What if my total shoulder patient says she is allergic to penicillin?

Is Patient-reported Penicillin Allergy Independently Associated with Increased Risk of Prosthetic Joint Infection After Total Joint Arthroplasty of the Hip, Knee, and Shoulder?

These authors note that patients with a self-reported penicillin allergy may be at greater risk for postoperative prosthetic joint infection (PJI) after total joint arthroplasty of the hip, knee, or shoulder. This increased risk of PJI has been attributed to these patients receiving a less-effective perioperative antibiotic. 

They asked, "are patients with a patient-reported penicillin allergy more likely to have a PJI after THA, TKA, or total shoulder arthroplasty than patients without such a reported allergy after controlling for risk factors such as BMI, anxiety, depression, and other comorbidities?"

They queried the records of 122 million patients comparing the 1-year incidence of PJI after TKA, total shoulder arthroplasty, and THA in patients with patient-reported penicillin allergy versus patients without a patient-reported penicillin allergy. 

After adjusting for potential confounding factors such as BMI, anxiety, depression and other comorbidities, they found that patient-reported penicillin allergy was independently associated with an increased odds of PJI after total shoulder arthroplasty (OR 3.9 [95% CI 2.7 to 5.4]; p < 0.01). 

The authors suspected but did not prove that this finding is a result of those patients reporting penicillin allergy receiving a second-line antibiotic for presurgical prophylaxis. Recent studies have demonstrated that 76%to 93% of patients with a patient-reported penicillin allergy receive noncephalosporin antibiotics such as clindamycin. Patients with a patient-reported pencillin allergy receiving clindamycin alone before total shoulder arthroplasty had a greater infection risk than did patients who received cefazolin alone (hazard ratio = 3.45) (see this link).

Of note is the fact that Cutibacterium, the most common cause of shoulder PJI, has variable susceptibility to the second-line antibiotics commonly used in patients with a patient-reported penicillin allergy (see link, link, link_A multi-institutional study of patients undergoing total shoulder arthroplasty demonstrated that patients with penicillin allergy receiving perioperative intravenous clindamycin had a four-times higher risk of a Cutibacterium infection compared with those receiving cefazolin (see link).

These authors suggest that in light of the observation that many patients reporting a penicillin allergy are in fact not allergic to penicillin, they suggest that surgeons consider preoperative allergy testing, such as using an intraoperative test dose, to aid in choosing the most appropriate antibiotic choice prior to shoulder arthroplasty and to amend patient medical records based on testing results. Similar to a skin test, the likelihood of anaphylaxis is low with the intraoperative test dose given the low probability of a true cephalopsorin allergy. Advantages of the intraoperative test dose are that reagents are easier to acquire than the skin test, and that the test can be performed in the relative safety of the anesthetic suite or operating room in case of adverse events.

Another factor to consider is that patients who are truly allergic to penicillin may have altered host defenses making them more susceptible to infection. It has been noted that patient allergies may be associated with inferior outcomes from shoulder arthroplasty (see link).

Our approach to total shoulder arthroplasty can be viewed by clicking here.

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To support our research to improve outcomes for patients with shoulder problems, click here.

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

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and 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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

What antibiotic prophylaxis should be used against shoulder periprosthetic infection?

At a recent journal club (thanks, Ben, for organizing), we discussed antibiotic prophylaxis for periprosthetic infections (PJI). It is known that multiple different organisms can cause PJI, but - especially in young healthy males - Cutibacterium is most commonly the culprit. We can provide a bit of an update on some of the key questions

(1) What is the best IV prophylactic antibiotic?

Cephalosporins seem superior as reported in Antibiotic Prophylaxis with Cefazolin Is Associated with Lower Shoulder Periprosthetic Joint Infection Rates Than Non-Cefazolin Alternatives. Among 7,713 shoulder arthroplasties 101were classified as having PJIs. Cutibacterium was identified in 44%, Staph aureus in 19%, Coagulase-negative staph in 12%, and Strep in 5%.

Cefazolin had been administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics (vancomycin, clindamycin, and alternative regimens were administered in 834 procedures (10.8%). 

PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered. Cefazolin administration, compared with non-cefazolin administration, was associated with a 69% reduction in all-cause PJI risk and a 78% reduction in C. acnes PJI risk. 

A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 for all-cause PJI and 2.94 for Cutibacterium PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 for all-cause PJI and 8.01 for Cutibacterium PJI. The latter may be due to the pervasive use of clindamycin as a treatment for acne - a practice that may select out clindamycin resistant Cutibacterium.

It is of interest that half of the periprosthetic infections were identified more than two years after the index arthroplasty - this complicates the analysis of antibiotic efficacy in studies with only a couple of years of followup.

(2) Is Clindamycin a good alternative for patients reporting penicillin allergy?

This question was addressed in Perioperative Clindamycin Use in Penicillin Allergic Patients Is Associated With a Higher Risk of Infection After Shoulder Arthroplasty. This study reviewed seven thousand one hundred forty primary shoulder arthroplasties comparing deep surgical site infection risk in 444 patients who received perioperative vancomycin alone or 508 receiving clindamycin alone because of penicillin allergy to 6188 patients who received cefazolin alone without penicillin allergy.

Seventy deep infections were observed; most common organism was Cutibacterium acnes (39.4%). 

Compared with patients treated with cefazolin, infection risk was not different for those treated with

vancomycin, but a higher risk of infection was identified for those treated with clindamycin alone. Thus in contrast to the first study above, these authors concluded that vancomycin is preferred over clindamycin for patients with penicillin allergy. Other studies have demonstrated that patients with multiple allergies have a poorer average prognosis after arthroplasty; one might also wonder whether patients with allergies to penicillin are more susceptible to infection independent of which antibiotic is used.

(3) How can we tell if patient-reported allergy should change the antibiotic choice?

This question was addressed in A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in “Penicillin-Allergic” Patients without the Need for Allergy Testing. These authors point out that patients who report a penicillin allergy are often given second-line antibiotic prophylaxis during total joint arthroplasty. As seen from the article above, the use of non-cephalosporin antibiotics exposes the patient to an increased risk of PJI. These authors assessed the effectiveness of a simple penicillin allergy screening program to guide the choice of antibiotic prophylaxis.

Basically patients were grouped into three groups

 "intolerance", 

"low risk allergy"

and "high risk allergy"

The "intolerance" and " low-risk"patients received cefazolin, and the high-risk cohort received non-cefazolin antibiotics.

The protocol group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol, the "control" group.

A total of 357 patients (17.2%) reported a penicillin allergy in the protocol group compared with 310 patients (14.9%) with a recorded allergy in the control group (p = 0.052). 

The number of patients who received non-cephalosporin antibiotics was significantly lower in the protocol group (5.7% compared with 15.2% in the control group; p < 0.001),whereas there was no difference in the rate of total allergic reactions.

Of the 239 low-risk patients (66.9%) in the protocol group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration. 

There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.

(4) Is there evidence that topical Vancomycin is effective against Cutibacterium?

Vancomycin is effective in preventing Cutibacterium acnes growth in a mimetic shoulder arthroplasty

Cutibacterium loves to form biofilms on titanium alloy - one of the most common materials used in shoulder arthroplasty. We recognize that in spite of all available prophylactic measures (skin prep, IV antibiotics), arthroplasty wounds are likely to be inoculated with Cutibacterium. This is especially an issue with patients at high risk (young, healthy males, with high skin surface loads of Cutibacterium and with high serum testosterone levels) as well as those patients truly allergic to cephalosporin antibiotics.

Topical vancomycin powder is a strategy for managing Cutibacterium inoculation at the time of shoulder arthroplasty. Its efficacy is difficult to test through clinical research.

These authors investigated the efficacy of vancomycin as prophylaxis for Cutibacterium growth in vitro using a mimetic shoulder arthroplasty.

Cutibacterium strains were applied to titanium alloy foil and embedded beneath multiple layers of collagen-impregnated cellulose scaffold strips containing human shoulder joint capsular fibroblasts, facilitating the development of an oxygen gradient with an anaerobic environment around the foil and inner layers. Agar plates inoculated with extracts from untreated constructs consistently resulted in the growth of large numbers of C acnes colonies

Ten milligrams of vancomycin powder was applied between the C acnes layer and the human cell–containing scaffold strips to model direct antibiotic application.

Intravenous vancomycin prophylaxis was modeled by adding vancomycin in media at 5 or 20 mg/mL. Treatments with vancomycin powder or vancomycin in media at 20-mg/mL dilution effectively prevented the recovery of any C acnes colonies. However, the lowest vancomycin dilution tested (5 mg/mL) was insufficient to prevent the recovery of C acnes colonies.

Vancomycin powder had no discernible short-term impact on shoulder capsule cell morphology, and the presence of these cells had no discernible impact on vancomycin degradation over time.

The authors concluded that topical vancomycin powder and high levels of vanancomycin in the media effectively prevented C acnes growth in a mimetic model of the shoulder arthroplasty environment. 

In our practice we use topical vancomycin powder in the medullary canal and in the wounds of shoulder arthroplasties, noting that the topical application avoids the risks and inconvenience of systematic vancomycin. 

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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).

When is it safe to give cephalosporin antibiotic prophylaxis to patients who are "allergic to penicillin"?

A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in “Penicillin-Allergic” Patients without the Need for Allergy Testing

These authors assessed the effectiveness of a simple, protocol-driven penicillin allergy screening program to predict the safety of administering cephalosporins to patients with a history of allergic reaction to penicillin.

Patients scheduled having primary total joint arthroplasty were risk-stratified into low or high-risk categories based on the criteria below:

The low-risk cohort received cefazolin, and the high-risk cohort received non-cefazolin antibiotics. 

The study group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol. 

A total of 357 patients (17.2%) reported a penicillin allergy in the study group compared with 310 patients (14.9%) with a recorded allergy in the control group. 

The allergy history of the patients in the study group is shown below

The number of patients who received non-cephalosporin antibiotics was significantly lower in the study group (5.7% compared with 15.2% in the control group).

There was no difference in the rate of total allergic reactions (0.8% compared with 0.7%.

Of the 239 low-risk patients (66.9%) in the study group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration. 

There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.

Thus the screening protocol allowed two-thirds of patients with a self-reported allergy to receive cefazolin without the need for additional consultations or testing; the overall rate of cefazolin usage

increased by 9%, to 94%, without an increase in adverse reactions.

The authors' protocol includes amending the medical record to indicate safe administration of cephalosporin as shown below

Comment: These data are of great importance to shoulder arthroplasty surgeons and their patients. Cutibacterium is the organism that causes most shoulder periprosthetic infections. Cephalosporins appear to be the antibiotic most effective against Cutibacterium. While Clindamycin is often used as prophylaxis in patients thought to be allergic to penicillin, over 25% of Cutibacterium have been found to be resistant to Clindamycin (see this link). 

As the authors point out, when tolerance of cephalosporins is observed, it is important to amend the medical record to so indicate. 

Another particularly informative article on this subject is Evaluation and Management of Penicillin Allergy A Review The abstract is reproduced below:

IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.

OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte–mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2%of cases, less than the 8%reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95%and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.

CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

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

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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)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

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

Note that author has no financial relationships with any orthopaedic companies

 

Shoulder arthroplasty - does metal sensitivity matter?

The effect of patient-reported metal allergies on the outcomes of shoulder arthroplasty


These authors sought to determine the results, complications, and failure rate among 43 patients with a self-reported metal allergy undergoing shoulder arthroplasty. Overall 1.6% of all their shoulder arthroplasty patients reported metal allergies.

Allergies reported included nickel (37), cobalt chrome (4), copper (2), zinc (1), titanium (1), gold (1), and nonspecific metal allergy (8); 8 patients reported multiple metal allergies. All components implanted in patients with nickel allergies contained nickel. At most recent follow-up, pain was rated as none or mild in 88% of shoulders. Active elevation improved from 80 to 141and external rotation from 24 to 52. Two revisions were performed for glenoid loosening (3.8%); both were revision cases with substantial glenoid bone loss. One patient with mild pain had a radiographically loose glenoid component 12 years after anatomic shoulder arthroplasty.

Their chart provides a useful insight into the metal content of some current arthroplasty systems

The authors point out that while skin patch testing is the gold standard for determining metal hypersensitivity and recommended for patients with a history of dermatitis prior to metallic implantation, prior studies have also shown no correlation between positive skin patch test results and outcomes in orthopedic arthroplasty surgery and that there is poor correlation between self-reported allergy and skin patch results, with only 30% of patients with a self-reported nickel allergy having a positive skin patch test.

All of the patients in this series had improvements in range of motion and pain relief after shoulder arthroplasty. This is in agreement with other arthroplasty studies, which have shown no increased complications in patients with metal allergies who have undergone hip or knee replacements with standard implants. In hip and knee patients with patch test–positive metal allergies, surgeons have reported no complications or symptoms associated with use of standard metallic implants.

Comment: Stimulated by this article, we reviewed over 100 articles discussing metal allergy and its relationship to total joint arthroplasty outcome. From this review we concluded:

(1) There is an inconsistent relationship between self reported metal allergies and skin tests.

(2) Patients with self-reported metal allergies and/or positive skin tests do not have worse outcomes when standard implants are used.

(3 There are no specific clinical tests for metal allergy that have demonstrated utility in the evaluation of patients with failed arthroplasty.

(4) No distinctive surgical findings of metal allergy have been identified at revision surgery that distinguish this proposed etiology of failure from others. 

(5) While some patients with suspected metal allergy have good results after revision with a hypoallergenic set of implants, these results have not been demonstrated to be superior to those of revision with standard implants.

A relevant article was recently published. Lymphocyte Transformation Testing (LTT) in Cases of Pain Following Total Knee Arthroplasty: Little Relationship to Histopathologic Findings and Revision Outcomes.

These authors point out that the utilization of lymphocyte transformation testing (LTT) has increased for diagnosing metal sensitivity associated with knee arthroplasty, but its validity for the diagnosis of TKA failure due to an immune reaction has not been established. They sought to characterize the relationship of a positive LTT result to histopathologic findings and clinical and functional outcomes in 27 well-fixed, aseptic, primary TKA cases in which the patient had persistent pain and/or stiffness and underwent revision due to a suspected metal allergy to nickel, as determined on the basis of positive LTT.  Periprosthetic tissue samples obtained at the time of revision surgery were scored using the aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) scoring system. 

Eight patients were categorized as mildly reactive; 8 patients, moderately reactive; and 11 patients, highly reactive to nickel by LTT. The predominant findings on routine histopathologic analysis were fibrosis and varying degrees of lymphocytic infiltration in 17 (63%) of the 27 cases. The average ALVAL score of the cohort was 3.1 +/- 1.9, of a maximum score of 10. Average Knee Society Score (KSS) values improved post-revision, as did range of motion (all p < 0.01). 

Neither LTT stimulation index as a continuous variable nor as a categorical variable (mildly reactive, moderately reactive, highly reactive) was correlated with ALVAL score, pre-revision function (as assessed by KSS-clinical, KSS-functional, and range of motion), or change in function at the most recent follow-up (0.015 < r < 0.30, 0.13 < p < 0.95). In addition, the ALVAL score did not correlate significantly with either pre-revision or post-revision KSS or range of motion (0.061 < r < 0.365, 0.09 < p < 0.88). 

The authors concluded that LTT results alone were insufficient for the diagnosis of TKA failure due to an immune reaction. A positive LTT may not indicate that an immune reaction is the cause of pain and stiffness post-TKA. 

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

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'

What about metal allergy in joint replacement?

Metal Hypersensitivity in Total Joint Arthroplasty 

These authors thoroughly reviewed the topic of metal allergy in joint replacement.

They found that 

» Metal hypersensitivity has been reported in various case reports and cohort studies. Type-IV (delayed-type) hypersensitivity to various implant metals, most frequently nickel, has been implicated in the pathogenesis of metal hypersensitivity.

» Currently, there are no guidelines for addressing suspected or known metal allergy preoperatively and there is no evidence-based support for either preoperative testing or routine use of hypoallergenic implants.

» Multiple diagnostic modalities are available for the workup of suspected metal hypersensitivity; the 2 most common are patch testing and lymphocyte transformation testing. However, the ability of these tests to diagnose disease and predict outcomes has not yet been demonstrated.

They concluded that there are no guidelines for addressing suspected or known metal allergy preoperatively and there is no evidence based support for either preoperative testing or routine use of hypoallergenic implants. Multiple diagnostic modalities are available for the workup of suspected metal hypersensitivity; however, the ability of these tests to diagnose disease and predict outcomes has not yet been elucidated.

A variety of hypoallergenic implants are available; however, no evidence-based guidelines exist for their use.

Comment: Here is some related information from a prior blog post

Shoulder arthroplasty in the patient with metal hypersensitivity

While a number of case reports have implicated metallic implants as a source of local and systemic allergic reactions, the link between metal hypersensitivity and poorly functioning or failing implants remains uncertain.  Based on their review, these authors recommend a cautious approach to patients with a history of metal hypersensitivity. In such patients they recommend a metallic implant with low to no nickel content. The fact is that the hard cobalt chrome components (from which humeral heads and glenospheres are commonly made) have nickel and the softer titanium components (from which humeral stems are commonly made) do not.

They conclude that (1) the role of metal hypersensitivity in poorly functioning or failing implants remains uncertain, (2) there is no conclusive evidence supporting the positive or negative predictive value of dermal patch testing preoperatively, (3) there is also no consensus on the best preoperative testing modality, (4) there are multiple studies that suggest an association (but not direct causality) between metal hypersensitivity and early implant failure as well as documented dermal manifestations after implantation in patients with metal sensitivities. 

Rather than using skin patch testing (as recommended by some), these authors advocate the use of an implant system  that does not contain nickel in any patient with a history that elicits concern for cutaneous metal hypersensitivity. In patients with a failed TSA, they recommend patch testing once infection and mechanical failure have been ruled out.

The great majority of head prostheses are made of chrome cobalt for a reason. The long term effects of using titanium rather than cobalt chrome heads remains to be determined.

This review prompts consideration of a recent post:

Females with Unexplained Joint Pain Following Total Joint Arthroplasty Exhibit a Higher Rate and Severity of Hypersensitivity to Implant Metals Compared with Males Implications of Sex-Based Bioreactivity Differences 

It has been reported that the prevalence of metal hypersensitivity in 10% of the general population, in 20% of people with well-performing implants, and in 60% of those with failing implants (Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001 Mar;83(3):428-36.).

These authors conducted a retrospective study of the rates and levels of metal sensitization in a selected group of 1,038 male and 1,575 female subjects with idiopathic joint pain following total joint arthroplasty (TJA) who were referred for sensitivity testing for cobalt, chromium and nickel.

A “no pain” control group consisted of age-matched control subjects who were tested prior to TJA implantation and had no reported history of metal allergy (n = 318).

Females demonstrated a significantly higher rate and severity of metal sensitization compared with males (median lymphocyte stimulation index (SI) among males was 2.8 (mean, 5.4; 95% confidence interval [CI], 4.9 to 6.0) compared with 3.5 (mean, 8.2; 95% CI, 7.4 to 9.0) among females (p < 0.05). Forty-nine percent of females had an SI equal to or greater than 4 (reactive) compared with 38% of males, and the implant-related level of pain was also significantly (p < 0.0001) higher among females (mean, 6.8; 95% CI, 6.6 to 6.9) compared with males (mean, 6.1; 95% CI, 6.0 to 6.3).

Interestingly, a positive sensitivity test was much more common than a positive self-reported history.

While the patients with painful joints had higher mean simulation indices, many had values in the normal range.

Here's another related post:

What Role Does Metal Hypersensitivity Play in Implant Complications?


The place of metal sensitivity testing in the evaluation of the painful arthroplasty, the cause/effect relationship of metal sensitivity to implant failure, and the success of revision to implants with different material compositions remain to be determined. In cases of suspected metal allergy it is important to exclude the possibility of a stealth infection from Propionibacterium, which may produce similar symptoms.

===

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

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'

Total shoulder arthroplasty: is Clindamycin a reasonable antibiotic in the penicillin allergic patient?

Perioperative Clindamycin Use in Penicillin Allergic Patients Is Associated With a Higher Risk of Infection After Shoulder Arthroplasty

These authors sought to determine whether infection rates differ between prophylactic antibiotic use for patients with or without penicillin allergy before shoulder arthroplasty surgery.

In 7140 primary shoulder arthroplasties operated between 2005 and 2016 they compared deep surgical site infection risk of patients who received perioperative vancomycin alone (6.2%,N= 444) or clindamycin alone (7.1%, N = 508) for penicillin allergy versus patients who received cefazolin alone without penicillin allergy (86.7%, N = 6,188).

Infections were identified using a comprehensive electronic screening algorithm of electronic medical records and administrative claims of the institution using International Classification of Disease, Clinical Modification, Ninth Revision (ICD-CM-9). They included all positive cultures with preoperative findings consistent with infection and negative cultures with positive surgeon findings for infection.The screening algorithm had a 97.8% sensitivity and 91.5% specificity.

Seventy deep infections (1.2% 5-year cumulative incidence) were observed. 

The most common organism was Cutibacterium (39.4%, N = 27). 

Compared with patients treated with cefazolin, infection risk was not different for those treated with vancomycin (hazard ratio = 1.17, 95% confidence interval 0.42 to 3.30, P = 0.8), but a higher risk of infection was identified for those treated with clindamycin alone (hazard ratio = 3.45, 95% confidence interval 1.84 to 6.47, P , 0.001).

They concluded that a four times higher risk of postoperative infection is found after prophylactic use of intravenous clindamycin antibiotic after shoulder arthroplasty and that Vancomycin is preferred over clindamycin for patients with penicillin allergy.

Comment: This important study gives us "news we can use" and demonstrates the great value of the Kaiser registry.

See related post What if my total shoulder patient says she's allergic to penicillin?

Our approach to total shoulder arthroplasty can be viewed by clicking here.

To see our technique for reverse total shoulder, click on this link.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

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

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and 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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder arthroplasty - what antibiotic to use in the penicillin allergic patient?

Perioperative Clindamycin Use in Penicillin Allergic Patients Is Associated With a Higher Risk of Infection After Shoulder Arthroplasty

These authors sought to determine whether infection rates differ between prophylactic antibiotic use for patients with or without penicillin allergy before shoulder arthroplasty surgery.
They identified 7140 primary shoulder arthroplasties operated between 2005 and 2016. They compared deep surgical site infection risk of patients who received perioperative vancomycin alone (6.2%,N= 444) or clindamycin alone (7.1%, N = 508) for penicillin allergy versus patients who received cefazolin alone without penicillin allergy (86.7%, N = 6,188).

70 deep infections (1.2% 5-year cumulative incidence)were observed. The most common organism was Cutibacterium acnes.

Compared with patients treated with cefazolin, infection risk was not different for those treated with vancomycin (hazard ratio = 1.17, 95% confidence interval 0.42 to 3.30, P = 0.8), but a higher risk of infection was identified for those treated with clindamycin alone (hazard ratio = 3.45, 95% confidence interval 1.84 to 6.47, P , 0.001).

Comment: Cutibacterium is developing an increased resistance to Clindamycin (see this link and this link). Clindamycin has the additional issue of an increased risk of Clostridium difficile bowel infections.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

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'

Total shoulder arthroplasty - what materials should we be using?

 The Biomaterials of Total Shoulder Arthroplasty Their Features, Function, and Effect on Outcomes

These authors review the materials used in total shoulder arthroplasty (TSA). They point out that the 2 main metal alloys used in TSA implants are Ti-6Al-4V (titaniumaluminum-vanadium) and CoCrMo (cobalt-chromium-molybdenum). Ti alloys are softer than CoCr alloys, making them less wear-resistant and more susceptible to damage, but they have improved osseointegration and osteoconduction properties. While some surgeons are interested in "osseointegration" of the humeral component, bone ingrowth is not necessary for secure durable fixation; furthermore, revision of an ingrowth stem carries with it a much higher complication risk than the revision of an impaction grafted smooth stem (see this link).

While metal allergy may be a concern in some patients having problems after TSA, the diagnosis of this metal allergy is difficult. This concern is not sufficiently compelling to merit the routine use of "hypoallergenic" prostheses. Prosthesis without nickel or chromium seem to be mechanically inferior, so avoiding the risk of "metal allergy" may give rise to other problems. For example, while ceramic and pyrolytic carbon humeral heads may have theoretical advantages, they also pose an increased risk of fracture - a complication unknown with cobalt chrome heads. 

On the glenoid side, cross linked polyethylene glenoids have an excellent record of survivorship as shown by the data from the Australian Orthopaedic Association. 

Comment: With the current state the art, total shoulder arthroplasty using standard implants has an established track record of excellent clinical outcomes. Efforts to improve on this track record may result in more costly implants and in unexpected outcomes (see this link).

Our time tested approach to total shoulder arthroplasty is shown in this link.

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

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and 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  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'