Why use topical Vancomycin powder as infection prophylaxis in shoulder arthroplasty?

Periprosthetic infection is a serious complication of shoulder arthroplasty. The most common causative organism is Cutibacterium residing in the pilosebaceous units of the dermis overlying the shoulder. As pointed out in a recent post (see this link), these commensal organisms cannot be eradicated by skin preparation prior to making the incision for shoulder arthroplasty. The result is unavoidable contamination of the wound (see Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis). 

Whether or not this contamination results in a periprosthetic infection depends on (1) the interaction between the host and bacterium and (2) the details of the surgical procedure: the intravenous prophylactic antibiotics used, open wound time, and the composition of the implants. Other measures may help manage the contamination before it establishes a biofilm on the implants: copious irrigation, povidone-iodine lavage and topical in-wound vancomycin. The effectiveness of these measures is difficult investigate rigorously because of the relative infrequency of Cutibacterium infections, the stealthy way in which they typically present, and - in most cases - the need to obtain deep tissue or explant specimens for cultures to determine if an infection is present.

Admitting the need for more robust evidence, let us review some of the information supportive of the use of topical vancomycin in reducing the risk of Cutibacterium periprosthetic infection. 

(1) The cost is low: if 1 to 2 grams are used, the total cost per surgery would range from $10 to $40.

(2) The risk is low:  The risks of vancomycin intravenous infusion reaction are minimized with topical use. The risks of allergy, nephrotoxity and ototoxicity are low with topical administration due to the limited systemic levels.

(3) In vitro data supportive of its effectiveness

    a) 2013 Antimicrobial Susceptibility of Propionibacterium acnes Isolates from Shoulder Surgery: Cutibacterium isolates from shoulder surgery were susceptible to vancomycin.

    b) 2017 In vitro susceptibility of Propionibacterium acnes to simulated intrawound vancomycin concentrations: When administered in a fashion meant to simulate time-dependent in vivo intrawound concentrations, vancomycin exhibited bactericidal activity against P. acnes [Cutibacterium].

     c) 2022 Vancomycin is effective in preventing Cutibacterium acnes growth in a mimetic shoulder arthroplasty: Vancomycin administration effectively prevented C acnes growth in a bioartificial shoulder joint mimetic implant.

(4) Clinical data

    a) 2011 Intrawound application of vancomycin for prophylaxis in instrumented thoracolumbar fusions.   Adjunctive local application of vancomycin powder decreased the postsurgical wound infection rate with statistical significance in posterior instrumented thoracolumbar spine fusions.

    b) 2017 The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis: the prophylactic administration of local vancomycin powder during shoulder arthroplasty is a highly cost-effective practice.

    c) 2017 Intrawound Vancomycin Powder Reduces Early Prosthetic Joint Infections in Revision Hip and Knee Arthroplasty: The use of intrawound vancomycin powder was associated with a significant reduction in the overall incidence of early PJIs following joint arthroplasty, however, only the revision procedures demonstrated a significant reduction in the rate of early PJIs.

    d) 2023 Vancomycin powder embedded in collagen sponge decreases the rate of prosthetic shoulder infection: Intrawound vancomycin powder significantly reduced the rate of periprosthetic shoulder infections without any increase in local and systemic aseptic complications at a minimum follow-up of 12 months. 

    e) 2024 Prophylactic use of vancomycin powder on postoperative infection after total joint arthroplasty: This systematic review of retrospective studies found that local prophylactic use of vancomycin powder in TJA can significantly reduce the incidence of postoperative infection.

Comment: Periprosthetic infection are devastating for the patient. Many variables influence a patient's risk, including sex, age, immune defenses, medications, comborbidities, prior surgery, prior injections, skin microbiome, bacterial virulence, surgical procedure, surgical time, as well as preoperative, intraoperative and postoperative prophylactic measures. Controlling for these variables to single out the clinical effectiveness of topical vancomycin in reducing infection rate would be a statistical nightmare. Laboratory data are encouraging and have the advantage of tightly controlling the variables, but they cannot duplicate the clinical situation.

Let's keep our eyes out for more light to shine on this topic.

Comments welcome at shoulderarthritis@uw.edu

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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). 

Intraopertive periprosthetic humeral fractures - risk factors and avoidance

 Deltoid Tuberosity Index Predicts Intraoperative Fracture Risk in Shoulder Arthroplasty

These authors sought to determine if the deltoid tuberosity index (DTI), a validated tool for radiographic assessment of proximal humerus bone mineral density, correlates with risk of intraoperative humerus fracture during primary shoulder arthroplasty.

The Deltoid Tuberosity Index (DTI) is measured immediately proximal to the deltoid tuberosity (highlighted with stars). The ratio of the outer cortical diameter (A) and the endosteal diameter (B) determines the DTI.

Eighteen intraoperative humerus fractures were identified and matched with 54 nonfracture primary shoulder arthroplasty cases. The two cohorts did not significantly differ in age, sex, BMI, type of arthroplasty surgery, mean ASA score, or preoperative osteoporosis diagnosis.

The mean DTI of the fracture cohort was significantly lower than the nonfracture cohort. A DTI value less than 1.44 was significantly associated with an increased risk of intraoperative humerus fracture (OR 19.6, 95% CI 2.4-155.6, p<0.0001). 

Fractures most commonly occurred in female patients (83%), reverse shoulder arthroplasty (89%), and with use of press-fit systems (72%).

The humeral diaphysis (50%) was the most common fracture location followed by tuberosity (33%) and then metaphysis (17%). The most common mechanisms of fracture were seating of stem trial or implant (33%) and reaming of humerus (17%). Four of the fractures were not identified intraoperatively and only identified on routine postoperative imaging and thus the mechanism was not known. The majority of fractures occurred with press-fit stems (72%).

Comment: While this study may be of help in predicting patients at risk for intraopertive humeral fractures, it does not suggest how these costly fractures might be avoided - especially in high risk shoulders. From the study we learn that most of the fractures were associated with "press fit" stems. Conventional press fitting involves reaming and broaching the humerus to obtain a tight fit of the humeral implant into the bone. Both reaming and broaching involve removal of bone, which obviously weakens the humerus. 17% of the fractures occurred during reaming. An additional 33% of the fractures occurred during seating of the trial or implant into the reamed/broached bone. 22% of the fractures occurred on reduction of the humerus, most likely a consequence applying torque to the weakened bone. Almost 90% of the fractures occurred at the metaphyseal level. Almost 90% occurred with reverse total shoulders, which require more torque to reduce. 

Of course the opposite of removing bone to achieve a snug fit is adding cancellous bone harvested from the humeral head to achieve a safe press fit - a technique known as impaction grafting.

Because cancellous bone is compressible, a snug fit can safely be achieved with a thinner stem, without the risk of fracture or loosening

In addition, impaction grafting broadly distributes the prosthesis-bone contact, minimizing the risk of stress shielding.

Impaction grafting can be used for humeral fixation with the ream and run procedure (see this link), anatomic total shoulder arthroplasty (see this link), the cuff tear arthropathy arthroplasty (see this link), and the reverse total shoulder arthroplasty (see this link).

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).

Fractures during shoulder arthroplasty surgery - how might they be avoided, what is the role of short stems?

 Intraoperative Fractures in Shoulder Arthroplasty: Risk Factors and Outcomes

These authors characterized the incidence of intra-operative fracture during shoulder arthroplasty and sought to identify risk factors for these fractures using an institutional database of shoulder arthroplasties (N = 1,773; 994 anatomic, 779 reverse).

They documented twenty-one (1.2%) intra-operative fractures (20 of the humerus one of the glenoid), the majority of which (91%) occurred in reverse shoulder arthroplasties compared to anatomic procedures (overall incidence:2.5% vs 0.2%). There were 7 intra-operative fractures of the greater tuberosity (33.3%), 8 metaphyseal fractures (38.1%), and 6 diaphyseal fractures (28.5%).

This study did not assess the effect of osteopenia on fracture risk.

Fractures occurred most commonly during either stem broaching (33%) or seating (33%), and were most likely to involve the metaphysis (53%) or greater tuberosity (33%). 5 fractures occurred during revision arthroplasty while 16 fractures occurred during primary procedures (overall incidence: 3.0 vs 1.0.

Risk factors included female gender, liver disease, and the use of short stems: 95% of the humeral fractures occurred with metaphyseal-fitting short stems while only 1 (5%) occurred with diaphyseal-fitting long stems. 

Comment: This study calls attention to the risk of fracture with short humeral stems in reverse total shoulder arthroplasty. Impaction grafting of a standard stem may provide a safer approach, especially if bone quality is an issue; see this link.

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).

Osteoporosis is a common risk factor for patients having shoulder arthroplasty

Osteoporosis and Implant-Related Complications After Anatomic and Reverse Total Shoulder Arthroplasty

In a study of the 68,730 patients, these authors found that the prevalence of an osteoporosis diagnosis at the time of surgery was 14.3% for anatomic TSA patients and 26.2% of reverse TSA patients.

Anatomic TSA patients with osteoporosis experienced significantly higher rates of periprosthetic fracture (odds ratio [OR], 1.49; P = 0.017) and revision shoulder arthroplasty (OR, 1.21; P = 0.009) within 2 years of surgery compared with matched controls without osteoporosis. 

Patients in the reverse TSA group with osteoporosis also had significantly higher rates of periprosthetic fracture (OR, 1.86; P = 0.001) and revision shoulder arthroplasty (OR, 1.42; P = 0.005) within 2 years of surgery compared with matched controls.

Comment: The risk of periprosthetic fracture cannot be eliminated in patients with osteoporosis. However, the risk may be lowered by attention to fall prevention, as discussed in this link. Certain surgical techniques may be effective in making the shoulder more resistant to fracture, such as impaction grafting of the humeral stem (see this link and this link).

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

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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'

Periprosthetic fractures following short stemmed reverse total shoulder. Is shorter better?

Short Stem Reverse Total Shoulder Arthroplasty Periprosthetic Type A Fracture

These authors report a case of a periprosthetic fracture from a low energy fall 8 months after a short stemmed reverse total shoulder arthroplasty.

 It was fixed with a locking plate.

An interesting related article regarding this prosthesis

Reverse shoulder arthroplasty with a short metaphyseal humeral stem showed that of 31 patients there were three intra-operative fractures and five late traumatic periprosthetic fractures.

Comment:  The need for a tight fit of the distal end of the short stemmed prosthesis may predispose the construct to intraoperative and postoperative fracture.

See also
Short-stem uncemented reverse shoulder arthroplasty - does it offer any advantage

Shoulder arthroplasty with a mini-stem humeral implant

Short stem humeral prosthesis: the risk of stress shielding. Is shorter better?

Our canal-protecting approach to reverse total shoulder is shown in this link.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at 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 including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, reverse total shoulder patient information,  CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Humeral shaft fracture after total shoulder arthroplasty

These are the x-rays of a right shoulder three years after a total shoulder arthroplasty. The shoulder was comfortable and fully functional.

Soon after the above films were obtained, the patient sustained a 6 foot fall landing with the mid humerus on the edge of a sharp rock. We were sent these x-rays:

 

The transverse midshaft humeral fracture is seen (a 'night stick' type of fracture). It is apparent that the splint was not controlling rotation.

We removed the arm from the splint and placed the arm in an ordinary sling. Three months later the fracture was healed clinically and radiographically and the shoulder essentially back to its pre fracture status.

Comment: While some had advised revision to a long stem prosthesis, in this case simple non-surgical management was effective.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Periprosthetic fracture and management

A patient with primary osteoarthritis

Had a total shoulder arthroplasty 4 years ago

Recently the patient fell, landing on the outstretched arm. At an outside facility, the arm was placed in a plaster splint and x-rays taken with the elbow externally and internally rotated. 

The patient was referred to us for internal fixation.

The splint was removed and the arm was placed in a sling that aligned the fracture well as revealed by two views shown below taken while the arm was in the sling with the forearm across the abdomen.

 

We anticipate that this fracture will heal without surgery.

Comment: This case points out that the thorax is often the best splint for a midshaft humeral fracture. It also shows that x-ray views of a fractured arm with the distal humerus internally and externally rotated may not be a good idea. 

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Consultation for those who live a distance away from Seattle.

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'

See from which cities our patients come.

See the countries from which our readers come on this post.