest for serveral reasons: (1) the appearance of a Cutibacterium PJI after a honeymoon of over a decade with excellent shoulder function leaves open the question of the source of these bacteria (were they introduced at the original surgery or did they become introduced later?). (2) the joint fluid did not grow bacteria, while all of the deep tissue and explant cultures did (suggesting that the bacteria were not planktonic, but were in biofilms on tissue and metal - a preoperative fluid aspiration would have been falsely negative). (3) the blood work and the frozen section did not suggest infection (suggesting the value of taking cultures at the time of all revisions, performing a thorough debridement and irrigation, applying topical antibiotics and keeping the patient on oral antibiotics until the results are known). (4) the well fixed stem was left in place to avoid the risk of fracture (only time will tell if the retained stem will give risk to recurrent infection).

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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).

Shoulder arthroplasty infections - they can present months or years after a post surgical 'honeymoon'

Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty.


Revisions of apparently "aseptic" shoulder arthroplasties are not infrequently culture positive for Propionibacterium, organisms that may be introduced at the time of the index surgery when the dermal sebaceous glands are transected. This report seeks to answer the question, Do surgeons performing revision shoulder arthroplasty years after the index procedure need to be concerned about the persistence of Propionibacterium?

The authors reviewed the medical records of 148 revision arthroplasties performed between July 2008 and June 2013 to find those revisions performed at least 3 years after the index procedure and at which intraoperative cultures were strongly positive for Propionibacterium.

They identified 14 cases of revision surgery performed 8 ± 4 years after the original arthroplasty for which deep cultures were strongly positive for Propionibacterium. A total of 109 specimens were obtained, 84 of which were positive. All 14 patients were male.

They concluded that shoulder arthroplasties revised for the mechanical problems of loosening or stiffness can be substantially culture positive for Propionibacterium, even if the revision is performed many years after the index procedure. Therefore, even in shoulder arthroplasties revised for mechanical problems years after the index procedures, surgeons should consider submitting multiple deep specimens for specific Propionibacterium culture. In the presence of persistent Propionibacterium, surgeons should consider the need for directed surgical and medical treatment in their management of a failed arthroplasty.

Comment: One of the features of a Propionibacterium infection in a shoulder arthroplasty is the delayed onset of stiffness and pain after a 'honeymoon' of excellent comfort and function.

Propionibacterium (P Acnes) in a shoulder arthroplasty - story with a happy ending

Seven years ago a man in his mid 60s presented with arthritis of his right shoulder

He elected to have a ream and run procedure. Cefazolin was administered preoperatively and discontinued after 24 hours.

He had excellent return of comfort and function until 18 months after his surgery when he noted discomfort around the insertion of the deltoid in the humerus. His pain was on use of the arm and not at rest.  The pain ran down the lateral arm to the area of tip of the prosthesis. His range of motion and strength are excellent. His x-rays showed excellent glenoid healing and no evidence of subsidence. There was a very small lucent zone at the tip of his prosthesis. His lab tests were unremarkable.

We preformed a revision arthroplasty with a single-stage exchange and the red protocol (see this link). Going in to surgery, we thought we were dealing with 'aseptic' loosening of the stem. However , pathology revealed a humeral membrane with greater than 5 neutrophils in at least 5 high-powered fields, with chronic inflammation and focal foreign body giant cell reaction, and another humeral membrane that showed fibrinous tissue with chronic inflammation, but only rare neutrophils. Two synovial fluid specimens were sent for analysis, including the initial fluid specimen with 15,050 white blood cells (83% neutrophils,) and 3440 red cells. The culture results were: fluid: one colony Propi,  humeral membrane 1+ Propi, stem explant 1+ Propi, and head explant 1+ Propi. After thorough debridement, a new prosthesis was inserted with Vancomycin soaked allograft.

After 5 weeks of intravenous vancomycin and oral rifampin, the antibiotics were discontinued because of neutropenia from which he recovered completely.

Recently we saw him back five years after his single stage revision. He had full function and no discomfort in his right shoulder. 

He presented to have his opposite side managed with a ream and run. This time we plan our current standard prophylaxis of Ceftriaxone and Vancomycin.

Comment: This case demonstrates the 'honeymoon' period than can be associated with Propionibacterium.

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How do revised shoulders that are culture positive for Propionibacterium differ from those that are not?

This article presents the investigation of 132 shoulders undergoing surgical revision of a prior shoulder arthroplasty, comparing the 66 that were culture positive for Propionibacterium to the 66 that did not culture out this organism.

The authors' goal was to identify preoperative and intraoperative characteristics that may alert surgeons to an increased likelihood of positive cultures. This is important because while many shoulder arthroplasties revised for pain, stiffness, or component loosening are culture positive for Propionibacterium, the results of these cultures remain unknown until days or weeks after surgery - too late to inform intraoperative surgical decisions and immediate postsurgical antibiotic treatment. 

The authors found that Propionibacterium-positive and Propionibacterium negative shoulders were similar with respect to many characteristics; however, Propionibacterium negative shoulders were revised sooner after the index procedure and were significantly more likely to be female, to have sustained a fall, to have instability, and to have rotator cuff deficiency. Propionibacterium-positive shoulders demonstrated more glenoid erosions, glenoid osteolysis, glenoid loosening, and a higher incidence of a soft tissue membrane between the humeral component and humeral endosteum. Shoulders culture positive for Propionibacterium were more likely to be culture positive for another bacteria, such as coagulase negative Staphylococcus.

A characteristic picture of Propionibacterium  infection is the onset of stiffness, pain, loosening and / or osteolysis after a 'honeymoon' of good function following a shoulder arthroplasty, especially in a male patient. Such shoulders may merit multiple deep cultures at the time of revision surgery and consideration of aggressive surgical and medical treatment.

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Click here to see the new Shoulder Arthritis Book

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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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Propionibacterium - they can't always be kept out of the shoulder arthroplasty field!

Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis


Recognizing that propionibacterium are commonly recovered from deep cultures obtained at the time of revision arthroplasty, these authors sought to determine whether deep cultures obtained at the time of primary arthroplasty could be substantially positive for Propionibacterium despite thorough skin preparation and aggressive preoperative intravenous antibiotic prophylaxis.

After timely administration of preoperative antibiotics - Ceftriaxone and Vancomyin - chosen specifically for their activity against Propionibacterium and after double skin preparation, specimens from the dermis, fascia, capsule, synovium, and glenoid tissue were sterilely harvested from 10 male patients undergoing primary shoulder arthroplasty and were submitted for culture for Propionibacterium.

Of the 50 specimens, 7 were positive for Propionibacterium: 3 in each of 2 patients and 1 in 1 patient. The specimen sources having positive anaerobic cultures were the dermis (1 of 10), fascia (2 of 10), synovium (1 of 10), and glenoid tissue (3 of 10). None of these patients had evidence of infection at the time of the arthroplasty.

The authors concluded that preoperative antibiotics and skin preparation do not always eliminate Propionibacterium from the surgical field of primary shoulder arthroplasty. The presence of these bacteria in the arthroplasty wound may pose a risk of delayed shoulder arthroplasty failure from the subtle type of periprosthetic infection typically associated with Propionibacterium.

Comment: These observations indicate that aggressive prophylaxis with systemic antibiotics and vigorous skin preparation are not always successful in eliminating Propionibacterium from the wounds of male patients undergoing shoulder arthroplasty.

This finding may encourage surgeons to assume that the surgical field may harbor these organisms - either because they were there preoperatively or because they were seeded from the hair follicles and sebaceous glands of the dermis at the time of skin incision. This realization may prompt the use of copious irrigation with antibiotic-containing saline solution and careful handling of the prostheses in an effort to minimize the number of Propionibacterium contacting the prosthesis and to reduce the risk of biofilm formation on the implants.

Patients having shoulder arthroplasty - especially males -  should be informed of the risk of delayed presentation of Propionibacterium, which may include pain, stiffness or component loosening without the usual clinical signs of infection.

We have come to recognize the "honeymoon" phenomenon - a period of initially excellent comfort and function after a shoulder arthroplasty followed by the progressive onset of stiffness and pain. When they honeymoon is over, concern for the effects of Propionibacterium rises.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'