Showing posts with label two stage revision. Show all posts

Saturday, June 21, 2025

What predicts the failure of a two-stage revision for periprosthetic infection?

A revision for an infected arthroplasty (PJI) is a big deal for the patient as described in Periprosthetic infection: what does my patient care about? The mental and physical toll is even greater when a two-stage revision is performed: two big procedures with an interposed period of living with a polymethylmethacrylate spacer between the two sides of the joint. The patient can be expected to ask how likely the two-stage procedure is to be successful if they go through all of that. We are not very good at making such predictions as I pointed out in Objective ignorance - a problem in predicting outcomes in climbing and in orthopaedic surgery

The authors of Isolation of Multiple Positive Cultures at Resection Arthroplasty is a Predictor of Failure Following Reimplantation studied 437 patients with chronic knee PJI of which almost one third had "culture negative infections," according to the 2013 Musculoskeletal Infection Society (MSIS) criteria. The minimum number of cultures obtained for all patients was 3 the average number of positive cultures was 2.9. The most commonly isolated organism at resection arthroplasty was coagulase-negative staphylococci, followed by coagulase-positive staphylococci, gram-negative organisms, and Streptococcus species. Of the positive cultures over 90% were soft issue samples (far outstripping the percent of positive cultures from cultures of synovial fluid and implant sonication).

Among those with postive cultures, more than one of six patients experienced treatment failure defined as either any reoperation for infection or PJI-related mortality.

Almost 96% of the patients who experienced failure following reimplantation had ≥2 positive cultures isolated at the time of resection arthroplasty in comparison to those who had successful treatment (75%) Furthermore, the presence of ≥2 positive cultures at resection was associated with an 8-fold increase in the odds of failure following the completion of a 2-stage protocol when compared with the presence of a single positive intraoperative culture (20% versus 3%).

Interestingly, of the patients with positive cultures at the time of failure over half had discordant culture results, meaning that the cultures from the second revision grew different organisms than those from the first revision. In these cases perhaps the first treatment got rid of the initially infecting bugs only to leave the door open for a second species of invader into unhealthy tissue. Thus, it seems important to take multiple intraoperative tissue samples at the second stage.

A few questions arise that I'd love some help answering:

Taken together do these data suggest that treatment failure of a two-stage revision is due to poor host resistance or to inadequate surgical and antibiotic treatment or both?

In that the average number of cultures obtained per patient was a minimum of 3, how senstive is threshold of ≥2 positive cultures to the number of samples taken?

What is the clinical importance of the observation that 75% of the patients with "successful" treatment had ≥2 positive cultures ; i.e. is ≥2 positive cultures at the time of the second procedure a clinically useful predictor of subsequent failure?

What is the best postoperative antibiotic treatment to implement after revision before the results of intraoperative cultures are finalized?

How should "culture negative infections be treated"?

Is the term "unexpectedly positive cultures" helpful, or do we treat all revisions as if they are potentially infected with intraoperative cultures, debridement and postoperative antibiotics?

Infections Are Intimidating

Black Vulture

Austin, Texas

April, 2025

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

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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).

Sunday, December 15, 2024

Revising the shoulder with a periprosthetic infection: how important is it to remove everything?

For most cases of shoulder periprosthetic infection, the single stage with complete implant exchange is the "go to" procedure.

However, in some patients with complex periprothetic infections in which complete implant exchange is difficult and risky, surgeons have competing priorities: 1. trying to cure the patient's infection or 2. trying to preserve the comfort and function of the patient's shoulder. The interesting thing about #1 is that no matter how hard we try, we can never be sure that we have removed every last bug from the shoulder and have eliminated the possibility of a recurrence down the line.

Vigorous attempts to stamp out infection may involve removal of all implants and cement, but these attempts may permanently compromise the comfort and function of the patient's shoulder. Imagine an elderly person with fragile bone and a well cemented implant who has developed drainage from her shoulder, which otherwise is functional and painless. Is she better served by complete explantation or by a washout, culture-specific antibiotics and - should she continue to drain - offering her the option of retaining her implants and managing the drainage with dressings?

The authors of Does retained cement or hardware during 2-stage revision shoulder arthroplasty for infection increase the risk of recurrent infection? sought to determine if incomplete removal of cement and hardware adversely affected the results of revision for infection.

Specifically they compared the rates of repeat infection at two years after 2-stage revision for prosthetic joint infection in 37 patients who had retained cement or hardware compared to those who had complete removal.

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 or repeat surgery for infection after the two-stage revision.

Six patients had retained cement and 1 patient had 2 retained broken glenoid baseplate screws after first-stage revision. 30 patients had no retained hardware.

10 cases had recurrent infection:

Patient demographics were not significantly associated with recurrent infection.

Of the 10 cases of recurrent infection, 1 case had retained cement/hardware while 9 had no retained cement/hardware.

Thus 1 of 7 (14%) with retained cement/hardware had a recurrent infection while 9 of 30 (30%) with no retained cement/hardware had a recurrent infection. Retained cement or hardware was not significantly associated with a repeat risk of infection.

The authors suggested that surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications.

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).

Sunday, October 20, 2024

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.

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
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).

Saturday, May 4, 2024

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
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).

Saturday, November 11, 2023

Periprosthetic infections: what we don't know.

Let's consider a case of an active male who had a ream and run procedure. His shoulder was somewhat stiff from the start. His stiffness did not resolve with therapy; he developed increasing pain. He had no fever, chills, or abnormal blood markers for infection.

Two years after his index procedure he had a single stage revision. At that time his synovial fluid showed 1000 neutrophils; two frozen section specimens had more than 10 cells per high-power field.

Postoperatively, he was placed on oral amoxicillin/clavulanate.

After surgery, eight tissue specimens each cultured positive for low levels of Cutibacterium.

So here are some clinically relevant questions:

(1) Were his pre-revision findings of stiffness and pain suggestive of a periprosthetic infection?

(2) Would a preoperative aspiration or arthroscopic biopsy have changed the management of this case?

(3) Were his surgical findings diagnostic of a periprosthetic infection?

(4) For this patient, how do the benefits and risks compare between a single stage and a two-stage revision?

(5) Postoperatively, while the culture results are pending (i.e. the organism is not yet unidentified), how do the benefits and risks compare between oral and intravenous antibiotics?

(6) Immediately after surgery (before culture results are available) what would be the antibiotic of choice?

(7) If the patient has ongoing pain and stiffness of the shoulder after his single stage revision, how will the surgeon know if there is a persisting infection?

A recent article, Periprosthetic Shoulder Infection management: one-stage should be the way - A systematic review and meta-analysis brought up more questions:

(8) "For this review, the rate of reinfection after a revision arthroplasty for a shoulder PJI was the main outcome assessed." How is a "reinfection" diagnosed? Does the definition require a re-operation to see if deep tissue specimens are culture positive (and for the same organism as was found in the index revision)? If a patient is doing poorly after a revision but does not have a re-operation, how does one know whether there is a "reinfection"?

(9) In this review, why is the complication rate for two-stage revision (21.26%) higher than that for one-stage revision (6.11%)? It may be that a shoulder having two procedures is more likely to have more complications than a shoulder having a single procedure.

(10) Why was the "reinfection rate" with a single stage (one stage) revision (1.14%) lower than that after a two-stage revision (8.81%). This gets to #7 above: how does a surgeon know if there is a "reinfection" if the shoulder is not re-operated with cultures taken at the time of re-operation. Since the complication rate was three times higher with the two-stage revisions, it seems likely that more of the two-stage revisions would have had re-operations and re-culturing.

(11) Does the organism cultured from the time of revision matter to the treatment and to the outcome? The isolated bacteria reported in the analyzed studies varied widely with respect to virulence, including Cutibacterium, Coagulase-negative Staph, Methicillin resistant Staph Aureus, E. Fecalis, Strep Viridans, and Pseudomonas. Reliable studies comparing the efficacy of different surgical and antibiotic regimens will require controlling for the infecting organism.

(12) What are the indications for a two-stage revision of a periprosthetic infection?

Comments: Some things we think we know

(1) Some perioprosthetic infections are obvious (pain, swelling, drainage, fever, chills, elevated serum inflammatory markers).

While the diagnosis of PJI may not difficult, it is still important to identify the causative organism.

(2) Many periprosthetic infections have a stealth presentation (unexplained onset of pain and stiffness after a "honeymoon" period of benign post-arthroplasty recovery).

These infections are typically caused by low virulence organisms, such as Cutibacterium. Often the diagnosis is made by obtaining specimens for culture at the time of a revision procedure performed for pain and stiffness. In that the results of these cultures are not finalized until weeks after the revision, the surgical and immediate postoperative antibiotic treatment must be decided without this information.

(3) Single stage revision with thorough debridement, prosthesis exchange and post-operative antibiotics can be effective treatment of shoulder periprosthetic infections caused by Cutibacterium. (see Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium).

(4) Two-stage revision is more morbid, has a higher complication rate and is more costly than a single stage revision, but can be considered in cases of obvious infection from a high virulence organism or when a prior single stage revision has failed.

(5) Postoperative intravenous antibiotics are more morbid, have a higher complication rate and are more costly than oral antibiotics, but can be considered in cases of obvious infection from a high virulence organism (see The Use and Adverse Effects of Oral and Intravenous Antibiotic Administration for Suspected Infection After Revision Shoulder Arthroplasty).

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

Follow on twitter: https://twitter.com/RickMatsen or https://twitter.com/shoulderarth
Follow on facebook: click on this link
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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).

Friday, October 21, 2022

Periprosthetic shoulder infections, single stage and two-stage revision

Periprosthetic joint infections (PJI) of the shoulder can be difficult to diagnose and difficult to treat. The most commonly infecting organisms are those that are commensal inhabitants of normal skin: Cutibacterium and coagulase negative Staphylococcus.

The clinical onset of a shoulder PJI can range from a "stealth" presentation (with the insidious onset of unexplained pain and stiffness months or years after the arthroplasty (see this link)) to an "obvious" presentation with swelling, erythema, component loosening and wound drainage (see this link).

The stealth presentation of a shoulder PJI

With stealth presentations, the surgeon cannot be sure at the time of surgery whether or not the pain and stiffness are due to infection or to some other cause - the final diagnosis must wait until cultures of deep specimens harvested at the time of revision are finalized several weeks after surgery. In that situation, a single stage revision - vigorous debridement, irrigation, and prosthesis exchange followed by antibiotic therapy until the culture results are finalized - provides an effective approach as demonstrated in Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium. The effectiveness of this approach is illustrated in the case presented below,

A 49 year old athletic man presented with osteoarthritis of the right shoulder, a Simple Shoulder Test score of 6 out of 12, and a type B2 glenoid with biconcavity, retroversion and posterior decentering.

Because of his active lifestyle he elected a ream and run arthroplasty. His six week postoperative films show centering of the humeral prosthesis in a concave glenoid.

Following this procedure, the patient was able to return to regular competitive swimming at the master’s level.

Five years after his index arthroplasty, he returned to the office with complaints of the insidious onset of pain and stiffness without an identified explanation (what we refer to is the "Honeymoon" phenomenon). His Simple Shoulder Test score was 3 out of 12. His CBC, sedimentation rate and C-reactive protein were all within normal limits. His radiographs showed glenoid erosion.

Six years after his index arthroplasty he had a single stage revision. At the time of his revision he was 55 years of age, ASA 2, BMI 24. The preoperative Propionibacterium cultures of his unprepared skin over the area of the prior incision were strongly positive with a EpidermalSpPV of 2. His intraoperative findings included synovitis. His revision was followed by six weeks of intravenous antibiotic treatment (Ceftriaxone) and 6 months of Augmentin. At 3 weeks after surgery his eight deep intraoperative cultures were strongly positive with a total Propionibacterium score (ShPS) of 7.4.

One year after his revision arthroplasty his Simple Shoulder Test score was 11 out of 12. His radiographs showed showed a centered humeral head with radiographic joint space between the humeral head and the glenoid.

He has returned to his regular swimming program

The obvious presentation of a shoulder PJI

In the obvious presentation of a shoulder PJI the shoulder typically shows signs of tenderness, swelling, drainage and component loosening along with laboratory evidence of inflammation in tests of serum and joint fluid and cultures positive for virulent organisms.
In this situation and in cases of failed single stage revision, surgeons often prefer a two-stage revision, with prothesis removal, debridement, irrigation and insertion of a methyl methacrylate spacer containing up to 5 grams of heat-resistant antibiotics, such as vancomycin, tobramycin and/or genatamycin in 40 grams of methyl methacrylate bone cement. The rationale for the use of these spacers is two-fold: (1) to provide ongoing local elution of antibiotics during the postoperative period and (2) to preserve the joint space for later re-implantation of a definitive arthroplasty; this is the "two-stage" approach to revision. The authors of Antibiotic Spacers for Shoulder Periprosthetic Joint Infection conducted an extensive review of the use of spacers to treat obvious periprosthetic infections of the shoulder. The sense of the literature gained from multiple relatively small case series is that the two stage approach is often effective in eradication of infection, but that the resulting shoulder comfort and function is only modest. The complications of antibiotic spacers include bone erosion, fracture of the spacer, loosening and rotation of the spacer, and humeral shaft fracture.

These authors prefer to manage obvious shoulder periprosthetic infections by fabricating shoulder spacers intraoperatively with the use of commercially available molds allowing for the creation of press-fit stems and the ability to control the antibiotic choice and concentration. After spacer implantation, patients are treated with intravenous antibiotics for 6 weeks based on culture-specific sensitivities. They then check ESR and CRP levels and do a shoulder aspiration once intravenous antibiotics have been discontinued for a minimum of 2 weeks. If serum markers remain elevated or if cultures are positive, then repeat irrigation and débridement is performed with insertion of a new spacer. If serum markers return to normal levels and aspirate cultures are negative, they proceed to the second stage of revision (insertion of a definitive arthroplasty implant) at 10 to 12 weeks after the placement of the antibiotic spacer. Five sets of intraoperative cultures are obtained at the time of reimplantation. Patients are started on oral antibiotics until these cultures finalize. If cultures are negative, then oral antibiotics are discontinued. If positive, intravenous antibiotics are restarted for a 6-week duration followed by possible lifetime suppression with oral antibiotic therapy.

It is noted that some patients elect to retain the methyl methacrylate spacer, rather than proceeding with the second of the two stage revision as shown in the example below. Spacer retention carries the risk of glenoid erosion.