A preformed antibiotic-loaded spacer for treatment for septic arthritis of the shoulder

One- vs. Two-Stage Revision for Periprosthetic Shoulder Infections: A Systematic Review and Meta-Analysis

Periprosthetic shoulder infection (PSI) remains a challenging complication after shoulder arthroplasty. Therapeutic options include one- or two-stage revision, irrigation and debridement, and resection arthroplasty. With our systematic review and meta-analysis, we aimed to compare one- and two-stage revisions for periprosthetic shoulder joint infections and determine the most appropriate therapeutic procedure. We performed an extensive literature search in PubMed, Ovid Medline, Cochrane Library, Web of Science, and CINAHL and filtered out all relevant studies. The meta-analysis was performed using the random-effects model, heterogeneity was analyzed using I2, and publication bias was assessed using the Egger's test. A total of 8 studies with one-stage revisions, 36 studies with two-stage revisions, and 12 studies with both one-stage and two-stage revisions were included. According to the random-effects model, the reinfection rate for the entirety of the studies was 12.3% (95% Cl: 9.6-15.3), with a low-to-moderate heterogeneity of I2 = 47.72%. The reinfection rate of the one-stage revisions was 10.9%, which was significantly lower than the reinfection rate of the two-stage revisions, which was 12.93% (p = 0.0062). The one-stage revision rate was significantly lower with 1.16 vs. 2.25 revisions in the two-stage revision group (p < 0.0001). The postoperative functional outcome in one-stage-revised patients was comparable but not statistically significant (p = 0.1523). In one- and two-stage revisions, most infections were caused by Cutibacterium acnes. In summary, our systematic review and meta-analysis show the superiority of single-stage revision regarding reinfection and revision rates in periprosthetic shoulder joint infection.

Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis

BACKGROUND

There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty.

METHODS

Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model.

RESULTS

After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03).

CONCLUSIONS

This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.

Antibiotic Spacers for Shoulder Periprosthetic Joint Infection: A Review

Periprosthetic joint infection is a rare but potentially devastating complication of shoulder arthroplasty. The most conservative treatment approach is a two-stage revision involving interval placement of an antibiotic cement spacer. The purpose of this study was to contextualize the use of antibiotic spacers in the current treatment paradigm of shoulder periprosthetic joint infection and to review the history of shoulder spacers, the different types (eg, stemmed versus stemless and prefabricated versus handmade), the antibiotic composition and dosage, and their efficacy and complications.

Advanced septic arthritis of the shoulder treated by a two-stage arthroplasty

BACKGROUND

The usual treatment of septic shoulder arthritis consists of arthroscopic or open lavage and debridement. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication. In such cases a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage is gaining popularity in recent years with the data in literature however being still limited.

AIM

To evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.

METHODS

We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.

RESULTS

Mean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70% respectively.

CONCLUSION

Short interval two-stage approach for septic shoulder arthritis is an effective treatment option. It should nonetheless be reserved for selected patients with advanced disease in which lavage and debridement have failed.

An Anatomic Intraoperatively Prepared Antibiotic Spacer in Two-Stage Shoulder Reimplantation for Deep Infection: The Potential for Early Rehabilitation

Molded antibiotic shoulder spacers allow for intraoperative customization of antibiotics and multiple size options. The purpose of this study was to evaluate the efficacy of an anatomic intraoperatively molded spacer in the two-stage treatment of infection and to assess the safety of early rehabilitation when the capsule and rotator cuff are present. During 2014 and 2015, 27 shoulders were treated with a molded antibiotic cement spacer as part of a two-stage treatment. Indications included periprosthetic joint infection (n=18), native shoulder infection (n=8), and infection after internal fixation (n=1). All patients were followed for a minimum of 2 years. Mean follow-up time was 29.6 months. Patients were allowed to perform motion exercises (group I; n=16) or were instructed to avoid motion (group II; n=11) after spacer implantation, depending on the condition of their rotator cuff. Infection was eradicated in 23 of the 27 shoulders (85%). At most recent follow-up, pain scores were lower in group I. Mean final elevation was 115° in group I compared with 93° in group II. Mean final active external rotation was 36°, with no difference between the groups. In 3 (4%) shoulders with significant proximal humeral bone loss, the spacer became rotationally unstable. An anatomic intraoperatively molded spacer can be implanted safely in two-stage treatment for deep infection and has a reasonable rate of eradication. When adequate capsule and rotator cuff tissue is present, early motion in between stages can be safely recommended with a trend toward improved forward elevation at final follow-up and may facilitate the second stage reimplantation. [Orthopedics. 2019; 42(4):211-218.].

Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty

BACKGROUND

The aim of this scoping review is to assess the current evidence regarding periprosthetic shoulder infection to inform development of evidence and consensus-based guidelines.

METHODS

A search of Medline, Embase and PubMed was performed; two authors screened the results independently for inclusion.

RESULTS

Totally 88 studies were included. Incidence of periprosthetic shoulder infection ranged from 0.7% to 7%. The most common organisms to cause periprosthetic shoulder infection were Propionibacterium acnes, Staphylococcus aureus, Staphylococcus epidermidis and coagulase-negative Staphylococcus. Male gender and younger age are the most reported risk factors. Erythrocyte sedimentation rate, C-reactive protein and serum/synovial biomarkers had limited diagnostic accuracy. Thirty-nine studies reported the outcome of surgical management of periprosthetic shoulder infection. Eradication rates vary from 54% to 100% for debridement procedures; 66-100% for permanent spacers; 50-100% following single-stage revision; 60-100% following two-stage revision; and 66-100% following resection arthroplasty.

CONCLUSION

There is wide heterogeneity in study designs and outcomes of studies are often contradictory and due to issues with methodology and small sample sizes the optimal pathways for diagnosis and management cannot be determined from this review. Future research should be based on larger cohorts and randomised trials where feasible to provide more valid research for guiding future treatment of periprosthetic shoulder infection.

One-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm

BACKGROUND

Studies on 1-stage exchange in septic shoulder arthroplasty are limited and show a wide variation of treatment strategies. This retrospective study investigated infection-free survival and function of 1-stage exchange of septic shoulder arthroplasty following a standardized treatment algorithm.

METHODS

The requirement for 1-stage exchange was an isolated microorganism from synovial fluid aspiration or synovial biopsy with an antibiotic susceptibility profile prior to revision surgery. If no microorganism was isolated or the underlying pathogen was a difficult-to-treat microorganism (not accessible for biofilm-active antibiotics, enterococci, and fungi), 2-stage exchange was performed. Function was assessed by the Constant score.

RESULTS

Fourteen patients were included, with a mean follow-up period of 5.8 years. The most and second most commonly detected microorganisms were Cutibacterium acnes (formerly Propionibacterium acnes), and Staphylococcus epidermidis, respectively. At 1-stage exchange, patients received local and systemic antibiotics based on the susceptibility profile of the microorganism. Twelve patients with insufficient rotator cuffs received reverse shoulder arthroplasty, whereas 2 patients with intact rotator cuffs underwent anatomic total shoulder arthroplasty. The infection-free survival rate at 1 and 5 years was 100% and 93% (95% confidence interval [CI], 59%-99%), respectively, with 1 recurrence of infection 22 months after 1-stage exchange. Another patient with limited range of motion underwent revision 6 months postoperatively, leading to a revision-free survival rate of 93% (95% CI, 59%-99%) and 86% (95% CI, 54%-96%) at 1 and 5 years, respectively. The mean Constant score was 65 (range, 44-95).

CONCLUSION

One-stage exchange with prior detection of the underlying microorganism provides satisfactory infection-free survival and function.

Complications of antibiotic cement spacers used for shoulder infections

BACKGROUND

Our aim was to evaluate complications related to commercially available antibiotic cement spacers used in the treatment of shoulder infections.

METHODS

We performed a retrospective review of commercially available antibiotic spacers implanted in 53 patients (60 spacers) between April 2009 and October 2017 as part of a 2-stage treatment plan for infection at the site of a shoulder arthroplasty (n = 39), other (non-arthroplasty) shoulder surgery (n = 8), or primary shoulder infection without previous surgery (n = 6). All patients were followed up from spacer placement to second-stage revision to shoulder arthroplasty. Ten patients retained the spacers and were followed up for a minimum of 1 year.

RESULTS

No complications were associated with implantation of the spacers. Of the 44 patients (50 spacers) who underwent a second-stage revision after a mean interval of 6 months (range, 2-18 months), 14 patients had 18 complications. Fourteen complications occurred between implantation and removal. The most common complication was bone erosion (6 in the glenoid and 2 in the humeral shaft). Other complications were fractures of the spacer (n = 4), spacer rotation (n = 3), and humeral fracture (n = 3). Two complications required reoperation. There were 4 spacer-related complications among the 10 patients who retained the implant (3 erosions of the humeral shaft and 1 humeral shaft fracture); none required reoperation or removal.

CONCLUSIONS

Complications related to antibiotic spacers are common especially between the first and second stage of revision, and awareness of these complications is important for the treating provider.

Periprosthetic Joint Infection of Shoulder Arthroplasties: Diagnostic and Treatment Options

Periprosthetic joint infection (PJI) is one of the most frequent reasons for painful shoulder arthroplasties and revision surgery of shoulder arthroplasties. Cutibacterium acnes (Propionibacterium acnes) is one of the microorganisms that most often causes the infection. However, this slow growing microorganism is difficult to detect. This paper presents an overview of different diagnostic test to detect a periprosthetic shoulder infection. This includes nonspecific diagnostic tests and specific tests (with identifying the responsible microorganism). The aspiration can combine different specific and nonspecific tests. In dry aspiration and suspected joint infection, we recommend a biopsy. Several therapeutic options exist for the treatment of PJI of shoulder arthroplasties. In acute infections, the options include leaving the implant in place with open debridement, septic irrigation with antibacterial fluids like octenidine or polyhexanide solution, and exchange of all removable components. In late infections (more than four weeks after implantation) the therapeutic options are a permanent spacer, single-stage revision, and two-stage revision with a temporary spacer. The functional results are best after single-stage revisions with a success rate similar to two-stage revisions. For single-stage revisions, the microorganism should be known preoperatively so that specific antibiotics can be mixed into the cement for implantation of the new prosthesis and specific systemic antibiotic therapy can be applied to support the surgery.

Acrylic bone cement: current concept review

Acrylic bone cement has had for years an important role in orthopedic surgery. Polymethylmethacrylate (PMMA) has been extended from the ophthalmological and dental fields to orthopedics, as acrylic cement used for fixation of prosthetic implants, for remodeling osteoporotic, neoplastic and vertebral fractures repair. The PMMA bone cement is a good carrier for sustained antibiotic release in the site of infection. Joint prostheses chronic infection requires surgical removal of the implant, in order to eradicate the infection process. This can be performed in the same surgical time (one-stage procedure) or in two separate steps (two-stage procedure, which involves the use of an antibiotic-loaded cement spacer). The mechanical and functional characteristics of the spacers allow a good joint range of motion, weight-bearing in selected cases and a sustained release of antibiotic at the site of infection. The improvement of fixation devices in recent years was not accompanied by the improvement of elderly bone quality. Some studies have tested the use of PMMA bone cement or calcium phosphate as augmentation support of internal fixation of these fractures. Over the past 20 years, experimental study of acrylic biomaterials (bone cement, bioglass ceramic, cement additives, absorbable cement, antibiotic spacers) has been of particular importance, offering numerous models and projects.