Antibiotic prophylaxis in primary and revision shoulder replacement: a systematic review

The Evolution of Reverse Shoulder Arthroplasty: A Review of Complications and the Rising Concern of Overuse

Reverse shoulder arthroplasty (RSA) was initially developed to manage cuff tear arthropathy in elderly patients. It has since become increasingly popular due to its ability to provide pain relief, enhance stability, and improve function in various complex shoulder pathologies. This review examines the evolution of RSA, including its expanded indications for use, complications, and the rising concern of potential overuse. While RSA has shown significant benefits in selected cases, its growing application in younger and more active patients raises questions about long-term outcomes and durability. Complications such as instability, infection, baseplate failure, and scapular notching remain substantial challenges, particularly in revision cases. The article emphasises the need for cautious patient selection and evidence-based practice to avoid overuse and ensure optimal patient outcomes. Future high-quality research with extended follow-up is essential to better understand RSA's long-term efficacy and safety, particularly in diverse and younger patient populations.

[Endoprosthesis in proximal humerus fractures -What is important?]

In cases of complex proximal humeral fractures a fracture prosthesis is an established treatment option. In the geriatric patient population, the use of reverse total shoulder arthroplasty is gaining in relevance. This article focuses on the specific requirements and challenges associated with the application of reverse total shoulder arthroplasty. Decisive for the success are a structured perioperative management, meticulous preoperative planning, thorough patient education and standardized protocols for infection and bleeding prophylaxis. Intraoperatively, emphasis is placed on precise implantation techniques and stable tuberosity fixation, of which the latter is essential for postoperative function. A humeral inclination of 135° has been shown to be associated with better tuberosity healing. Complications, such as scapular notching or instability can be minimized through an accurate surgical technique and optimized implant management. Postoperative care is tailored to the individual, employing either a shoulder abduction brace or an early functional rehabilitation approach. Overall, reverse shoulder arthroplasty provides an effective fracture treatment for geriatric patients, ensuring long-term functional and clinical benefits.

Antibiotic prophylaxis and incidence of infection following elbow arthroplasty: a nationwide study

BACKGROUND AND PURPOSE

 Periprosthetic joint infection (PJI) after elbow arthroplasty is a serious complication. Evidence of the best antibiotic prophylaxis for elbow arthroplasty is lacking. We aimed to investigate the regimens presently used in Sweden, incidence of PJI, and the bacteria most frequently found in elbow PJI.

METHODS

 A questionnaire was sent out to all Swedish units performing elbow arthroplasty in 2019 asking about antibiotic prophylaxis routines. The Swedish Elbow Arthroplasty Register (SEAR) and national inpatient and outpatient registers (NPR) from the National Board of Health and Welfare were searched for procedures related to all primary total- or hemi-elbow arthroplasties performed during 2019-2021. Results of microbiological analyses of the suspected PJI cases were collected from the respective laboratory.

RESULTS

 Most centers used only cloxacillin (44%) or cloxacillin together with benzylpenicillin (44%), as prophylaxis. 250 primary procedures were performed between 2019 and 2021, and the most used antibiotic prophylaxes were cloxacillin (61%) and cloxacillin with benzylpenicillin (23%). In the NPR, 20 patients (8%) with a diagnosis that could indicate PJI were found and 9 (3.6%) had a confirmed PJI. The most common bacteria were Staphylococcus epidermidis, Cutibacterium acnes, and Staphylococcus aureus.

CONCLUSION

 Most centers used cloxacillin antibiotic prophylaxis for elbow arthroplasty. The incidence of PJI was 3.6%. The most frequent diagnosed pathogen was Staphylococcus epidermidis.

Shoulder Periprosthetic Joint Infection: Principles of Prevention, Diagnosis, and Treatment

➢ Shoulder periprosthetic joint infection (PJI) is a potentially devastating complication after arthroplasty and is projected to rise with increasing numbers of performed arthroplasties, particularly reverse shoulder arthroplasties.➢ Important considerations for the diagnosis and treatment of shoulder PJI include age, sex, implant type, primary compared with revision shoulder surgery, comorbidities, and medications (i.e., corticosteroids and disease-modifying antirheumatic drugs). ➢ Diagnosis and management are unique compared with lower-extremity PJI due to the role of lower-virulence organisms in shoulder PJI, specifically Cutibacterium acnes.➢ Treatment pathways depend on chronicity of infection, culture data, and implant type, and exist on a spectrum from irrigation and debridement to multistage revision with temporary antibiotic spacer placement followed by definitive revision arthroplasty.

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.

A Literature Review of Cutibacterium Acnes: From Skin Commensal to Pathogen in Shoulder Surgery

Cutibacterium acnes, previously known as Propionibacterium acnes, is a gram-positive rod in the pilosebaceous glands and commonly implicated in acne vulgaris. Its role in prosthetic joint infections, particularly in shoulder surgeries, has recently gained attention due to its prevalence around the shoulder girdle. This review collates evidence on the pathogenic role of C. acnes in shoulder surgeries, discussing preventive measures, risk factors, clinical presentation, investigation, and treatment strategies. C. acnes infections are complex, often presenting with non-specific symptoms and delayed diagnoses. Risk factors include male sex, presence of hair, shoulder steroid injections, and previous shoulder surgeries. Investigations such as inflammatory markers, synovial fluid analysis, diagnostic arthroscopy, tissue cultures, and advanced molecular techniques like next-generation sequencing and multiplex polymerase chain reaction are explored for their effectiveness in detecting C. acnes. Treatment strategies range from prolonged antibiotics and antibiotic spacers to single-stage and two-stage revision surgeries. Studies indicate that single-stage revision may provide better outcomes compared to two-stage revision. Effective management of C. acnes infections requires careful assessment, relevant investigations, and tailored treatment approaches. This review emphasizes the need for further research to address intraoperative contamination and to develop more efficient diagnostic and treatment methods.

The influence of gut microbiome on periprosthetic joint infections: State-of-the art

Early periprosthetic joint infection constitutes one of the most frightening complications of joint replacement. Recently, some evidence has highlighted the potential link between dysregulation of the gut microbiota and degenerative diseases of joints. It has been hypothesized that microbiome dysbiosis may increase the risk of periprosthetic joint infection by facilitating bacterial translocation from these sites to the bloodstream or by impairing local or systemic immune responses. Although the processes tying the gut microbiome to infection susceptibility are still unknown, new research suggests that the presurgical gut microbiota-a previously unconsidered component-may influence the patient's ability to resist infection. Exploring the potential impact of the microbiome on periprosthetic joint infections may therefore bring new insights into the pathogenesis and therapy of these disorders. For a successful therapy, a proper surgical procedure in conjunction with an antibacterial concept is essential. As per the surgical approach, different treatment strategies include surgical irrigation, debridement, antibiotic therapy, and implant retention with or without polyethylene exchange. Other alternatives could be one-stage or two-stage revisions surgery. Interventions that either directly target gut microbes as well as interventions that modify the composition and/or function of the commensal microbes represent an innovative and potentially successful field to be explored. In recent times, innovative therapeutic methods have arisen in the realm of microbiome restoration and the management of gut-related ailments. These progressive approaches offer fresh perspectives on tackling intricate microbial imbalances in the gastrointestinal tract. These emerging therapies signify a shift towards more precise and individualized approaches to microbiome restoration and the management of gut-related disorders. Once a more advanced knowledge of the pathways linking the gut microbiota to musculoskeletal tissues is gained, relevant microbiome-based therapies can be developed. If dysbiosis is proven to be a significant contributor, developing treatments for dysbiosis may represent a new frontier in the prevention of periprosthetic joint infections.

Debridement, antibiotics, and implant retention (DAIR) for the early prosthetic joint infection of total knee and hip arthroplasties: a systematic review

PURPOSE

Early periprosthetic joint infection (PJI) represents one of the most fearsome complications of joint replacement. No international consensus has been reached regarding the best approach for early prosthetic knee and hip infections. The aim of this updated systematic review is to assess whether debridement, antibiotics, and implant retention (DAIR) is an effective choice of treatment in early postoperative and acute hematogenous PJI.

METHODS

This systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The diagnostic criteria defining a PJI, the most present pathogen, and the days between the index procedure and the onset of the PJI were extracted from the selected articles. Additionally, the mean follow-up, antibiotic regimen, and success rate of the treatment were also reported.

RESULTS

The articles included provided a cohort of 970 patients. Ten studies specified the joint of their cohort in PJIs regarding either hip prostheses or knee prostheses, resulting in 454 total knees and 460 total hips. The age of the patients ranged from 18 to 92 years old. Success rates for the DAIR treatments in the following cohort ranged from 55.5% up to a maximum of 90% (mean value of 71%).

CONCLUSION

Even though the DAIR procedure is quite limited, it is still considered an effective option for patients developing an early post-operative or acute hematogenous PJI. However, there is a lack of studies, in particular randomized control trials (RCTs), comparing DAIR with one-stage and two-stage revision protocols in the setting of early PJIs, reflecting the necessity to conduct further high-quality studies to face the burden of early PJI.

The Choice of Antibiotic Prophylaxis Influences the Infection Reoperation Rate in Primary Shoulder Arthroplasty: Analysis From the Swedish Shoulder Arthroplasty Register

BACKGROUND

Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes , benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection.

QUESTIONS/PURPOSES

After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin?

METHODS

Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model.

RESULTS

When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio [HR] 2.40 [95% confidence interval (CI) 1.35 to 4.25]; p = 0.003) and compared with clindamycin alone (HR 1.78 [95% CI 1.11 to 2.85]; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 [95% CI 0.42 to 1.32]; p = 0.31).

CONCLUSION

Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method.

LEVEL OF EVIDENCE

Level Ⅲ, therapeutic study.

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.

Complications of reverse shoulder arthroplasty: a concise review

Reverse shoulder arthroplasty is an ideal treatment for glenohumeral dysfunction due to cuff tear arthropathy. As the number of patients treated with reverse shoulder arthroplasty is increasing, the incidence of complications after this procedure also is increasing. The rate of complications in reverse shoulder arthroplasty was reported to be 15%-24%. Recently, the following complications have been reported in order of frequency: periprosthetic infection, dislocation, periprosthetic fracture, neurologic injury, scapular notching, acromion or scapular spine fracture, and aseptic loosening of prosthesis. However, the overall complication rate has varied across studies because of different prosthesis used, improvement of implant and surgical skills, and different definitions of complications. Some authors included complications that affect the clinical outcomes of the surgery, while others reported minor complications that do not affect the clinical outcomes such as minor reversible neurologic deficit or minimal scapular notching. This review article summarizes the processes related to diagnosis and treatment of complications after reverse shoulder arthroplasty with the aim of helping clinicians reduce complications and perform appropriate procedures if/when complications occur.