One Versus 2-Stage Revision for Shoulder Arthroplasty Infections: A Systematic Review and Analysis of Treatment Selection Bias

Infection after shoulder replacement: A literature review and strategies on diagnosis, management, and clinical outcomes

Infection following shoulder arthroplasty is on the rise as recent data have shown, potentially due to the increase in the number of shoulder arthroplasties being performed. Despite this increase, infective complications in lower limb procedure still exceed those of the upper limb. Infection in the shoulder usually occurs as a low-grade infection due to the most common causative pathogen (Propionibacterium acnes) and can be easily missed. Therefore, a high index of suspicion is needed to make the diagnosis. Furthermore, the use of MSIS criteria can greatly enhance the diagnosis of Periprosthetic Joint Infection (PJI) if appropriately utilised. There are a number of options in the treatment of PJIs; with the 2-stage procedure appearing to be the most commonly utilised, however, the 1-stage has been shown to have similar outcomes, if not superior. The choice of antibiotics should be determined by the antimicrobial susceptibility test and in conjunction with local guidelines and microbiology support. This is usually done as part of the preoperative work up from the pre-surgical aspirate/specimen cultures.

Shoulder arthroplasty in the management of native shoulder joint infections has a high complication rate and poor functional outcome - a systematic review

Background

Shoulder arthroplasty is a treatment option of the sequelae of native shoulder joint infections. However, the functional outcomes and re-infection rates are unknown. The aim of this review was to analyse the outcome of shoulder arthroplasty in patients with native shoulder infections.

Methods

A review of the online databases MEDLINE and Embase was conducted according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Studies reporting either primary or secondary infections of native shoulder joints treated with any form of arthroplasty were included and appraised using the methodological index for non-randomised studies (MINORS) tool.

Results

Fourteen studies were eligible for inclusion. Mean age ranged from 56 to 72 years and the mean follow-up from 20.5 months to 8.2 years. Primary shoulder infections were present in 50 patients and secondary infections in 86. 76 patients underwent a two stage: 46 patients a single-stage procedure whilst 14 refused second-stage surgery. Mean post-operative Constant score ranged from 38 to 56.2. The overall reported re-infection rate was 2.3% and complication rate was 26%.

Conclusion

Shoulder arthroplasty in the management of either primary or secondary native shoulder infections has a high complication rate and low functional outcome but low re-infection rates at short-term follow-up.

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.

[Shoulder periprosthetic infections-what to do? : Diagnosis and treatment]

Treatment of an infected shoulder prosthesis differs significantly from other joint infections because of the unique microbiome, dominated by Cutibacterium acnes. The cause of an infection, its time of onset, the bacterial spectrum and comorbidities have to be considered for evaluation and treatment. The diagnostic workup is sometimes complex, and the recognition of a chronic and low-grade infection is often difficult because typical clinical and laboratory markers may be normal. Treatment is surgical; the therapeutic spectrum ranges from arthroscopic irrigation and open debridement with the exchange of components to one- and two-stage revisions using antibiotic-loaded spacers. Early detection and a targeted, appropriate therapy are crucial to avoid extensive soft tissue and bone damage.