Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review

Preoperative corticosteroid injections are associated with a higher periprosthetic infection rate following primary total shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

Corticosteroid injections (CSIs) are commonly used for the treatment of shoulder pain in patients with osteoarthritis and rotator cuff arthropathy. These injections may increase the risk of infection following eventual shoulder arthroplasty. The purpose of this study was to perform a systematic review and meta-analysis of existing data to explore the relationship between preoperative CSI's and postoperative periprosthetic joint infection (PJI) following shoulder arthroplasty.

METHODS

A literature search was performed on PubMed, Embase, and Web of Science databases through September 29, 2023. Of the 4221 retrieved, 7 studies including 136,233 patients were included for qualitative analysis. Studies describing patients receiving CSI prior to shoulder arthroplasty and the effect on postoperative infection risk were included in the systematic review and subsequent meta-analysis. Assessment of risk of bias was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Receiving a CSI prior to shoulder arthroplasty was found to have a statistically significant association with increased risk for PJI (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06-1.19; P < .0001). The rate of PJI increased when injections were given closer to the time of surgery. Patients who received an injection at any time point before surgery had a 5.4% risk of PJI compared to 7.9% and 9.0% in patients receiving an injection within 3 months and 1 month of surgery, respectively. This time dependent association however did not reach statistical significance: 1 month OR 1.48; 95% Cl: 0.86-2.53; P = .16, 3 months OR 1.95; 95% Cl: 0.95-4.00; P = .07.

CONCLUSION

The results of this systematic review and meta-analysis demonstrate that patients receiving corticosteroid shoulder injections prior to shoulder arthroplasty may be at an increased risk for PJI postoperatively. While time dependent stratification did not reach statistical significance, our findings indicate a clear trend of increased risk for patients receiving injections closer to surgery.

Preventing Infections in Reverse Shoulder Arthroplasty

PURPOSE OF REVIEW

Reverse shoulder arthroplasty (rTSA) is a commonly performed procedure to treat degenerative conditions of the shoulder. With its growing utilization, techniques to reliably diagnose and treat prosthetic joint infection (PJI) have become increasingly important. In this review we outline the current research and prevention methods of prosthetic joint infection in rTSA. This includes preoperative considerations, intraoperative, and postoperative treatment algorithms.

RECENT FINDINGS

There is currently no established standardized protocol for preoperative infection prevention or post operative management. However, recent studies have identified risk factors for infection, as well as successful prevention techniques that can be implemented to minimize infection risk. Although there is no standardized protocol currently utilized to diagnose and treat shoulder PJI, we outline a potential set of preventative measures and postoperative management strategies that clinicians can use to properly diagnose and treat patients with this difficult condition.

Hydrogen Peroxide May Reduce the Risk for Revision Surgery and Infection in Primary Shoulder Arthroplasty: Two-year Follow-up From a Prospective, Blinded, Controlled Trial

BACKGROUND

The purpose of this study was to determine whether the addition of hydrogen peroxide to the preoperative skin preparation for primary total shoulder arthroplasty is associated with a difference in patient-reported outcomes, risk for postoperative infection, and risk for revision surgery at a minimum of 2-year follow-up.

METHODS

This was a prospective, blinded, and controlled trial, which included a consecutive series of patients undergoing primary shoulder arthroplasty. The control group underwent standard sterile skin preparation using ethyl alcohol and ChloraPrep applicators, and the peroxide group had the same preparation with the addition of hydrogen peroxide between the alcohol and ChloraPrep applications. We then compared patient-reported outcome scores (American Shoulder and Elbow Surgeons Shoulder Score [ASES], simple shoulder test [SST], visual analog scale [VAS]), infections, and revision surgeries between the two groups at 2-year follow-up.

RESULTS

Of the 61 patients included in the original study, 52 of 58 (85%) living patients agreed to participate in this study. No preoperative differences were observed between groups. No difference was observed in ASES, SST, or VAS scores at 2 years. More revision surgeries were done in the control group (7 versus 2, P = 0.268) and Cutibacterium acnes infections (2 versus 0, P = 0.168).

CONCLUSION

The addition of hydrogen peroxide to the preoperative skin preparation before primary shoulder arthroplasty is safe, and additional research is warranted to investigate whether it may decrease the risk for revision surgery and postoperative C acnes infection.

LEVEL OF EVIDENCE

III.

Association between radiographic soft-tissue thickness and increased length of stay, operative time, and infection rate after reverse shoulder arthroplasty

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a widely performed surgical procedure to address various shoulder pathologies. Several studies have suggested that radiographic soft-tissue thickness may play a role in predicting complications after orthopedic surgery, but there have been limited studies determining the use of radiographic soft-tissue thickness in RSA. The purpose of this study was to evaluate whether radiographic soft-tissue thickness could predict clinical outcomes after RSA and compare the predictive capabilities against body mass index (BMI). We hypothesized that increased radiographic shoulder soft-tissue thickness would be a strong predictor of operative time, length of stay (LOS), and infection in elective RSA.

MATERIAL AND METHODS

A retrospective review of patients undergoing RSA at an academic institution was conducted. Preoperative radiographic images were evaluated including measurements of the radius from the humeral head center to the skin (HS), deltoid radius-to-humeral head radius ratio (DHR), deltoid size, and subcutaneous tissue size. Different correlation coefficients were used to analyze various types of relationships, and the strength of these associations was classified based on predefined boundaries. Subsequently, multivariable linear and logistic regressions were performed to determine whether HS, DHR, deltoid size, and subcutaneous tissue size could predict LOS, operative time, or infection while controlling for patient factors.

RESULTS

HS was the most influential factor in predicting both operative time and LOS after RSA, with strong associations indicated by standardized β coefficients of 0.234 for operative time and 0.432 for LOS. Subcutaneous tissue size, deltoid size, and DHR also showed stronger predictive values than BMI for both outcomes. In terms of prosthetic joint infection, HS, deltoid size, and DHR were significant predictors, with HS demonstrating the highest predictive power (Nagelkerke R2 = 0.44), whereas BMI did not show a statistically significant association with infection. Low event counts resulted in wide confidence intervals for odds ratios in the infection analysis.

CONCLUSION

Greater shoulder soft-tissue thickness as measured with concentric circles on radiographs is a strong predictor of operative time, LOS, and postoperative infection in elective primary RSA patients.

After primary shoulder arthroplasty appropriate vancomycin antibiotic prophylaxis does not lead to increased infectious complications when compared to cefazolin

BACKGROUND

In primary shoulder arthroplasty (SA), intravenous (IV) cefazolin has demonstrated lower rates of infectious complications when compared to IV vancomycin. However, previous analyses included SA cohorts with both complete and incomplete vancomycin administration. Therefore, it is currently unclear whether cefazolin still maintains a prophylactic advantage to vancomycin when it is appropriately indicated and sufficiently administered at the time of surgical incision. This study evaluated the comparative efficacy of cefazolin and complete vancomycin administration for surgical prophylaxis in primary shoulder arthroplasty with respect to infectious complications.

METHODS

A retrospective cohort study was conducted utilizing a single institution total joint registry database, where all primary SA types (hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse shoulder arthroplasty) performed between 2000 to 2019 for elective and trauma indications using IV cefazolin or complete vancomycin administration as the primary antibiotic prophylaxis were identified. Vancomycin was primarily indicated for patients with a severe self-reported penicillin or cephalosporin allergy and/or MRSA colonization. Complete administration was defined as at least 30 minutes of antibiotic infusion prior to incision. All included SA had at least 2 years of clinical follow-up. Multivariable Cox proportional hazard regression was used to evaluate all-cause infectious complications including survival free of prosthetic joint infection (PJI).

RESULTS

The final cohort included 7177 primary SA, 6879 (95.8%) received IV cefazolin and 298 (4.2%) received complete vancomycin administration. Infectious complications occurred in 120 (1.7%) SA leading to 81 (1.1%) infectious reoperations. Of the infectious complications, 41 (0.6%) were superficial infections and 79 were (1.1%) PJIs. When categorized by administered antibiotics, there were no differences in rates of all infectious complications (1.6% vs. 2.3%; P = .352), superficial complications (0.5% vs. 1.3%; P = .071), PJI (1.1% vs. 1.0%; P = .874), or infectious reoperations (1.1% vs. 1.0%; P = .839). On multivariable analyses, complete vancomycin infusion demonstrated no difference in rates of infectious complications compared to cefazolin administration (hazard ratio [HR], 1.50 [95% confidence interval (CI), 0.70 to 3.25]; P = .297), even when other independent predictors of PJI (male sex, prior surgery, and Methicillin-resistant Staphylococcus aureus colonization) were considered.

CONCLUSIONS

In comparison to cefazolin, complete administration of vancomycin (infusion to incision time greater than 30 minutes) as the primary prophylactic agent does not adversely increase the rates of infectious complications and PJI. Prophylaxis protocols should promote appropriate indications for the use of cefazolin or vancomycin, and when necessary, ensure complete administration of vancomycin to mitigate additional infectious risks after primary SA.

Outcomes following revision reverse shoulder arthroplasty for infection

BACKGROUND

In comparison to primary reverse shoulder arthroplasty (RSA) procedures, revision arthroplasty can be a longer and more complex procedure leading to an increased risk of complications. The reported rates of infection in primary RSA range from 1% to 19% and the cost impact on patients and health care systems is significant, leading to multiple revision surgeries. The purpose of this study was to evaluate the postoperative outcomes, complications, and revision rates for revision reverse shoulder arthroplasty (rRSA) due to infection compared with rRSA for noninfectious causes.

METHODS

Patients who underwent rRSA between 2009 and 2020 by a single fellowship-trained orthopedic surgeon at a single institution were retrospectively identified through a prospectively collected database. Patients were separated into 2 cohorts based on revision diagnosis: (1) rRSA due to infection (rRSAi) and (2) rRSA due to noninfectious causes (rRSAn). Patient-reported outcome scores (PROs), including the Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart score, and active range of motion (ROM) were collected preoperatively and at a minimum 1-year follow-up. Postoperative complications and revision rates were also collected.

RESULTS

A total of 93 patients (n = 19 rRSAi group, n = 74 rRSAn group) with a mean age of 68 years were included in this analysis. All baseline demographics were comparable between groups. No significant differences were found in preoperative or postoperative PROs and ROM between the 2 groups. Postoperative complication rates and revision rates were comparable between the groups.

CONCLUSION

RSA due to infection results in similar patient-reported outcome scores, range of motion, and revision rates when compared to rRSA for noninfectious causes. Our results suggest that despite the unique challenges associated with rRSA for infection, patient outcomes do not differ from cases attributed to noninfectious causes. More efforts are warranted to further validate and contextualize these findings, considering the protentional influence of patient-specific and implant-specific factors.

Two-Stage Exchange Arthroplasty for Periprosthetic Reverse Shoulder Arthroplasty Infection Provides Comparable Functional Outcomes to Primary Reverse Shoulder Arthroplasty

This study aimed to compare functional outcomes after two-stage revision reverse shoulder arthroplasty (RSA) for periprosthetic joint infection (PJI) with the results of primary RSA. Patients affected by PJI and treated by means of two-stage revision RSA were 1:1 matched with a group of patients who were treated electively with RSA without developing any complications. Out of 1477 RSAs performed between 2009 and 2021, 16 patients developed a PJI. Each matched cohort comprised 16 patients (3 females, 13 males). The mean age was 69.13 ± 5.43 years old in the PJI group and 70.28 ± 5.04 (p = 0.543) in the matched cohort. The mean follow-up was 41.23 ± 26.9 months in the PJI group and 28.5 ± 20.2 (p = 0.142) in the matched group. Only one patient showed recurrent PJI five years after revision RSA. Comparison between the PJI patients and matched patients did not show any significant differences at the latest follow-up, nor for subjective shoulder value (SSV) (p = 0.101) or Constant score (p = 0.134). Two-stage exchange RSA for PJI allows for appropriate control of the disease and good functional outcomes. Comparison with an age- and sex-matched cohort of uninfected patients showed no significant differences, thus confirming the idea that revision surgeries may lead to satisfactory functional outcomes, as expected after primary surgery.

Discordance between patient-reported and objectively measured internal rotation after reverse shoulder arthroplasty

BACKGROUND

Patient satisfaction after reverse shoulder arthroplasty (RSA) partly relies on restoring functional internal rotation (IR). Although postoperative assessment of IR includes objective appraisal by the surgeon and subjective report from the patient, these evaluations may not vary together uniformly. We assessed the relationship between objective, surgeon-reported assessments of IR and subjective, patient-reported ability to perform IR-related activities of daily living (IRADLs).

METHODS

Our institutional shoulder arthroplasty database was queried for patients undergoing primary RSA with a medialized-glenoid lateralized-humerus design between 2007-2019 and minimum 2-year follow-up. Patients who were wheelchair bound or had a preoperative diagnosis of infection, fracture, and tumor were excluded. Objective IR was measured to the highest vertebral level reached with the thumb. Subjective IR was reported based on patients' rating (normal, slightly difficult, very difficult, or unable) of their ability to perform 4 IRADLs (tuck in shirt with hand behind back, wash back or fasten bra, personal hygiene, and remove object from back pocket). Objective IR was assessed preoperatively and at latest follow-up and reported as median and interquartile ranges.

RESULTS

A total of 443 patients were included (52% female) at a mean follow-up of 4.4 ± 2.3 years. Objective IR improved pre- to postoperatively from L4-L5 (buttocks to L1-L3) to L1-L3 (L4-L5 to T8-T12) (P < .001). Preoperatively reported IRADLs of "very difficult" or "unable" significantly decreased postoperatively for all IRADLs (P ≤ .004) except those unable to perform personal hygiene (3.2% vs. 1.8%, P > .99). The proportions of patients who improved, maintained, and lost objective and subjective IR was similar between IRADLs; 14%-20% improved objective IR but lost or maintained subjective IR and 19%-21% lost or maintained the same objective IR but improved subjective IR depending on the specific IRADL assessed. When ability to perform IRADLs improved postoperatively, objective IR also increased (P < .001). In contrast, when subjective IRADLs worsened postoperatively, objective IR did not significantly worsen for 2 of 4 IRADLs assessed. When examining patients who reported no change in ability to perform IRADLs pre- vs. postoperatively, statistically significant increases in objective IR were found for 3 of 4 IRADLs assessed.

CONCLUSIONS

Objective improvement in IR parallels improvements in subjective functional gains uniformly. However, in patients with worse or equivalent IR, the ability to perform IRADLs postoperatively does not uniformly correlate with objective IR. When attempting to elucidate how surgeons can ensure patients will have sufficient IR after RSA, future investigations may need to use patient-reported ability to perform IRADLs as the primary outcome measure rather than objective measures of IR.

Management of periprosthetic joint infection of shoulder arthroplasty: Single-stage versus two-stage protocols. A systematic review and meta-analysis of the literature

Background

The treatment of shoulder prosthetic joint infections (PJIs) requiring removal of the prosthesis is not well defined. This article aims to systematically review and compare the results of the literature in single-stage and two-stage protocols in the treatment of shoulder PJI.

Methods

An in-depth search on PubMed/Scopus/Web of Science databases and cross-referencing search was carried out concerning the articles reporting detailed data on the topic.

Results

A total of 486 shoulder PJIs were included: 137 treated with single-stage and 349 with two-stage procedure. A similar distribution between early and not-early infections (19.1% vs 80.9%) was found between the two groups. The overall rate of success in terms of PJI eradication was significantly higher in the single-stage group (95.6% vs 85.7%, p < 0.001). The non-infection-related complications rate was 13.8% in the single-stage group and 37.6% in the two-stage group (p < 0.001), the non-infection-related revision rate was 8% and 18.9%, respectively (p = 0.005).

Discussion

The single-phase protocol showed a higher success rate in eradicating the infection and a lower complication rate. However, the low number of patients included, the low quality of the articles, the lack of data on clinical severity and bacteriological virulence suggest caution in conclusions.

Preventing and Treating Infection in Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty.

RECENT FINDINGS

The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

Cutibacterium positive cultures in total joint arthroplasty: a comparison of the hip, knee, and shoulder

PURPOSE

Cutibacterium spp. (formerly Propionibacterium) is a slow growing, Gram-positive, anaerobic bacteria and is an emerging clinical entity in prosthetic joint infection (PJI). This study compares the presentation, surgical management, and post-operative antibiotic therapy of patients with positive intraoperative cultures during revision total joint arthroplasty (TJA) of the hip, knee, and shoulder.

METHODS

This was a retrospective cohort study of patients from 2014 to 2020 of 57 revision TJAs (27 total hip arthroplasty (THA), 17 total shoulder arthroplasty (TSA), and 13 total knee arthroplasty (TKA)) with intraoperative cultures positive for Cutibacterium at a tertiary academic centre. Patient demographics, pre-operative labs, radiographs, and aspirate results were collected. Intraoperative data was reviewed. Post-operative antibiotic therapy and repeat infections were recorded. Data was compared with univariate analyses.

RESULTS

There was no significant difference in pre-operative lab values between the cohorts. All cohorts had > 58% radiographic lucency. Revision TSA patients had significantly fewer pre-operative aspirates. Six patients undergoing revision THA, three TKA and one TSA had a repeat infection requiring further surgery. Four in the THA cohort and one in the TKA cohort with repeat infections did not receive prolonged antibiotic therapy.

CONCLUSION

Cutibacterium is an infectious agent that can present in an indolent fashion after TJA. It commonly causes progressive radiographic lucency. The workup and post-operative management differs in the hip, knee, and shoulder, which is likely due to existing literature guiding physician practice. In all joints, Cutibacterium is a virulent pathogen that can cause repeat infections requiring surgical treatment.

The Association of Benign Prostatic Hyperplasia on Postoperative Complications and Periprosthetic Joint Infections Following Total Shoulder Arthroplasty

Background

A recently proposed risk factor for periprosthetic joint infections (PJI) in men is benign prostatic hyperplasia (BPH). The objective was to explore the association of BPH on 1) 90-day complications, 2) length of stay (LOS), 3) readmission rates, and 4) healthcare expenditures following total shoulder arthroplasty (TSA).

Methods

A retrospective query was performed using a nationwide claims database from January 2005 to March 2014 for male patients undergoing primary TSA. The study cohort included 5067 patients with BPH while 50,720 patients served as the comparison cohort. Logistic regression determined the association of BPH on complications and readmissions. A p value less than 0.001 was significant.

Results

Patients with BPH had higher incidence and odds (36.8 vs. 6.2%; OR: 2.73, p < 0.0001) of all ninety-day medical complications including PJIs (0.49 vs. 0.32%; OR: 1.54, p < 0.001). BPH patients had longer in-hospital LOS (3- vs. 2-days, p < 0.0001). Study group patients had higher 90-day episode of care reimbursements ($13,653 vs. $12,688), p < 0.0001).

Conclusions

BPH is associated with increased complications and healthcare expenditures following total shoulder arthroplasty. The investigation can be used to educate BPH patients of the possible adverse events which may occur within ninety-days following primary TSA for the treatment of glenohumeral osteoarthritis.

Prosthetic joint infections of the shoulder: A review of the recent literature

Introduction

Shoulder arthroplasty is a common treatment for shoulder arthritis. Prosthetic joint infection of the shoulder (PJIS) is a debilitating complication to the patient and the healthcare system. Incidence of infection is 0.98-5% for primary arthroplasty. The mean hospital cost for two-stage revision was approximately $35,824. The aim of this paper is to review the recent literature and collate the latest evidence to aid diagnosis and treatment of this serious complication.

Methods

A literature review was performed using PubMed and Google Scholar databases. A search strategy was adopted using the keywords: 'infection' AND 'shoulder arthroplasty' OR 'total shoulder arthroplasty'OR 'TSA' OR 'reverse shoulder arthroplasty' OR 'RSA' OR 'rTSA'. This initial search resulted in 349 articles. A PRISMA flowchart process was followed. Duplicates were removed, screening was performed and the resulting full texts were analysed and further excluded, leaving 46 articles suitable for inclusion. A PICO search strategy was also used.

Results and interpretation

Risk factors for PJIS include procedure type, trauma indications and patient factors.The organism commonly isolated is Cutebacterium acnes, which makes diagnosis challenging due to its indolent nature. Investigations include biochemical tests, synovial aspirate, tissue cultures and radiological examinations.Treatment depends on the depth of the infection and the patient requirements. Medical treatment with antibiotics to local debridement, cement spacer and revision arthroplasty have all been described in the literature. A multidisciplinary decision is made on the microbiological evidence and patient factors.

Conclusion

PJIS is a rare but potentially devastating complication of shoulder arthroplasty and diagnosis is often challenging. There has been much research performed recently, providing more evidence on how to optimise management.

Risk factors for the development of a peri-prosthetic joint infection up to 2 Years following primary reverse shoulder arthroplasty

Background

Reverse shoulder arthroplasty (RSA) has become commonly used to treat glenohumeral osteoarthritis (GHOA), of which complications such as peri-prosthetic joint infections (PJIs) may develop. The objective of this study was to compare patient demographics of those who did and did not develop PJIs within 2 years after primary RSA for GHOA and identify risk factors for this sequela.

Methods

A nationwide database was queried from 2005 to 2014 for Medicare patients treated with primary RSA (International Classification of Disease (ICD-9) procedural code 81.88) for GHOA. Patients who developed PJIs within 2-years of primary RSA defined the study group, whereas those who were devoid of infections represented the comparison group. Our study consisted of 51,824 patients, of which 879 (1.69%) developed a PJI. Patient demographics comprising the Elixhauser comorbidity index (ECI) were compared using Chi-Square analyses. Multivariable logistic regression models were used to compute the odds-ratios (OR) of patient-specific factors associated with acquiring a PJI within 2 years after RSA. P values less than 0.002 were significant.

Results

Patients developing a PJI had higher mean ECI (8 vs. 6; p < 0.0001). The greatest risk factors for developing PJIs within 2-years following RSA were male sex (OR: 2.10, 95%CI: 1.81-2.43, p < 0.0001), pathologic weight loss (OR: 1.78, 95%CI: 1.45-2.17, p < 0.0001), iron deficiency anemia (OR: 1.75, 95%CI: 1.49-2.06, p < 0.0001), morbid obesity (OR: 1.52, 95%CI: 1.21-1.88, p = 0.0001), rheumatoid arthritis (OR: 1.32, 95%CI: 1.13-1.54, p = 0.0003), arrhythmias (OR: 1.26, 95%CI 1.09-1.46, p = 0.001), and depressive disorders (OR: 1.23, 95%CI 1.06-1.43, p = 0.001).

Conclusions

The greatest risk factors for PJIs within 2 years of primary RSA included male sex; additional modifiable risk factors included iron deficiency anemia, pathologic weight loss, and obesity. Preoperative screening can help to identify modifiable risk factors and alter management for high-risk patients to potentially minimize PJIs.

Techniques for Decreasing Bacterial Load for Open Shoulder Surgery

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Benzoyl peroxide (BPO) 5% has been shown to reduce Cutibacterium acnes load on the skin. BPO 5% with miconazole nitrate (MN) 2% may be beneficial, whereas BPO 5% with clindamycin cream 1% to 1.2% does not seem to have additive effects when compared with BPO 5% alone. Chlorhexidine gluconate solutions reduce the total bacterial load on the skin, but do not seem to have a significant effect on C. acnes.

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ChloraPrep seems to be the best surgical skin preparation to decrease overall positive skin cultures. Preincisional hydrogen peroxide 3% application has been shown to be a cost-effective practice to inhibit growth of C. acnes. Vancomycin powder before deltopectoral interval closure has antimicrobial effects against C. acnes and is a cost-effective practice. Finally, Bactisure surgical lavage is protective against the formation of biofilms.

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IV cefazolin has been shown to be more effective for shoulder arthroplasty infection prophylaxis than antibiotic alternatives such as vancomycin. Thus, patients with a questionable history of penicillin allergy should undergo additional testing.

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For shoulder surgery infection prophylaxis, we recommend the use of BPO 5% cream for 5 days preoperatively with chlorhexidine wipes the night before and the morning of surgery. IV cefazolin should be administered perioperatively, and patients with a questionable history of penicillin allergy should be tested. Surgeons should consider preincisional application of hydrogen peroxide 3% for 5 minutes, followed by standard ChloraPrep preparation. Normal saline should be used for preclosure lavage. Finally, application of vancomycin powder deep to the deltopectoral interval closure should be considered.

Benign prostatic hyperplasia is associated with increased 90-day medical complications but not peri-prosthetic joint infections following reverse shoulder arthroplasty

INTRODUCTION

Studies have shown male sex to be a predisposing factor for peri-prosthetic joint infections (PJIs). Symptomatic benign prostatic hyperplasia (BPH) has been suggested as an additional risk for PJI. This study aimed to assess the impact of BPH on (1) lengths of stay (LOS), (2) complications (medical and implant-related), (3) readmission rates, and (4) healthcare expenditures after reverse shoulder arthroplasty (RSA).

METHODS

Utilizing a nationwide sample from the 2010-2020 PearlDiver insurance database, an analysis was performed retrospectively for all males who underwent primary RSA. Males with BPH (n = 2,184) represented the study group and were ratio-matched with men without a history of BPH (n = 10,832) in a 1:5 manner by medical comorbidities. T-tests compared LOS and healthcare expenditures. Multivariate logistic regression models were used to determine the effect of BPH on 90-day medical complications, 2-year implant complications, and readmissions. A p value less than 0.001 was statistically significant.

RESULTS

In-hospital LOS (1.96 days vs. 1.99 days, p = 0.683) did not significantly differ between cohorts. Males with BPH had significantly greater occurrence and odds (34.3% vs. 21.2%, odds ratio (OR):1.84, p < 0.0001) of all 90-day medical complications, including urinary tract infections (9.3% vs. 3.1%, OR:3.23, p < 0.0001), pneumonias (6.0% vs. 3.9%, OR:1.61, p < 0.0001), and acute kidney injuries (7.7% vs. 5.0%, OR:1.60, p < 0.0001). Two-year implant-related complications were comparable between study and control groups (12.2% vs 10.9%, OR:1.14, p = 0.073), including PJIs (2.3% vs. 2.2%, OR:1.02, p = 0.874). Readmission rates (1.88% vs. 2.11%, p = 0.482) and average global 90-day reimbursements ($26,301 vs. $24,399), p = 0.535) were similar between men with and without BPH.

DISCUSSION

Males with a history of BPH have greater rates of medical complications, including UTIs and acute kidney injuries, within 90 days following RSA. BPH does not appear to be a risk factor for 2-year implant-related complications including PJIs.

LEVEL OF EVIDENCE

III.

Antibiotic Prophylaxis with Cefazolin Is Associated with Lower Shoulder Periprosthetic Joint Infection Rates Than Non-Cefazolin Alternatives

BACKGROUND

Although prophylactic antibiotics are considered the standard of care, data with regard to the comparative efficacy of specific antibiotics in the prevention of periprosthetic joint infection (PJI) have remained limited. This study evaluated whether perioperative antibiotic choice affects rates of PJI development in shoulder arthroplasty.

METHODS

From 2000 to 2019, all primary shoulder arthroplasty types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed for elective and trauma indications with perioperative antibiotic data and a minimum follow-up of 2 years were identified from a single institution. Demographic characteristics, PJI risk factors, and PJI-free survivorship data were retrieved. Multivariable analyses were conducted to determine the association between the antibiotic administered and the development of PJI.

RESULTS

Of 7,713 shoulder arthroplasties, cefazolin was administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics consisting of vancomycin (465 procedures [6.0%]), clindamycin (345 procedures [4.5%]), and alternative regimens (24 procedures [0.31%]) were administered in 834 procedures (10.8%). PJIs occurred in 101 shoulder arthroplasties (1.3%), with Cutibacterium acnes as the most common pathogen (44 procedures [43.6%]). PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered, with 0.91% greater survival free of PJI at 1 month, 1.4% at 1 year, and 2.7% at 15 years (p < 0.001). 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 (p < 0.001). A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 (95% confidence interval [CI], 1.22 to 4.40; p = 0.010) for all-cause PJI and 2.94 (95% CI, 1.12 to 7.49; p = 0.028) for C. acnes PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 (95% CI, 2.83 to 9.05; p < 0.001) for all-cause PJI and 8.01 (95% CI, 3.63 to 17.42; p < 0.001) for C. acnes PJI.

CONCLUSIONS

In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. These risk discrepancies were observed across all infectious pathogens and may be considered even greater when C. acnes was the infecting bacterium.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early aseptic reoperation after shoulder arthroplasty increases risk of subsequent prosthetic joint infection

Background

Despite the success of anatomic total shoulder arthroplasty (TSA) and reverse shoulder arthroplasty (RSA), the clinical course of some patients necessitates operative intervention in the acute postoperative period. In this study, we evaluate the risk of subsequent prosthetic joint infection (PJI) in patients who undergo an aseptic reoperation within 90 days of primary shoulder arthroplasty.

Method

A retrospective review of patients with primary TSA and RSA was performed using a commercially available national database (PearlDiver Inc., Fort Wayne, IN, USA). Queries were performed with use of International Classification of Diseases, Ninth Revision and Tenth Revision and Current Procedural Technology codes. Patients were divided into cohorts based on undergoing aseptic reoperation, reoperation for PJI, or no reoperations within 90 days of index procedure. Primary outcome was subsequent PJI within 1 year of index procedure. Observed PJI rates were compared using chi-square analysis. Risk factors for PJI were compared using logistic regression.

Results

From 2010 to 2018, a total of 96,648 patients underwent primary shoulder arthroplasty: 46,810 underwent TSA and 49,838 underwent RSA. The rate of aseptic reoperation within 90 days was 0.72% and 1.5% in the TSA and RSA cohorts, respectively. At 1 year postoperatively, patients who underwent an aseptic reoperation within 90 days had an elevated risk of subsequent PJI compared with the overall rate of PJI in the TSA (3.54% vs. 0.75%; P < .001) and RSA (3.08% vs. 0.73%; P < .001) cohorts. On multivariate logistic regression analysis, aseptic reoperation within 90 days was identified as a significant risk factor for subsequent PJI in the TSA cohort (odds ratio, 14.19; P < .001) and RSA cohort (odds ratio, 8.38; P < .001). The most common indication for aseptic reoperation was postoperative prosthetic joint instability in both the TSA (31%) and RSA (49%) cohorts.

Conclusion

Aseptic reoperation within 90 days of primary TSA or primary RSA was associated with a notably increased risk of subsequent PJI.

Radiological changes, infections and neurological complications after reverse shoulder arthroplasty related to different design types and their rates: Part II

Early reported complication rates with the Grammont-type reverse shoulder arthroplasty (RSA) were very high, up to 24%.A 'problem' is defined as an intraoperative or postoperative event that is not likely to affect the patient's final outcome, such as intraoperative cement extravasation and radiographic changes. A 'complication' is defined as an intraoperative or postoperative event that is likely to affect the patient's final outcome, including infection, neurologic injury and intrathoracic central glenoid screw placement.Radiographic changes around the glenoid or humeral components of the RSA are very frequently observed and described in the literature.High complication rates related to the Grammont RSA design led to development of non-Grammont designs which led to a dramatic fall in the majority of complications.The percentage of radiological changes after RSA is not negligible and remains unsolved, despite a decrease in its occurrence in the last decade. However, such changes should be now considered as simple problems because they rarely have a negative influence on the patient's final outcome, and their prevalence has dramatically decreased.With further changes in indications and designs for RSA, it is crucial to accurately track the rates and types of complications to justify its new designs and increased indications. Cite this article: EFORT Open Rev 2021;6:1109-1121. DOI: 10.1302/2058-5241.6.210040.

The utility and cost of atypical cultures in revision shoulder arthroplasty

BACKGROUND

At the time of revision shoulder arthroplasty, it is common practice to take cultures to evaluate for prosthetic joint infection even when an alternative cause of failure has been identified. Although isolation of fungal or acid-fast organisms is rare, it remains common practice to send all specimens for aerobic, anaerobic, and atypical (fungal and acid-fast) cultures. We hypothesize that the rate of positive atypical cultures at the time of revision shoulder arthroplasty is very low and routine use imposes a considerable financial burden on the health care system.

METHODS

A retrospective review of all revision shoulder arthroplasties performed between January 1, 2010, and December 31, 2019, at our institution was performed. Patients with a hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, or pre-existing antibiotic spacer who underwent revision to hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, antibiotic spacer, or resection arthroplasty were included. Electronic patient charts were reviewed to gather patient, surgical, and culture data. An analysis of the hospital billing charges associated with each culture was performed using our hospital billing database and the current procedural terminology (CPT) codes for aerobic, anaerobic, fungal, and acid-fast cultures. A secondary outcome analysis was performed to identify factors associated with positive cultures.

RESULTS

A total of 237 revision shoulder arthroplasties performed on 189 patients were analyzed. Cultures were sent on 158 of 237 (66.7%) surgeries with an average of 2.2 specimens per surgery. A total of 341 aerobic, 331 anaerobic, 187 fungal, and 174 acid-fast cultures were collected. Positive cultures were found in 52 of 341 (15.2%) aerobic cultures and 36 of 331 (10.9%) anaerobic cultures. The most commonly isolated organism was Cutibacterium acnes (42.2%), followed by methicillin-resistant Staphylococcus aureus (15.6%), coagulase-negative Staphylococcus species (13.3%), and methicillin-sensitive S. aureus (12.2%). There were zero positive fungal or acid-fast cultures in our series. The total billing charges for aerobic, anaerobic, fungal, and acid-fast cultures over the study period were $77,748, $23,832, $8,789, and $106,662, respectively, with atypical cultures accounting for 53.2% of the total charges for all cultures. For a single sample sent for all 4 culture types, atypical cultures account for 69% of the total amount charged.

CONCLUSION

Isolation of fungal or acid-fast organisms at the time of revision shoulder arthroplasty is rare and imposes a considerable financial burden when these atypical cultures are sent on a routine basis. The collection of fungal and acid-fast cultures should be reserved for patients in whom risk factors for these atypical organisms have been identified.

The diagnostic effect of α-defensin, D-dimer, and IL-6 in periprosthetic joint infection: A systematic review and diagnostic meta-analysis

BACKGROUND

Periprosthetic joint infection (PJI) is the most common complication after artificial joint replacement as previously reported. However, the main problem at present is its difficulty in diagnosis. This systematic review and meta-analysis aimed to compare the diagnostic accuracy of α-defensin, D-dimer, and interleukin-6 (IL-6) in clinical practice.

METHOD

Online databases were systematically searched until June 18th, 2020 with keywords and medical sub-headings terms. Studies mentioned the sensitivity and specificity of biological markers in detecting PJI were included in our study. The sensitivity, specificity, and diagnostic odds ratios (DORs) were obtained after integration.

RESULTS

A total of 34 studies with 1036 patients diagnosing as PJI were included for comparing α-defensin, D-dimer, and IL-6. The sensitivity and specificity of α-defensin for PJI were 0.88 and 0.96, and the DOR was 189 (95% CI 72-496), respectively. The sensitivity and specificity of D-dimer (0.82 and 0.72) and IL-6 (0.80 and 0.89) were lower than α-defensin.

CONCLUSION

The detection of α-defensin is a promising biomarker for diagnosing PJI. The optional cut-off needs to be curtained when using other biomarkers.