Periprosthetic Shoulder Infection Research Articles

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.

The effect of different antibiotic combinations in calcium sulfate cement on the growth of Cutibacterium acnes and Staphylococcus periprosthetic shoulder infection isolates

BackgroundProsthetic joint infections (PJI) of the shoulder are a devastating complication of shoulder arthroplasty and are commonly caused by Staphylococcus and Cutibacterium acnes. Absorbable calcium sulfate beads are sometimes used for delivering antibiotics in PJI. This study evaluates the in vitro effect of different combinations of gentamicin, vancomycin, and ertapenem in beads made from calcium sulfate cement on the growth of C. acnes and coagulase-negative Staphylococcus strains. MethodsThree strains of C. acnes and five strains of coagulase-negative Staphylococcus from clinically proven shoulder PJI were cultured and plated with calcium sulfate beads containing combinations of vancomycin, gentamicin, and ertapenem. Plates with C. acnes were incubated anaerobically while plates with Staphylococcus were incubated aerobically at 37°C. Zones of inhibition were measured at intervals of 3 and 7 days using a modified Kirby Bauer technique, and beads were moved to plates containing freshly streaked bacteria every 7th day. This process was run in triplicate over the course of 56 days. Statistical analysis was conducted using SPSS v. 28 with repeated measures ANOVA and pairwise comparisons with Tukey correction. ResultsIn experiments with C. acnes, beads containing ertapenem + vancomycin and vancomycin alone formed the largest zones of inhibition over time (p<.001). In experiments with Staphylococcus, beads containing vancomycin alone formed the largest zones of inhibition over time for all five strains (p<.001). Zones of inhibition were 1.4x larger for C. acnes than for Staphylococcus with beads containing vancomycin alone. For both C. acnes and Staphylococcus, beads containing ertapenem had the strongest initial effect, preventing all bacterial growth in C. acnes and almost all growth for Staphylococcus during the first week but dropping substantially by the second week. Beads containing gentamicin alone consistently created smaller zones of inhibition than beads containing vancomycin alone, with vancomycin producing zones 5.3x larger than gentamicin in C. acnes and 1.3x larger in Staphylococcus (p<.001). DiscussionThese data suggest that for both C. acnes and Staphylococcal species, calcium sulfate beads impregnated with vancomycin were most effective at producing a robust antibiotic effect. Additionally, ertapenem may be a viable supplement in order to create a more potent initial antibiotic effect but is not as effective as vancomycin when used alone. Gentamicin alone was not effective in maintaining consistent and long-term antibiotic effects. These results indicate that amongst the antibiotics currently commercially available to be used with calcium sulfate, vancomycin is consistently superior to gentamicin in the setting of C. acnes and coagulase negative Staphylococci.

Preoperative Prophylactic Antibiotics Administration Does Not Influence Culture Yield in Revision Shoulder Arthroplasty.

The importance of administrating prophylactic antibiotics prior to a surgical procedure is well established. Given the difficulty in diagnosing shoulder periprosthetic infections, which are more indolent in nature, some advocate holding prophylactic antibiotics prior to obtaining cultures as there is a concern antibiotics may lead to a false negative culture result. The purpose of this study is to determine whether administration of antibiotics prior to obtaining cultures in revision shoulder arthroplasty influences culture yield. This was a retrospective analysis of revision shoulder arthroplasty cases performed at a single institution between 2015 and 2021. During the study period, each surgeon had a standardized protocol that dictated whether antibiotics were given or held prior to each revision surgery. Each case was categorized into either a Pre-culture antibiotic group, if antibiotics were administered prior to incision, or a Post-culture antibiotic group if antibiotics were administered after incision and obtaining cultures. Basic demographics and the International Consensus Meeting (ICM) scoring criteria provided by the Musculoskeletal Infection Society was used to categorize the probability of periprosthetic joint infection for each case. Culture positivity was calculated as the ratio of positive cultures and total number of cultures obtained. One hundred and twenty-four patients met inclusion criteria. There were 48 patients in the Pre-culture group and 76 patients in the Post-culture group. No significant difference in patient demographics or ICM criteria (p=0.09) was observed between the two groups. With regards to culture positivity, there was no difference between the Pre-culture antibiotic group and the Post-culture antibiotic group (16% vs 15%, p=0.82, confidence interval= 8-25% vs. 10-20%, respectively). In the setting of revision shoulder arthroplasty, timing of antibiotic administration did not significantly influence culture yield. This study supports the use of prophylactic antibiotics prior to obtaining cultures in revision shoulder arthroplasty.

Transcutaneous compression suture with iodine gauze for wound closure in revision surgery for therapy-resistant periprosthetic shoulder infections

To successfully treat a periprosthetic infection, successful bacteria eradication and successful wound closure are mandatory. Despite adequate surgical débridement in the deep, persistence of wound drainage and subsequent persistence of periprosthetic infection may occur, especially in patients with compromised soft tissue conditions. This study presents a transcutaneous compression suture technique with iodine gauze that was used in patients with persistent wound secretion in therapy-resistant periprosthetic shoulder infections in order to achieve successful infection control and wound healing. All patients with persistent periprosthetic or implant-associated shoulder joint infections despite correct previous surgical and antibiotic therapy attempts were included in the study. In all patients, in addition to repeat deep surgical débridement, a transcutaneous "iodine-gauze-compression-suture" was performed with postoperative antibiotic therapy. The primary endpoint was infection control; the secondary endpoint was wound healing rate; and the third endpoint was complication rate after index surgery. Ten consecutive patients with a mean age of 74 (±7.6) years and a mean follow-up of 14 (±2) months were included. All ten patients showed infection control and successful wound healing, with no need for further revision surgery. In 8 out of 10 patients, the wound healing was fast and completely uncomplicated. Two out of 10 patients showed delayed wound healing with fibrin coatings for 3 and 4 weeks, respectively. No additional intervention was necessary in both patients. Transcutaneous iodine gauze compression sutures were used to achieve successful infection control without additional revision surgery in 10 out of 10 patients who previously underwent surgery with failed infection control. This wound closure technique is a reliable adjunctive therapy method in the treatment of implant-associated infections of the shoulder in patients with fragile wound conditions.

Revision of failed reverse total shoulder arthroplasty with reverse: short-term clinical outcomes

The prevalence of failed reverse total shoulder arthroplasty (rTSA) is increasing. This can often present a challenging clinical situation with substantial bone loss and limited reconstruction options. This study reports a single tertiary referral center's experience with revision of failed rTSA managed with revision rTSA of bone-interfacing components. Following institutional review board approval, all revision shoulder arthroplasty cases performed at a single institution between 2012 and 2020 were reviewed. Cases in which rTSA was revised to a new rTSA construct with revision of at least one bone-interfacing implant (humeral stem and/or baseplate) with a minimum two-year follow-up were identified. Characteristics of revision cases-including indications, bony stock, revised components, and use of bone graft-were collected. All patients were contacted for patient-reported outcome measures at a minimum of two-years following surgery. In addition, the incidence and indication for any reoperation following revision were determined. Thirty-three patients with an average age of 66 years (range: 46-82) 19 (58%; 19/33) being female met inclusion criteria and had a mean follow-up of 4.2 years (range: 2-8). The most common indication for revision rTSA included humeral component loosening (33%; 11/33), baseplate loosening (27%; 9/33), and instability (21%; 7/33). Pre-revision infectious workup demonstrated no cases of periprosthetic shoulder infection. Thirteen cases had massive bone loss-five treated with humeral allograft prosthetic composite, five with glenoid bone grafting, and three with custom glenoid implant. In total, 10 cases (30%; 10/33) required re-operation at mean of 13 months (range: 1-44) for instability (4), humeral loosening (2), infection (1), baseplate loosening (1), or periprosthetic fracture (1). The re-operation rate for patients with revised baseplates only, humerus only, or combined was 23% (3/13), 28% (5/18), and 27% (3/11), respectively. Overall, VAS pain improved from 6.5 preoperatively to 2.0 (p<0.001) and the ASES score improved from 30.7 to 67.5 (p<0.001). However, postoperative SANE score averaged only 51.2% (range: 2-100). This study demonstrates that failed rTSA can be salvaged with a revision rTSA. However, patient expectations for functional improvements should be tempered and a high re-operation rate should be expected.

Vancomycin powder embedded in collagen sponge decreases the rate of prosthetic shoulder infection.

Shoulder arthroplasty is a successful procedure to treat degenerative and traumatic diseases of the glenohumeral joint. Periprosthetic infection represents an infrequent but dreaded complication (2%-4%). Application of intrawound vancomycin powder seems to reduce periprosthetic infections, but limited information is available on its efficiency in shoulder arthroplasty. The purpose of this study was to evaluate if the vancomycin powder embedded in a collagen sponge could decrease the rate of prosthetic shoulder infection. A retrospective analysis of 827 patients undergoing total shoulder arthroplasty was performed. The study involved a control group of 405 patients and a group of 422 with the intraoperative insertion of intrawound vancomycin powder. Incidence of periprosthetic infection was evaluated comparing the 2 groups at a minimum follow-up of 12 months. Patient demographics, comorbidities, and perioperative information were compared between the 2 groups. No infection was observed in the group treated with intrawound vancomycin, and 13 cases of infection were observed in the control group (3.2%) (P value <.001) without subacromial vancomycin application. No wound complications requiring revision were observed as a result of intrawound vancomycin application. Intrawound vancomycin powder significantly reduces the rate of periprosthetic shoulder infections without any increase in local and systemic aseptic complications at a minimum follow-up of 12 months. Our results support the use of intrawound local vancomycin for prophylaxis of shoulder periprosthetic infections.

One-stage revision for infected shoulder arthroplasty: prospective, observational study of 37 patients

Periprosthetic joint infection is a severe complication of joint replacement surgery. Thus two-stage exchange remains the gold standard, one-stage exchange is now widely recommended. We hypothesized that, for patients with chronic periprosthetic shoulder infection (PSI), treatment with a one-stage exchange would be an effective approach to eradicate infection, relieve pain, and restore function to the involved shoulder. This monocenter cohort study in a Bone and Joint Infection Referral Center (11/2003-05/2020) included all patients with confirmed PSI treated by one-stage revision. Data were extracted from the prospective database, including demographics, infection characteristics, and functional evaluations (range of motion and Constant Score at admission and last follow-up). The primary outcome was the 2-year reinfection-free rate. We included 37 patients. The refection-free rate was 5%. The most commonly isolated pathogen was Cutibacterium acnes (68%), isolated alone (15 patients, 41%) or as polymicrobial infections (10 patients, 27%). The Constant Score increased significantly from 24 to 53 (P=.001). Range of motion (forward elevation, abduction) was also significantly improved after surgery. Mean active forward elevation increased significantly by 45° from 60° to 105° postoperatively (P<.001), mean abduction increased by 42° from 55° to 97° (P<.001). Results from our prospective cohort-extracted series suggest that one-stage revision is a reliable treatment with a low infection recurrence rate. Improved functional outcomes can be achieved with one-stage exchange. Our patients' overall functional results were similar to those previously reported for one-stage revision and better than those reported after two-stage exchange. Patients with multiple previous surgeries seem to have worse functional outcomes than the subgroup without surgery before the index arthroplasty. Our results and literature search findings suggest that one-stage revisions effectively eradicate PSIs, with good functional outcomes.

Arthroscopic tissue biopsy as a preoperative diagnostic test for periprosthetic shoulder arthroplasty infections: a systematic review and meta-analysis.

The diagnosis of periprosthetic infection in shoulder arthroplasty remains a challenge. Conventional methods for evaluating periprosthetic joint infections are poor because of lower-virulence organisms affecting the shoulder. The aim of our systematic review was to evaluate the diagnostic accuracy of preoperative arthroscopic tissue cultures compared with tissue biopsy samples obtained at the time of revision surgery. We conducted a systematic search of the MEDLINE, Embase, and Cochrane Central databases. The inclusion criteria consisted of studies that used arthroscopy to obtain preoperative tissue cultures for the diagnosis of shoulder arthroplasty infections. Studies were excluded if they obtained non-arthroscopic tissue samples. We reported the sensitivity, specificity, positive predictive value, and negative predictive value. Culture findings from the arthroscopic biopsy samples were also compared with conventional tests of fluoroscopy-guided joint aspiration and serum inflammatory marker testing (positive erythrocyte sedimentation rate or C-reactive protein) within the included studies. A meta-analysis was performed to assess the overall diagnostic accuracy of the studies. Our search strategy yielded 795 potentially relevant publications; 572 underwent title and abstract screening, and 14 studies underwent full-text review, of which 7 were included in our systematic review. The studies represented a balance of shoulder arthroplasty types, including anatomic total shoulder arthroplasty (n=75, 38%), reverse total shoulder arthroplasty (n=60, 30%), and hemiarthroplasty (n=64, 32%). There were 56 of 120 arthroscopic procedures that returned positive tissue culture findings compared with 64 of 157 positive open biopsy culture findings obtained from revision surgery. The meta-analysis total for sensitivity and specificity for all studies combined indicated that arthroscopic tissue cultures (0.76 [95% confidence interval (CI), 0.57-0.88] and 0.91 [95% CI, 0.79-0.97], respectively) were superior to both aspiration (0.15 [95% CI, 0.03-0.48] and 0.93 [95% CI, 0.65-0.99], respectively) and a positive erythrocyte sedimentation rate or C-reactive protein level (0.14 [95% CI, 0.02-0.62] and 0.83 [95% CI, 0.56-0.95], respectively) in diagnosing periprosthetic shoulder infections. Our systematic review demonstrated that preoperative arthroscopic tissue biopsy used for microbiology cultures accurately predicts intraoperative culture findings obtained during revision surgery with high sensitivity and specificity. Additionally, arthroscopy appears to be superior to conventional techniques of joint aspiration and inflammatory marker testing. Therefore, arthroscopic tissue cultures may be an emerging useful tool to help guide the management of periprosthetic infections in shoulder arthroplasty.

Tailored modular spacers and handmade spacers in periprosthetic shoulder infection: clinical and functional results after 2-year follow-up

BackgroundThe diagnosis and treatment of periprosthetic shoulder infections are challenging; two-stage procedure using antibiotic-loaded spacers offers appropriate infection resolution and satisfactory clinical results. The main purpose of this study was to compare functional results in patients who keep different type of spacers as definitive treatment after first-stage procedure for periprosthetic shoulder infections. Secondary aim was to evaluate clinical and functional scores comparing patients who still hold the spacers with patients who already underwent prosthesis reimplantation. Materials and MethodsForty eight patients treated with tailored modular (TM) or handmade (HM) spacer for shoulder chronic infection were enrolled. Twenty five patients (52.1%) underwent reverse shoulder arthroplasty implantation; 23 patients (47.9%) decided to hold the spacer and to continue to use it as a functional prosthesis (17 TM spacers, 6 HM spacers). Clinical data were recorded and functional scores were calculated at 35.2-month follow-up after last shoulder surgical procedure. Visual analog pain scale was used to measure pain; Constant Score, Simple Shoulder Test, Disabilities of the Arm, Shoulder and Hand Score, and American Shoulder and Elbow Surgeons score were calculated to assess shoulder function. ResultsWe found no significant score differences in patients treated with different kind of antibiotic spacers after first-stage and second-stage procedure. Prosthesis reimplantation seems to be the best option for patients who are motivated, active, and medically stable, achieving better functional results compared to spacer retention, although we found no statistically significant improvement in pain reduction before and after prosthesis reimplantation. ConclusionsTwo-stage exchange procedures with antibiotic spacer are highly effective in infections eradication. No superiority was found in TM spacers over HM ones when the spacer was retained and when the second-stage procedure took place. Second-stage procedure appears to be effective only in improving shoulder function and not in reducing pain regardless of the kind of antibiotic-loaded spacer used. We suggest to avoid second-stage procedure in low-demanding patients with reasonable shoulder function and acceptable pain control (visual analog scale <3).

Comparison of surgical treatment options in periprosthetic shoulder infections: a systematic review from 2016 to 2022.

Periprosthetic shoulder infection (PSI) management proves to be challenging because of patient morbidity, poor outcomes and need for reoperations. Different surgical treatment methods have been defined; however, a prominent method could not be determined. This systematic review investigated the most recent articles about various treatment modalities used in the surgical treatment of PSI to find the most effective method in terms of infection clearance and function. The keywords were searched using PubMed (MEDLINE), ScienceDirect (Elsevier), and Google Scholar databases on September 30, 2022. Studies which report on operative treatment and have longer than 2-year follow-up were included in this review. Of the 555 studies in total, 16 were reviewed. The absence of symptomatic persistent infection (PI) during follow-up was regarded as a satisfactory outcome. Functional outcomes were analyzed according to the reported mean pooled Constant and Murley Score (CMS) and shoulder forward elevation degree (FE) for each treatment group. A total of 339 patients (139 female, 197 male) with 342 shoulders from sixteen studies were included. The mean age of the patients was 67.5±3.8 years, mean follow-up duration was 53.3±19.5 months. In total, 217 shoulders were treated with two-stage revision, 59 were treated with one-stage revision, 37 were treated with definitive spacer, 23 were treated with debridement, antibiotics, and implant retention (DAIR), and 6 were treated with resection arthroplasty. The PI rate in whole treatment groups was 9.9%. The PI rate was significantly highest in the DAIR group (30.4%, P=0.001), while there was no significant difference between other treatment groups (P=0.23). CMS and FE were available for 156 and 190 shoulders, respectively. CMS was highest in the one-stage revision group (63.4±5.9, P=0.001), and FE was highest in the DAIR group (119.3°±28.5°, P=0.001). The revision surgeries (one-stage and two-stage revision) were more effective than the non-revision surgeries in functional outcomes. In terms of infection clearance, revision procedures were more successful. Surgeons should prefer revision methods over non-revision procedures when feasible.

Changes in microbiological spectrum and antibiotic susceptibility in two-stage exchange for periprosthetic shoulder infections.

Periprosthetic joint infections (PJI) are a major concern in shoulder arthroplasty, which in some cases require two-stage exchange. While it was shown that low-virulence bacteria are the most isolated pathogens in shoulder PJI, little is known about changes in microbiological spectrum and resistance patterns during two-stage revision. This retrospective study included all patients (n = 25) who received a two-stage revision from January 2011 to December 2020 for shoulder PJI in one institution. Microbiological spectrum, antimicrobial resistance patterns, and re-revision rates of culture positive first- and second-stage procedures were analyzed. The mean follow-up time was 29.7months (range 8; 115months). At final follow-up, subjective shoulder value (SSV) and visual analog scale (VAS) score for pain and satisfaction with the surgery were assessed. In 25 patients, a total of 54 2-stage exchange procedures were performed and positive cultures were obtained in 36 of these surgeries (66.7%). A total of 7 out of 25 patients (28.0%) showed a positive microbiological culture at first and second stages. In those patients, the mean time between first and second stages was 30.9weeks (range 6; 70). Three out of those seven patients (42.9%) had a polymicrobial spectrum with one microorganism persistent at stage two, including Cutibacterium acnes (n = 1) and Staphylococcus epidermidis (MRSE) (n = 2). In all these cases, antimicrobial resistance patterns changed. All cultures with monomicrobial spectrum (n = 4) at first stage showed a changed spectrum. Patients with positive first- and second-stage revisions showed a mean SSV of 49.3% ± 23.5 versus 52.9% ± 29.5 in single positive patients (p = 0.76). Re-revision was performed in five cases, two of those in patients with positive first- and second-stage cultures. There is a high rate of changes in microbiological spectrum and resistance patterns between culture positive first- and second-stage procedures as well as subsequent re-revisions. Intraoperative samples during reimplantation should be taken and resistance reconsidered in case of re-revision.

What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study.

Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0±1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P<.001) and the strength of positivity was significantly higher (P<.001) in true-positive cultures compared with false-positive cultures. This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.

Diagnostic Performance of Advanced Metal Artifact Reduction MRI for Periprosthetic Shoulder Infection.

The diagnosis of periprosthetic shoulder infection (PSI) in patients with a painful arthroplasty is challenging. Magnetic resonance imaging (MRI) may be helpful, but shoulder implant-induced metal artifacts degrade conventional MRI. Advanced metal artifact reduction (MARS) improves the visibility of periprosthetic bone and soft tissues. The purpose of our study was to determine the reliability, repeatability, and diagnostic performance of advanced MARS-MRI findings for diagnosing PSI. Between January 2015 and December 2019, we enrolled consecutive patients suspected of having PSI at our academic hospital. All 89 participants had at least 1-year clinical follow-up and underwent standardized clinical, radiographic, and laboratory evaluations and advanced MARS-MRI. Two fellowship-trained musculoskeletal radiologists retrospectively evaluated the advanced MARS-MRI studies for findings associated with PSI in a blinded and independent fashion. Both readers repeated their evaluations after a 2-month interval. Interreader reliability and intrareader repeatability were assessed with κ coefficients. The diagnostic performance of advanced MARS-MRI for PSI was quantified using sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC). When applying the International Consensus Meeting (ICM) 2018 criteria, of the 89 participants, 22 (25%) were deemed as being infected and 67 (75%) were classified as being not infected (unlikely to have PSA and not requiring a surgical procedure during 1-year follow-up). The interreader reliability and intrareader repeatability of advanced MARS-MRI findings, including lymphadenopathy, joint effusion, synovitis, extra-articular fluid collection, a sinus tract, rotator cuff muscle edema, and periprosthetic bone resorption, were good (κ = 0.61 to 0.80) to excellent (κ > 0.80). Lymphadenopathy, complex joint effusion, and edematous synovitis had sensitivities of >85%, specificities of >90%, odds ratios of >3.6, and AUC values of >0.90 for diagnosing PSI. The presence of all 3 findings together yielded a PSI probability of >99%, per logistic regression analysis. Our study shows the clinical utility of advanced MARS-MRI for diagnosing PSI when using the ICM 2018 criteria as the reference standard. Although the reliability and diagnostic accuracy were high, these conclusions are based on our specific advanced MARS-MRI protocol interpreted by experienced musculoskeletal radiologists. Investigations with larger sample sizes are needed to confirm these results. Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Better diagnostic value of tissue cultures obtained during mini-open and arthroscopic procedures compared with sterile punctures to identify periprosthetic shoulder infections: a retrospective cohort study.

This study aimed to determine the sensitivity and specificity of sterile shoulder needle aspiration and cultures obtained during arthroscopic and mini-open procedures for detecting periprosthetic shoulder infections using tissue cultures from revision surgery as the gold standard. All shoulder arthroplasty patients who underwent a synovial fluid puncture between August 2012 and February 2018 were selected. In addition, arthroplasty patients with cultures obtained during arthroscopic or mini-open procedures between May 2014 and May 2021 were selected. When sterile punctures or biopsy procedures were followed by revision surgery with collection of 6 tissue cultures, patients were included in the study and efficacy measures were calculated. Fifty-six patients were included in this study (with 57 punctures) and underwent analysis of puncture results after exclusions. Positive puncture results were found for Cutibacterium acnes, Staphylococcus aureus, Staphylococcus hominis, Actinomyces neuii, and Proteus mirabilis. These puncture cultures showed a sensitivity of 20.0% and specificity of 90.6%. From May 2014 to May 2021, 51 biopsy procedures were performed (15 arthroscopic and 36 mini-open); 37 biopsy procedures were included in this study (12 arthroscopic and 25 mini-open) for analysis after exclusions. Positive culture results were found for C acnes, Staphylococcus epidermidis, Staphylococcus saccharolyticus, and Streptococcus species. Arthroscopic biopsy cultures showed a sensitivity of 60.0% and specificity of 85.7%. For the mini-open biopsy cultures, the sensitivity and specificity were 66.7% and 85.7%, respectively. Sterile punctures for culture have a low sensitivity and a high specificity for diagnosing periprosthetic shoulder infections. Tissue cultures obtained during mini-open and arthroscopic procedures have a higher sensitivity for detecting periprosthetic shoulder infections.

Acne cream reduces the deep Cutibacterium acnes tissue load before elective open shoulder surgery: a randomized controlled pilot trial.

Cutibacterium acnes is the main pathogen in periprosthetic shoulder infections. In acne vulgaris therapy, benzoyl peroxide-miconazole nitrate cream effectively reduces the superficial C acnes burden of the skin. Its additional potential in the subcutaneous and capsular layers (eg, for prevention of future periprosthetic shoulder infections) is unknown. The aim of this study was to investigate the efficacy of a topical acne vulgaris cream (benzoyl peroxide-miconazole nitrate) to reduce subcutaneous and capsular C acnes in individuals with C acnes skin colonization undergoing open shoulder surgery. A prospective randomized pilot trial was performed, allocating 60 adult patients (1:1) to either a 7-day preoperative application of a commercial acne cream (benzoyl peroxide-miconazole nitrate) on the preoperative skin (intervention group) or no cream (control group) from November 1, 2018, to May 31, 2020. The superficial skin of the shoulder was sampled at enrollment and before incision, and deep subcutaneous and capsular shoulder samples were taken during surgery. Sixty patients (mean age, 59 years; 55% female patients) undergoing primary open shoulder surgery (17 Latarjet procedures and 43 arthroplasties) were included in the study. At baseline, both randomized groups showed the presence of C acnes on the skin at a rate of 60% (18 of 30 patients in intervention group and 19 of 30 patients in control group, P=.79). In patients with C acnes skin colonization, the intervention resulted in a significant reduction in the overall number of intraoperative samples with positive findings compared with the control group (8 of 18 patients vs. 16 of 19 patients, P=.01), especially in capsular samples (0 of 18 patients vs. 4 of 19 patients, P=.04). The topical 7-day preoperative skin application of acne cream (benzoyl peroxide-miconazole nitrate) significantly reduced the intraoperative C acnes load in 56% of the patients in the intervention group compared with 16% of the control patients.

Can Metal Artifact Reduction Sequence Magnetic Resonance Imaging (MARS-MRI) Help In The Diagnosis Of Periprosthetic Shoulder Infection?

The purpose of our study was to determine the reliability, repeatability, and diagnostic performance of metal artifact reduction magnetic resonance imaging (MARS-MRI) findings for the diagnosis of peri-prosthetic shoulder infection (PSI).

Outcomes after resection arthroplasty versus permanent antibiotic spacer for salvage treatment of shoulder periprosthetic joint infections: a systematic review and meta-analysis.

Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs. A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I2 statistic. A P value of .05 was set as significant. The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001). When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.

The role of serum D-Dimer for the diagnosis of periprosthetic shoulder infection

IntroductionD-Dimer was recently identified as an additional biomarker in the diagnosis of hip and knee periprosthetic joint infection (PJI). Currently, there is only one study in literature dealing with the role of D-Dimer in the diagnosis of shoulder PJI. The purpose of this study was, therefore, to validate the sensitivity and specificity of D-Dimer in detecting shoulder PJI.Materials and methodsAll patients, who underwent septic or aseptic revision shoulder arthroplasty in our institution between November 2018 und March 2021, were analyzed. Our cohort consisted of 30 patients, of that 14 (47%) had a shoulder PJI according the last proposed criteria of the International Consensus Meeting. The diagnostic validity of serum D-Dimer regarding the detection of PJI was analyzed.ResultsThe mean D-Dimer level was significantly higher for the patients with shoulder PJI compared to patients with aseptic failure (1.44 ± 1 mg/l vs. 0.76 ± 0.6 mg/l, p = 0.025). Coagulase-negative staphylococci were the most commonly isolated pathogens, in 9/14 patients (64%), followed by Cutibacterium acnes in 5/14 patients (36%). According to the ROC analysis, a serum D-Dimer threshold of 0.75 mg/l had a sensitivity of 86% and a specificity of 56% for detection of a shoulder PJI. The area under curve was 0.74. A serum C-reactive protein (CRP) cutoff of 10 mg/l showed a sensitivity of 69% and a specificity of 88%. When both serum D-Dimer and CRP above the thresholds of 0.75 mg/l and 10 mg/l, respectively, were used to identify a PJI the sensitivity and specificity were 57% and 100%, respectively.ConclusionsSerum D-Dimer showed a good sensitivity but a poor specificity for the diagnosis of shoulder PJI. Combination D-Dimer and CRP led to improvement of the specificity, however, at the cost of sensitivity. Thus, combination of both methods may be used as a confirmatory test in the diagnosis of shoulder PJI but not to rule out infection.Level of evidenceDiagnostic level II.

Factors associated with failure of surgical revision and IV antibiotics to resolve Cutibacterium periprosthetic infection of the shoulder

Cutibacterium is the most common organism causing shoulder periprosthetic infection (PJI). While most shoulder PJIs are well treated by prosthesis exchange and antibiotics, in some cases this treatment fails to resolve the infection. The factors associated with these failures have not been previously identified. The aim of this study was to identify the characteristics of patients with failure of treatment for PJI. Thirty-five patients suspected of having Cutibacterium PJI had revision arthroplasty with single-stage implant exchange followed by intravenous antibiotics. The characteristics of those with ≥ two positive cultures at revision surgery were compared to those who did not. The characteristics of those patients having a re-revision with ≥ two positive deep cultures (documented treatment failures) were compared to those who did not. The 17 patients that had ≥ two positive cultures at their index revision were more likely to be male, to have had ream and run procedures, and to have higher loads of Cutibacterium on pre-operative cultures of their unprepared skin. The five patients that had documented treatment failure had higher loads of Cutibacterium on their skin and in deep cultures obtained at their index revision. Patients harboring high loads of Cutibacterium on their unprepared skin prior to revision and high loads of Cutibacterium on deep cultures at the time of their index revision are at increased risk for failure of implant exchange and antibiotics to resolve a Cutibacterium PJI.

Defining a Synovial Fluid White Blood Cell Count Threshold to Predict Periprosthetic Infection after Shoulder Arthroplasty.

Background: The diagnosis of periprosthetic shoulder infection (PSI) requires a thorough diagnostic workup. Synovial fluid aspiration has been proven to be a reliable tool in the diagnosis of joint infections of the lower extremity, but shoulder specific data is limited. This study defines a threshold for synovial fluid white blood cell count (WBC) and assesses the reliability of microbiological cultures. Methods: Retrospective study of preoperative and intraoperative fluid aspiration of 31 patients who underwent a revision of a shoulder arthroplasty (15 with PSI defined by IDSA criteria, 16 without infection). The threshold for WBC was calculated by ROC/AUC analysis. Results: WBC was significantly higher in patients with PSI than in other patients. A threshold of 2800 leucocytes/mm3 showed a sensitivity of 87% and a specificity of 88% (AUROC 0.92). Microbiological cultures showed a sensitivity of 76% and a specificity of 100%. Conclusions: A threshold of 2800 leucocytes/mm3 in synovial fluid can be recommended to predict PSI. Microbiological culture has an excellent specificity and allows for targeted antibiotic therapy. Joint aspiration presents an important pillar to diagnose PSI.