Single stage or two stage revision for suspected arthroplasty infection? What is the Paused Single Stage?

Here is a presentation from a recent course at the meeting of the American Shoulder and Elbow Surgeons that addresses some commonly asked questions.

What about the case in which  complete removal of all metal and cement would jeopardize the integrity of the humerus and long term function? Inspired by Dr. Hatzidakis and Jason Hsu we consider the Paused Single Stage (PaSS) as shown in this case.

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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). 

 

Recurrent infection after two-stage revision arthroplasty

We prefer to treat suspected periprosthetic shoulder infections with a single stage revision: thorough debridement, antibiotic/Betadine irrigation, topical antibiotics, complete exchange of implants, and a course of postoperative antibiotics. Two stage revision is usually reserved for cases of draining sinus, infection with particularly virulent organisms, or failed prior single stage revision. Completion of a two stage procedure requires (a) removal of implants and insertion of a spacer at the first stage and (b) insertion of new implants at a second procedure. Not only does the two stage require two surgeries, it also subjects the patient to increased challenges of spacer fixation/removal and challenges of fixation of the final implants. A substantial percentage of patients planned for a two stage never end out having the second stage completed.

Evaluating whether a revision surgery has failed to eliminate an infection is a problem because the only sure evidence of a failed revision for infection is evidence that the organism cultured at the first stage persists in the shoulder. This evidence can come from cultures obtained at the second stage (or a joint aspirate, arthroscopic biopsy, or draining sinus) that are positive for the original causative organism. 

Because the organisms that are most commonly isolated from failed shoulder arthroplasties tend to form biofilms on implants, it is preferable to remove all metal and plastic components and cement when performing a revision for suspected periprosthetic shoulder infection. However, complete removal of cement and retained fragments of broken hardware can be not only difficult, but also hazardous, risking the integrity of bone and the surrounding neurovascular structures.

Against this background, let's look at a recent article Does retained cement or hardware during 2-stage revision shoulder arthroplasty for infection increase the risk of recurrent infection? that compared the rates of repeat infection after 2-stage revision for PJI in patients who had retained cement or hardware compared to those who had complete removal. The authors retrospectively analyzed two-stage revision total shoulder arthroplasties (TSAs) performed for infection with minimum two-year follow-up. Postoperative radiographs after the first-stage were reviewed to evaluate for retained cement or hardware. Repeat infection was defined as either ≥2 positive cultures at the time of the second-stage with the same organism that was cultured during the first-stage revision or repeat surgery for infection after the two-stage revision in patients that met the ICM criteria for probable or definite infection. 

Thirty-seven patients were included in the analysis. Stage one revision failed to resolve the periprosthetic infection in ten patients (27%). The authors found that the risk of recurrent infection was not associated with age, BMI, comorbidity index, patient, sex, or presence of diabetes. 

Only two of the 10 (20%) of the cases of recurrent infection were culture positive for Cutibacterium at the index surgery, while 16 of the 27 (59%) of the cases without recurrent infection were culture positive for Cutibacterium at the index surgery. 70% of the recurrent infections were due to Staph Aureus or were polymicrobial.

Six patients had retained cement and one patient had two retained broken glenoid baseplate screws after first-stage revision.  All retained cement identified in this study was distal to the humeral stem

Of the ten cases of recurrent infection, one case involved retained cement/hardware. 

The authors point out that surgeons must balance the potential benefit of complete cement/hardware removal against the risks.

Comment: It is interesting that while 1 of 7 patients with retained cement or hardware were documented has having recurrent infection, 9 of 30 patients without retained cement or hardware had recurrent infection. Thus we must wonder why the initial surgery failed to achieve its objective of successful infection resolution in these 9 cases of complete cement and hardware removal. The pie graphs shown above suggest that a determinant of the percentage of success in resolving the infection at the first stage may be whether the infection was due to Cutibacterium (lower risk of failure) versus Staph aureus or polymicrobial (higher risk of failure). Not assessed in this study are the possible effects on infection recurrence of adjunctive measures at the first stage procedure, such as antibiotic and Betadine irrigation, topical antibiotics, and postoperative antibiotic choice, route of administration and duration.

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/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
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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 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
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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).

Revision for infection - one stage or two stage?

Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty

These authors reviewed 50 shoulders having a two stage revision of a periprosthetic shoulder joint infection between 1980 and 2010:  10 hemiarthroplasties, 24 anatomic total shoulder arthroplasties, and 1 reverse total shoulder arthroplasty.

Persistent infection, defined as positive cultures in samples obtained at the time of reimplantation, was identified in 5 shoulders (15%); 50% of persistent infections grew Propionibacterium acnes. Reoperation for "aseptic" glenoid loosening was performed in 2 additional shoulders. 

There was an overall rate of unsatisfactory results approaching 40%. 

Comment: The management of a failed shoulder arthroplasty with a possible infection requires careful thought on how the shoulder is evaluated and how it is managed before the results of cultures taken at surgery are finalized. The approach in the article referenced above should be contrasted to that used in the article posted here:

Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium

These authors point out that cultures taken at the time of revision shoulder arthroplasty are often positive for Propionibacterium.  They tested the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive.

Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.

Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.

After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.

The patient self-assessed functional outcomes for those shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group).

Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.

The culture-positive group were 89% male with a mean age of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement. 

The control group were 39% male with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement. 

Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive. 

The authors concluded that the clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases. 

Fourteen patients reported side effects to antibiotics, indication that patients should be educated with regard to potential antibiotic side effects.

While a two-stage revision may be indicated for the 'obvious' infections, this article suggests that a single stage revision may be sufficient for the management of 'stealth' presentations.

This article carefully distinguishes between (a) the 'obvious' presentation of a shoulder infection with findings such as abnormal blood tests (WBC, ESR, C-reactive protein), erythema, fever, and/or wound drainage from (b) the 'stealth' presentation in which none of these findings are present in shoulder arthroplasties revised for pain, stiffness or component loosening combined with cultures positive for organisms such as Propionibacterium. While in the past some have referred to the second group of  cases as "unexpected positive cultures in revision shoulder arthroplasty", it is now preferable simply to report the clinical findings (i.e. is there obvious clinical evidence of infection?), the number of specimens, and the culture results. Furthermore, since it is not currently possible to distinguish "true infections", "contamination", "false-positive cultures", "non-pathogenic Propionibacterium growth", it is preferable to avoid these terms and, again, reporting the clinical findings, the number of specimens, and the culture results. As pointed out below, rather than referring to a culture result as 'positive' or 'negative' it is preferable to report the load of the organism in the specimens

Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty
A Study of 137 Culture-Positive Cases

There has been a tendency in the recent literature to report cultures obtained at revision shoulder arthroplasty as being 'positive' or 'negative' or to assign revised shoulders to arbitrarily defined categories, in some cases distinguished by a single culture result (see below).

These authors took a different approach, one that considered the semi-quantitative results of all the cultures obtained from a revised shoulder - the 'load' of bacteria recovered from the shoulder using a defined culturing protocol.

They studied 137 revision shoulder arthroplasties from which a minimum of 4 specimens had been submitted for culture and that had 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.

They found that 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, or other) 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. These observations indicate that Propionibacterium are not evenly distributed through the tissues and implants of a failed shoulder arthroplasty so that more than a few samples are necessary to detect the presence of bacteria.

Another interesting finding was that the type of specimen submitted for culture affected the likelihood of culture positivity. 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). This finding provides a possible explanation for the limited utility of a culture-negative joint fluid aspiration in ruling out an infection.

A third intestine finding was the inter-sex difference in Propionibacterium load recovered from revised shoulders. 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).

Finally. the authors found that the percent of cultures positive for Propionibacterium varied widely among the cases with no apparent 'threshold' that could be used to distinguish 'definite infection' from 'probable infection' or 'probable contaminant' (see below).

This study provides an approach for standardizing:
(1) the harvesting of specimens = five samples of explants or tissue
(2) the culturing of specimens = aerobic and anaerobic media
(3) the period of observation = at least 17 days
(4) the reporting of culture results = Specimen Propi Value, Shoulder Propi Score and Average Shoulder Propi Score.

Such standardization and objective presentation of the results may facilitate comparison among investigators with respect to the characteristics of revised shoulder arthroplasties and the effectiveness of different surgical and medical approaches to their management.

An informed commentary on this article can be found at "The Emperor May Truly Have New Clothes" J Bone Joint Surg Am, 2017 Jan 18; 99 (2): e7 . https://doi.org/10.2106/JBJS.16.01148

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The reader may also be interested in these posts:

Healing through joint replacement

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, 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.

Two stage revision shoulder arthroplasty – how often do we get to stage 2?

A paper entitled "STAGE 1 SHOULDER ARTHROPLASTY: RISK FACTORS FOR REPEAT STAGE 1, SPACER RETENTION AND MORTALITY" was presented at the 2017 open meeting of the American Shoulder and Elbow Surgeons (see this link).

These authors sought to provide the perspective from a national Medicare database on the the outcomes at one year following stage 1 shoulder arthroplasty revision for patients who underwent removal of an infected shoulder prosthesis and placement of an antibiotic spacer.

975 patients who underwent shoulder arthroplasty prosthesis removal and cement spacer placement for infection met all inclusion and exclusion criteria. Within 1 year postoperatively, 21 patients died (2.2%), 70 patients had a repeat stage I procedure (7.2%), 55 patients had a girdlestone-type procedure (5.6%), 349 patients retained their spacers (35.8%) and the remaining 480 patients had a shoulder arthroplasty re-implanted (49.2%)

Independent risk factors for death within 1 year following stage 1 revision included older age, alcohol use, coronary artery disease (CAD) and hemodialysis

Independent risk factors for repeat Stage 1 revision include younger age, morbid obesity, diabetes mellitus and coronary artery disease. 

Independent risk factors for no re-implantation within one year include female gender, older age, tobacco use, alcohol use and inflammatory arthritis.

Only half of patients underwent re-implantation. 

One third of patients retained their spacer and just less than 10% repeated a stage 1 procedure.

Comment: We surely look forward to the publication of the full paper that would include the details of the type of infection and the condition of the shoulder. However, this abstract does indicate that a two stage revision is not always completed, leaving the patient with either a spacer or a resection arthroplasty.


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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

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, 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.

Infected shoulder replacements - how should they be treated?

Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty

These authors report their results with two-stage implantation for deep periprosthetic infections in 35 shoulders (10 hemiarthroplasties, 24 anatomic total shoulder arthroplasties,1 reverse total shoulder arthroplasty).

Preoperative testing showed leukocytosis in 1 patient, elevated C-reactive protein concentration in 67%, elevated erythrocyte sedimentation rate in 61%, and positive preoperative aspiration in 69%.

At most recent follow-up (4.1 years) the patient had significant improvements in pain (from 4.4 to 2 on a 5-point scale; P < .0001), mean forward elevation (64°-118°; P < .0001), and mean external rotation (14°-41°; P < .0001).

Persistent infection, defined as positive cultures in samples obtained at the time of reimplantation, was identified in 5 shoulders (15%); 50% of persistent infections grew Propionibacterium acnes.

Reoperations for infection included irrigation and débridement (1), a second 2-stage reimplantation (2), and resection arthroplasty (1); 2 additional patients were treated with chronic suppression. Reoperation for aseptic glenoid loosening was performed in 2 additional shoulders.

There was an overall rate of unsatisfactory results approaching 40%.

Comment: Reports of treatment of periprosthetic infections are complicated by (1) the lack of a useful definition of "periprosthetic infection" that includes both obvious presentations (drainage, erythema, elevated white blood counts, sedimentation rate, C-reactive protein) and stealth presentation (no clinical or blood lab evidence of infection, but substantially positive cultures of deep tissues obtained at revision arthroplasty) and (2) the well documented observation that clinical manifestations of infection can present years after a shoulder arthroplasty (so that the 'success' of treatment can be difficult to determine).

Because of the added morbidity of a two-stage approach to a suspected infection, we reserve the two-stage for cases of obvious infection that present, for example, with wound drainage, elevated serum markers of systemic inflammation (CBC, Sed Rate, C-repactive protein), and bacteria other than Propionibacterium and coagulase negative staph. In the remaining cases we prefer a single-stage revision as reported here:

Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium

These authors point out that cultures taken at the tim of revision shoulder arthroplasty are often positive for Propionibacterium.  They tested the hypothesis that the functional outcomes of revising Propionibacterium culture-positive failed arthroplasties with a single-stage revision and immediate antibiotic therapy are not inferior to the clinical outcomes of revising failed shoulder arthroplasties that are not culture-positive.

Fifty-five shoulders without obvious clinical evidence of infection had a single-stage revision arthroplasty. Specifically all components (humeral and glenoid) were removed, a thorough debridement was carried out and a new humeral hemiarthroplasty was inserted with Vancomycin impregnated allograft. The residual glenoid bone was smoothed, but not bone grafted. No glenoid components were replaced.

Preoperative antibiotics were withheld until culture specimens were taken; a minimum of 5 tissue or explant specimens were obtained from each shoulder. Specimens were cultured for 21 days on blood agar (trypticase soy agar with 5% sheep blood), chocolate agar, Brucella agar (with blood, hemin, and vitamin K), and brain-heart infusion broth. Bacteria that were isolated received a full species-level identification by means of 16S rDNA sequencing.

After all culture specimens were obtained, 15 mg/kg of vancomycin and 2 g of ceftriaxone were administered intravenously. Patients were continued on antibiotics until the results of the cultures were finalized. Two or more cultures became positive, the infectious disease service started intravenous ceftriaxone and/or vancomycin through a PICC line with oral rifampin for 6 weeks followed by oral antibiotics in the form of amoxicillin and clavulanate or doxycycline for a minimum of 6months.

The patient self-assessed functional outcomes for those shoulders with ≥2 positive cultures for Propionibacterium (the culture-positive group) were compared with shoulders with no positive cultures or only 1 positive culture (the control group).

Below is an example of what is referred to as a 'stealth' presentation in which there were no preoperative symptoms or signs of infection, yet the cultures from revision surgery were strongly positive.

The culture-positive group were 89% male with a mean age of 63.5 ± 7.2 years. The mean Simple Shoulder Test (SST) scores for the 27 culture-positive shoulders improved from 3.2 ± 2.8 points before the surgical procedure to 7.8 ± 3.3 points at a mean follow-up of 45.8 ± 11.7 months after the surgical procedure (p < 0.001), a mean improvement of 49% of the maximum possible improvement. 

The control group were 39% male with a mean age of 67.1 ± 8.1 years. The mean SST scores for the 28 control shoulders improved from 2.6 ± 1.9 points preoperatively to 6.1 ± 3.4 points postoperatively at a mean follow-up of 49.6 ± 11.8 months (p < 0.001), a mean improvement of 37% of the maximum possible improvement. 

Subsequent procedures for persistent pain or stiffness were required in 3 patients (11%) in the culture-positive group and in 3 patients (11%) in the control group; none of the revisions were culture-positive. 

The authors concluded that the clinical outcomes after single-stage revision for Propionibacterium culture-positive shoulders were at least as good as the outcomes in revision procedures for control shoulders. Two-stage revision procedures may not be necessary in the management of these cases. 

Fourteen patients reported side effects to antibiotics, indication that patients should be educated with regard to potential antibiotic side effects.

While a two-stage revision may be indicated for the 'obvious' infections, this article suggests that a single stage revision may be sufficient for the management of 'stealth' presentations.

This article carefully distinguishes between (a) the 'obvious' presentation of a shoulder infection with findings such as abnormal blood tests (WBC, ESR, C-reactive protein), erythema, fever, and/or wound drainage from (b) the 'stealth' presentation in which none of these findings are present in shoulder arthroplasties revised for pain, stiffness or component loosening combined with cultures positive for organisms such as Propionibacterium. While in the past some have referred to the second group of  cases as "unexpected positive cultures in revision shoulder arthroplasty", it is now preferable simply to report the clinical findings (i.e. is there obvious clinical evidence of infection?), the number of specimens, and the culture results. Furthermore, since it is not currently possible to distinguish "true infections", "contamination", "false-positive cultures", "non-pathogenic Propionibacterium growth", it is preferable to avoid these terms and, again, reporting the clinical findings, the number of specimens, and the culture results.

Again it is important to recognize that each report regarding periprosthetic infections needs to grapple with the question "What is an infection of a shoulder joint replacement?" as discussed here:

What is a "periprosthetic shoulder infection"? A systematic review of two decades of publications.

These authors point out that while as many as 50% of revision shoulder arthroplasties are culture positive, a consistent, clinically useful definition of a "periprosthetic shoulder infection" is lacking. They conducted a systematic review of the published literature with respect to (1) the definition of a "periprosthetic shoulder infection", (2) the pre-operative evaluation for possible infection, and (3) the harvesting and culturing of specimens at the time of surgical revision.

They found a remarkable lack of consistency in the way different authors defined an 'infection', in the way authors evaluated patients with possible infections before surgery and in the way authors obtained and analyzed specimens obtained for culture harvested at the time of the surgical revision of failed shoulder joint replacements.

This inconsistency makes it very difficult to compare different treatment approaches to failed shoulder joint replacements, recognizing that some of them will have substantial bacteria in the joint, the presence of which may go unrecognized until the culture results are finalized at 2 to 3 weeks after surgery.

Comment: It is critically important not to combine, confuse or commingle data from "obvious infections" (i.e. those with swelling, redness, drainage, fever, chills, elevated serum markers of inflammation) where the diagnosis of infection is apparent with cases of "stealth" presentation (i.e. the unexplained onset of pain and stiffness of the shoulder after a 'honeymoon' of good function in which specimens obtained at revision surgery are strongly positive for organisms such as Propionibacterium).

Here's an example of a stealth presentation:

A 50 year old patient presented desiring a ream and run arthroplasty for severe glenohumeral arthritis





After surgery, the shoulder progressively regained comfort and function. Subsequently, however it started to become stiff and painful without obvious explanation. Eight years after his shoulder arthroplasty, the patient returned to the office with no clinical, laboratory, or radiographic evidence of infection.





A single stage revision was performed (soft tissue releases, prothesis exchange) without any evidence of inflammation, joint fluid, loosening, or osteolysis. Five explant and tissue cultures were sent. The patient was discharge on the yellow protocol (Augmentin) until the results of the cultures were final.

The culture results were
Humeral head explant: 3+ Propionibacterium
Humeral stem explant: no growth
Collar membrane: 1+ Propionibacterium
Humeral periosteum: 1+ Propionibacterium
Joint capsule: no growth

At this point the red protocol (IV ceftriaxone) was started and continued for 6 weeks followed by a 6 month course of Augmentin. The patient has a comfortable shoulder and has regained most of the lost shoulder motion.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

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, 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.

Shoulder periprosthetic infections - the costly two-stage reimplantation

The hospital cost of two-stage reimplantation for deep infection after shoulder arthroplasty

These authors suggest that in North America, two-stage reimplantation is the most common treatment strategy used for the infected shoulder arthroplasty. They sought to determine the cost of two-stage reimplantation for deep infection after shoulder arthroplasty 57 shoulders having this procedure between 2003 and 2012.

Implants placed at reimplantation included anatomic total shoulder arthroplasty (a-TSA) in 58%, reverse total shoulder arthroplasty (r-TSA) in 40%, and hemiarthroplasty (HA) in 2%. The costs of the two stage procedure were compared to those of  2953 primary shoulder arthroplasties (a-TSA in 55%, r-TSA in 28%, and HA in 17%). 

The mean hospital cost per shoulder for two-stage reimplantation was $35,824, significantly higher than for primary procedures $16,068. 

For part A (hospital services), the mean cost for two-stage reimplantation was $29,85, compared to $13,508 for primaries. 

For part B (professional costs), mean costs were $5973 versus 2560 (95% CI: 2512 to 2608) respectively.

Data on the (1) organisms treated with the two stage procedure, (2) the success of the procedure in eliminating the infection, and (3) the comfort and function of shoulders having a two stage reimplantation are not provided.

Comment: This article documents that the two procedures that comprise a two-stage reimplantation for infection are just over twice as costly as a single stage primary. This analysis does not include the facts that (1) the risks and complications of two-stage reimplantation are also higher and (2) patients may choose not to have or may expire before the second stage.

For this reason, for most cases of infection we consider a single stage exchange as explained in this link and as demonstrated in this link. The cost for a single stage procedure is not substantially different from a primary arthroplasty.  The advantages of the single stage include avoiding the risks, complications and costs of a second procedure. A two stage revision is considered for recurrent periprosthetic infections, infections with particularly virulent organisms, infections in patients with immunologic compromise, and those with draining sinuses.

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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.

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