Septic Shoulder Research Articles

Septic arthritis of the glenohumeral joint: A case series and review of investigative and treatment strategies

IntroductionGlenohumeral septic arthritis is most caused by hematogenous seeding of the joint by S. Aureus, and also as a result of previous surgery or intra-articular injection. Although rare, septic arthritis of the glenohumeral joint has poor prognosis. In patients who survive the infection, the potential to cause rapid and catastrophic damage to articular cartilage, frequently causes lifelong morbidity. MethodsFour consecutive patients (five shoulders) treated at our institution between December 2019 to September 2020 were identified for the study. Medical records were reviewed, and basic demographics of the patient series included age, sex, race, BMI were collected. Information such as comorbidities, inciting injuries, history of presentation, examination findings, biochemical results, radiological findings, aspiration results and cultures, intra-operative findings, as well as blood cultures were extracted. ResultsFour patients (age range of 65–83 years old) underwent a single arthroscopic washout of the glenohumeral joint. All four patients (3 female, 1 male) presented with acute swollen should joint/s with raised inflammatory markers (ESR, CRP and WBC). Staph Aureus was identified in 50% (n ​= ​2) of the cases with Mycobacterium Kansasii and Group B Streptococcus isolated in the other 2 patients. Half of the cases (n ​= ​2) were deemed to be caused by direct spread of pathogens whereas the other half of the cases (n ​= ​2) were deemed to be due to hematogenous spread. All patients exhibit resolution of clinical infection following the treatment. MRI were done for all patients which aided in the diagnosis of a septic shoulder joint. ConclusionOur case series shown that single arthroscopic washout and debridement provides acceptable to good short-term outcomes for septic arthritis of the glenohumeral joint. In this case series, the authors have found MRI to be a useful radiographic aid to diagnosis. Level of evidenceCase series.

Does needle penetration of the shoulder joint prior to arthroscopy increase infection risk? The effect of preoperative magnetic resonance arthrogram or corticosteroid injection.

Prior literature has associated preoperative corticosteroid shoulder injection (CSI) with infection following shoulder surgery. A recent study found an equally elevated risk of total knee arthroplasty infection with preoperative injection of either CSI or hyaluronic acid. The implication is that violation of a joint prior to surgery, even in the absence of corticosteroid, may pose an elevated risk of infection following orthopedic surgery. The aim of the present study was to determine whether violation of the shoulder joint for magnetic resonance arthrogram (MRA) poses an elevated risk of infection following shoulder arthroscopy, and to compare this risk to that introduced by preoperative CSI. A national, all-payer database was queried to identify patients undergoing shoulder arthroscopy between January 2015 and October 2020. Patients were stratified into the following groups: (1) no CSI or MRA within 6months of surgery (n=5000), (2) CSI within 2weeks of surgery (n=1055), (3) CSI between 2 and 4weeks prior to surgery (n=2575), (4) MRA within 2weeks of surgery (n=414), and (5) MRA between 2 and 4weeks prior to surgery (n=1138). Postoperative infection (septic shoulder or surgical site infection) was analyzed at 90 days, 1 year, and 2 years, postoperatively. Multivariable logistic regression analysis controlled for differences among groups. MRA within 2weeks prior to shoulder surgery was associated with an increased risk of infection at 1year (odds ratio [OR], 2.17; P=.007), while MRA 2-4weeks preceding surgery was not associated with an increased risk of postoperative infection at any time point. By comparison, CSI within 2weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.72; P=.022), 1 year (OR, 1.65; P=.005), and 2 years (OR, 1.63; P=.002) following surgery. Similarly, CSI 2-4weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.83; P<.001), 1 year (OR, 1.62; P<.001), and 2 years (OR, 1.79; P<.001). Preoperative CSI within 4weeks of shoulder arthroscopy elevates the risk of postoperative infection. Needle arthrotomy for shoulder MRA elevates the risk of infection in a more limited fashion. Avoidance of MRA within 2weeks of shoulder arthroscopy may mitigate postoperative infection risk. Additionally, the association between preoperative CSI and postoperative infection may be more attributed to medication profile than to needle arthrotomy.

Septic shoulder osteoarthritis post-covid-19 vaccination: A case report with literature review

This report emphasizes the relevance of MRI in non-resolving inflammation post-covid-19 vaccination in a 63-year-old female. In this patient, clinical examination was suggestive of septic arthritis confirmed by biology and MRI, which demonstrated cartilaginous damage and an extension of the infection to the bone. Therapeutical possibilities and prevention techniques are described and substantiated with a brief review of post-vaccinal arthritis cases in the literature. This report aims to delineate the utility of early MRI performance in persistent joint inflammation and the different possibilities available to the patient for optimal management at the early stages of the disease.

Factors affecting the occurrence of osseous lesions in septic shoulder arthritis and the recurrence rate after arthroscopic surgery

The purpose of this study was to determine the incidence of osseous lesions and the recurrence rate after arthroscopic surgery in shoulder septic arthritis patients and evaluate the influencing factors. We retrospectively reviewed 44 patients who underwent arthroscopic surgery for septic arthritis of the shoulder between January 2012 and September 2019. The average age of the patients was 65.57 ± 14.2 years, and 56.8% were female patients. The minimum follow-up period was 12 months (average, 32.8 ± 14.2 months; range, 12-72 months). We assessed variables including sex, age, underlying diseases, duration from symptom onset to magnetic resonance imaging (MRI), duration from symptom onset to surgery, radiologic results (radiography and MRI), history of injection therapy, and postoperative infection. The incidence of osseous lesions and the recurrence rate were calculated according to independent variables. In addition, multivariate logistic regression was performed to identify the risk factors for osseous lesions and recurrent infection after adjustment for other variables. Twenty-one patients had an osseous lesion on MRI, and 12 patients had evidence of bone erosion on radiographs. In univariate analyses, significant (P < .05) risk factors for the presence of osseous lesions were female sex, lower C-reactive protein level, and longer duration from symptom onset to MRI. The overall infection recurrence rate was 22.7% (10 of 44 patients). Culture results and the duration from symptom onset to surgery were significant risk factors for recurrent infection (P < .05). As the duration from symptom onset to MRI increased by 1 day, the probability of osseous lesions increased 1.31-fold (95% confidence interval, 1.08- to 1.59-fold; P = .007), and this probability was significantly higher after correction for other risk factors. To reduce the severity of septic shoulder infection, timely diagnosis and treatment are essential. Even if osseous lesions are present, good results can be obtained if meticulous débridement is performed through arthroscopic surgery. However, functional and radiologic long-term follow-up studies are needed in patients with osseous lesions.

Glenohumeral Arthrodesis Using Pelvic Reconstruction Plates: a Series of 15 Patients

Glenohumeral joint arthrodesis has become a rare entity due to the introduction of shoulder arthroplasty. It is an excellent salvage procedure for patients with severe shoulder dysfunction, with limited treatment options, indicated for brachial plexus injury, tumour resection, chronic infection, failed prosthetic arthroplasty, or pseudoparalysis of the shoulder due to combined rotator cuff and deltoid deficiency. Shoulder arthrodesis relieves the patient of pain and gives a decent amount of function. The aim of this study was to examine the mid-term outcomes of glenohumeral arthrodesis with 2 pelvic recon plates. This study was done in a tertiary referral centre over a period of about 2 years. All the patients were operated on with 2AO 3.5mm recon plates and screws. Indications for surgery comprised unreconstructable rotator cuff tears, a neoplastic lesion, paralytic disorders, TB shoulder, arthritic disease unsuitable for arthroplasty, and sequelae of septic shoulder. Cancellous grafts were used in all operated patients, while a cortical graft was used in the tumour case to fill the bone defect after tumour excision. A minimum of 18 months was essential for inclusion into the study. 15 patients were included in the study. All the patients had decreased postoperative pain, which further decreased to pain-free status at further follow-up visits. All the arthrodeses produced bony union with average time to union of 5.4 months. All patients could feed and dress themselves with the ipsilateral limb. The only complication noted in this series was a superficial infection in 3 patients only, which subsided after wound wash, debridement and antibiotics for 10 days. 1. With specific indications, shoulder arthrodesis results in a good painless postoperative shoulder function and thus presents an excellent operative option. 2. The position of arthrodesis chosen here ensures that the arm rests comfortably at the side. 3. The patients can move their hands to their mouth and facial regions. 4. Recon plates should be used for arthrodesis because they are easy to shape without compromising on strength. 5. Few complications of procedure are there but it is a great therapeutic measure in selected individuals.

Disproportionate burden of septic versus aseptic revision total shoulder arthroplasty: a comparative assessment of operative time and work relative value units

Periprosthetic infection (PJI) remains a challenging complication in total shoulder arthroplasty. Surgical treatment options can include 1 or 2-stage revision procedures, temporizing articulating spacers, and resection arthroplasty, with many cases resulting in transfer of patient care to a tertiary care center. While these cases can impose significant cost and clinical burden for both surgeons and hospital systems, there is limited data about the operative time investment and reimbursement compared to aseptic revision cases. The purpose of the current study was to compare work relative value units and operative times for aseptic and septic shoulder arthroplasty revision procedures. We hypothesize that staged, PJI-related revision shoulder arthroplasty is associated with significant differences in operative time and work relative value units assigned as compared to aseptic revisions. This study utilized data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Inclusion criteria included all patients that underwent a revision total shoulder arthroplasty between January 1, 2010 and December 31, 2018. Procedures were grouped as either aseptic or septic revisions and further stratified into 1 stage and each stage of a 2-stage revision for septic cases. The RVU-to-dollar conversion factor was provided by the United States Centers for Medicare and Medicaid Services (CMS). This was used to obtain total reimbursement and reimbursement per minute estimates. When assessing the ratio of RVUs per minute of operative time across the groups, we found that the second stage of a 2-stage septic revision had a significantly lower RVU per minute operative time ratio (0.25) when compared to both the aseptic 2-component revision (0.34) and the first stage of a 2-stage septic revision (0.29). This translated to a significantly lower dollar per minute operative time value. The current study found that the second stage of a 2-stage septic revision was undervalued in the number of RVUs per minute of operative time when compared to an aseptic revision or even its first stage counterpart. An adjustment or redistribution of relative value units for these procedures may offset the disproportionate clinical burdens encountered with definitive treatment of these complications. Level III.

Arthroscopic Removal of an Intra-Articular Migrating Plant Awn Associated with Septic Shoulder Joint Arthritis in a Dog

Abstract Objective The aim of this study was to describe the clinical presentation, advanced imaging findings and outcomes of arthroscopic treatment of a bacterial septic shoulder arthritis caused by the penetration of a migrating plant awn in a dog. Case Report A 10-month-old, 11 kg, sexually intact male Cocker Spaniel was diagnosed with septic arthritis of the right scapulohumeral joint. Computed tomography revealed marked articular effusion and thickening of the capsule of the right shoulder joint. Ultrasound of the shoulder identified a bilinear hyperechoic structure located within the joint consistent with a plant (grass) awn. Arthroscopy was used for foreign body removal. Antibiotic treatment was prescribed according to bacteriologic sensitivity tests. Treatment was successful: the dog completely recovered and under high levels of activity showed neither clinical signs nor recurrence of lameness on follow-up at 6 and 24 weeks after surgery. Conclusion Migrating plant awn can be the cause of septic arthritis in a dog. The combination of advanced imaging techniques and arthroscopy allowed accurate diagnosis, reduced the risk of surgical complications and shortened recovery time in this patient. Considering the benefits of minimally invasive techniques, arthroscopy represents an excellent option for the treatment of dogs with similar intra-articular foreign bodies.

Clinical Results after Arthroscopic Treatment of Septic Shoulder with Proximal Bone Involvement.

If osteomyelitis is confined to the proximal humerus, arthroscopic debridement with multiple punctures at the infected bone might be sufficient to eradicate the septic shoulder with bone involvement. From 2005 to 2017, 15 patients received arthroscopic debridement with multiple punctures. We included patients with septic shoulder arthritis with proximal bone involvement and excluded patients with glenohumeral joint destruction or extension of bone involvement to the diaphysis of the humerus. We performed multiple punctures for drainage of proximal humerus after complete arthroscopic debridement of septic soft tissue. Infection laboratory studies and postoperative magnetic resonance image were evaluated. For clinical outcome measurements, range of motion, pain visual analog scale, functional visual analog scale, American shoulder elbow surgeon scores, constant scores, and simple shoulder test were evaluated. There were 11 males and 4 females with a mean age of 53years (range 28-73years). Mean follow-up was 32months (range 12-115months). There was no reinfection case. The postoperative C-reactive protein levels were normalized in all. The postoperative magnetic resonance image showed no bony involvement of the proximal humerus in all patients except one patient. The clinical scores and range of motion were significantly improved postoperatively. Six patients underwent secondary surgery for rotator cuff tear at a mean time period of 25months (range 4-104months) from the index period. Septic shoulder with proximal bone involvement can be successfully treated with arthroscopic debridement with multiple punctures. Level IV, treatment study.

The Prognostic Value of a Novel Magnetic Resonance Imaging-Based Classification for Septic Arthritis of the Shoulder.

The purposes of the present study were (1) to create a magnetic resonance imaging (MRI)-based classification system for septic shoulder arthritis and to show the results of arthroscopic debridement based on the classification in eradicating the infection, and (2) to determine the distribution of the Gächter stages, which are determined on the basis of arthroscopic findings only, in each grade of the novel classification system. The present study included 31 patients who underwent arthroscopic debridement for the treatment of acute septic arthritis of the shoulder between January 2001 and December 2015. The mean duration of follow-up was 2.3 years. The included patients were assessed with use of a novel classification system based on preoperative radiographic and MRI findings. MRI findings were classified as Grade I (only synovitis or joint effusion), Grade II (marrow edema in the bare area of the humeral head), Grade III (cartilaginous erosion), Grade IV (osseous erosion), and Grade V (osseous erosion on MRI also observed on radiographs). No changes on radiographs were observed in Grades I to IV. The intraclass correlation coefficients (ICCs) for interobserver and intraobserver reliability were calculated. The overall reinfection rate was 54.8% (17 of 31). Among patients with Grade-I, II, III, IV, and V involvement, the reinfection rates were 0 of 4, 1 of 6, 2 of 4, 9 of 12, and 5 of 5, respectively. A diverse distribution of Gächter stages were found in each grade of the novel classification system, with the exception of Grade V. The ICCs for interobserver and intraobserver reliability were 0.81 and 0.80 for the novel classification system. The ICCs for interobserver and intraobserver reliability were 0.75 and 0.78 for Gächter stages. This novel classification system for the grading of acute shoulder infections on the basis of radiographs and MRI allows preoperative grading of septic arthritis to be performed objectively. Patients who were classified as Grade III or higher in the novel classification system had higher reinfection rates than those who were classified as Grade I or II and required more aggressive treatment to eradicate the infection.

Pseudo paralysis of the shoulder and increased C-reactive protein are predictive factors for septic shoulder in children superior to other clinical symptoms: A retrospective case series of 25 patients

PurposeThe aim of the study was to evaluate predictable parameters with the highest sensitivity used in the diagnosis of children septic shoulder arthritis.MethodsAll children treated in our paediatric orthopaedic hospital between 2000 and 2017 with intraoperative verified septic arthritis of the shoulder were included in this retrospective study. Diagnostic procedures e.g. ultrasound, MRI, radiograph or blood samples as well as typical clinical symptoms were evaluated as predictable parameters for septic shoulder arthritis in paediatric patients. Descriptive statistics as well as sensitivity analysis were performed.ResultsIn all, 25 children, 20 boys and five girls, aged from eight days to 15 years, were included for further statistical analysis. All parameters included were tested for sensitivity with binomial confidence intervals (Cis) of 95%. Predictive parameters with highest sensitivity were pseudo paralysis (100%, CI 0.86 to 1.00) and C-reactive protein (CRP) (96%, CI 0.79 to 0.99) superior to temperature (52%, CI 0.3 to 0.73), white blood count (11%, CI 0.01 to 0.34), radiograph (21%, CI 0.04 to 0.50), ultrasound (71%, CI 0.47 to 0.88) or MRI (100%, CI 0.78 to 1.00).ConclusionThe diagnosis of a septic arthritis of the shoulder in children can be challenging for the clinician and especially for the resident doctor. Clinical symptoms such as pseudo paralysis and increased CRP level must be considered as predictive markers not to delay further diagnostics and treatment.Level of EvidenceIV

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

BACKGROUNDThe 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.AIMTo evaluate the results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.METHODSWe 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.RESULTSMean 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.CONCLUSIONShort 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.

Surgical Treatment of Septic Shoulders: A Comparison Between Arthrotomy and Arthroscopy

To compare the efficacy, as measured through the rate of reoperation, and rates of other 30-day perioperative complications between arthrotomy and arthroscopy for the treatment of septic native shoulders in a national patient population. Patients who were diagnosed with septic arthritis in a native shoulder and underwent irrigation and debridement through arthrotomy or arthroscopy were identified in the 2005-2016 National Surgical Quality Improvement Program database. Patient preoperative characteristics were characterized. Rate of reoperation, a proxy used to measure treatment efficacy, and other perioperative complications were compared between the 2 procedures. In total, 100 patients undergoing shoulder arthrotomy and 155 patients undergoing shoulder arthroscopy for septic shoulder were identified. On univariate analysis, there were no statistically significant differences in patient preoperative characteristics, operative time (60 vs. 48minutes, P= .290), length of stay (7.5 vs. 6.6days, P= .267), or time to reoperation (8.9 vs. 7.2days, P= .594) between the 2 surgical groups. On multivariate analysis controlling for patient characteristics, there were no statistically significant differences in risk of reoperation (relative risk [RR]= 1.914, 99% confidence interval [CI]= 0.730-5.016, P= .083), any adverse events (RR= 1.254, 99% CI= 0.860-1.831, P= .122), minor adverse events (RR= 1.304, 99% CI= 0.558-3.047, P= .421), serious adverse events (RR= 1.306, 99% CI= 0.842-2.025, P= .118), or readmission (RR= 0.999, 99% CI= 0.441-2.261, P= .998) comparing arthrotomy with arthroscopy. By demonstrating similar rates of reoperation, other postoperative complications, and 30-day readmissions, the current study suggests that arthrotomy and arthroscopic surgery have similar efficacy in treating septic shoulders. However, owing to the small sample size, there is still the possibility of a type II error. Level III, therapeutic retrospective comparative study.

Infection after Arthroscopic Cuff Tear Repair (Case Report)

Septic shoulder arthritis following arthroscopic surgery is a rare complication, according to the literature it arises from 0.006% to 2,1% of cases. We report on a case of 58 y.o. Patient, admitted to our setting 10 days after arthroscopic intervention on the right shoulder joint in another hospital. Based on clinical, laboratory and instrumental assessment septic shoulder arthritis was diagnosed. Arthroscopic lavage and debridement surgery with bioabsorbable antibacterial agent implantation was performed. Long term follow-up in 6 months showed good results with full range of motion, absence of pain and elimination of infection.

Two Cases of Infective Endocarditis in Patients with Atopic Dermatitis

Patients with atopic dermatitis have high rates of skin surface colonization of Staphylococcus aureus. At the same time, S. aureus is the major causative organism in infective endocarditis, approximately accounting for 30%~50% cases of infective endocarditis. A 22-year-old male with severe atopic dermatitis presented with fever and myalgia. He was diagnosed with active infective endocarditis causing multiple cerebral infarction, splenic infarction, and septic shoulder requiring synovectomy. Blood culture proved methicillinsensitive Staphylococcus aureus bacteremia, and the culture from the skin revealed same bacteria. After treated with intravenous antibiotics for 6 weeks, patient was improved. Another 42-year-old female with severe atopic dermatitis who presented with fever and chilling was hospitalized due to acute infective endocarditis. She also had left flank pain and visual disturbance, due to splenic infarction and acute cerebral infarction, respectively. As blood culture revealed methicillin-sensitive Staphylococcus aureus bacteremia, she treated with intravenous antibiotics for 6 weeks. The route of entry of two patients was attributed to the patient eczematous scratching lesion of poorly controlled atopic dermatitis. Infective endocarditis can result in the context of acute deterioration of atopic dermatitis. Dermatologists need to pay attention to this risk and actively manage such conditions in order to decrease the risk of infective endocarditis arising from skin lesions in atopic patients. For these reasons, we herein report two cases of infective endocarditis in patients with atopic dermatitis.

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

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

Septic Shoulder Joint After Pneumococcal Vaccination Requiring Surgical Debridement

Inflammatory complications after routine vaccination, including pain, local erythema, and bursitis, have been reported. Several cases of bursitis after vaccination, most commonly with the pneumococcal and influenza vaccines, have been reported in the literature [1–8]. Many of these cases have been attributed to poor technique of the administrator or an inflammatory reaction when the vaccine is deposited in the subdeltoid space [1, 3, 7]. Many of these reactions are self-limiting and demonstrate good relief with subacromial corticosteroid injection [1–4, 7]. We report a case of a patient who rapidly developed a septic shoulder joint after pneumococcal vaccination in her right deltoid. This required prompt surgical shoulder arthrotomy, irrigation, and debridement.

Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population

Background: Shoulder arthroscopy is well established as a highly effective and safe procedure for the treatment for several shoulder disorders and is associated with an exceedingly low risk of infectious complications. Few data exist regarding risk factors for infection after shoulder arthroscopy, as previous studies were not adequately powered to evaluate for infection. Purpose: To determine patient-related risk factors for infection after shoulder arthroscopy by using a large insurance database. Study Design: Case-control study; Level of evidence, 3. Methods: The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files from 2005 to 2014 for patients undergoing shoulder arthroscopy. Patients undergoing shoulder arthroscopy for a diagnosis of infection or with a history of prior infection were excluded. Postoperative infection within 90 days postoperatively was then assessed with International Classification of Diseases, Ninth Revision codes for a diagnosis of postoperative infection or septic shoulder arthritis or a procedure for these indications. A multivariate binomial logistic regression analysis was then utilized to evaluate the use of an intraoperative steroid injection, as well as numerous patient-related risk factors for postoperative infection. Adjusted odds ratios (ORs) and 95% CIs were calculated for each risk factor, with P < .05 considered statistically significant. Results: A total of 530,754 patients met all inclusion and exclusion criteria. There were 1409 infections within 90 days postoperatively (0.26%). Revision shoulder arthroscopy was the most significant risk factor for infection (OR, 3.25; 95% CI, 2.7-4.0; P < .0001). Intraoperative steroid injection was also an independent risk factor for postoperative infection (OR, 1.46; 95% CI, 1.2-1.9; P = .002). There were also numerous independent patient-related risk factors for infection, the most significant of which were chronic anemia (OR, 1.58; 95% CI, 1.4-1.8; P < .0001), malnutrition (OR, 1.42; 95% CI, 1.2-1.7; P = .001), male sex (OR, 2.71; 95% CI, 2.4-3.1; P < .0001), morbid obesity (OR, 1.41; 95% CI, 1.2-1.6; P < .0001), and depression (OR, 1.36; 95% CI, 1.2-1.5; P < .0001). Conclusion: Intraoperative steroid injection was a significant independent risk factor for postoperative infection after shoulder arthroscopy. There were also numerous significant patient-related risk factors for postoperative infection, including revision surgery, obesity, male sex, chronic anemia, malnutrition, depression, and alcohol use, among others.

Patient-Related Risk Factors for Postoperative Infection Following Shoulder Arthroscopy: An Analysis of Over 420,000 Patients

Objectives:Shoulder arthroscopy has been traditionally associated with low infection rates. A recent large study reported a 0.27% infection rate following shoulder arthroscopy. The yearly incidence of infectious complications is not negligible, however, given the large volume of procedures performed. Little data exists regarding risk factors for infection following shoulder arthroscopy, as previous studies are not adequately powered to evaluate for infection. The objective present study was to determine patient-related risk factors for infection following shoulder arthroscopy a large insurance database.Methods:The PearlDiver patient records database was used to query the 100% Medicare Standard Analytic Files from 2005-2012 patients undergoing shoulder arthroscopy procedures using CPT codes 29806, 29807, 29824, 29826, 29827 and 29828. Patients undergoing shoulder arthroscopy for a diagnosis of infection were excluded. Postoperative infection within 90 days postoperatively was then assessed using both ICD-9 codes for a diagnosis of postoperative infection or septic shoulder arthritis, or a procedure for these indications, including either open or arthroscopic irrigation and debridement. A multivariate binomial logistic regression analysis was then utilized to evaluate the use of an intraoperative steroid injection as well as numerous patient-related risk factors for postoperative infection, including: age, gender, obesity, morbid obesity, tobacco use, alcohol abuse, diabetes mellitus, inflammatory arthritis, hypercoagulable disorder, hyperlipidemia, hypertension, peripheral vascular disease, congestive heart failure, coronary artery disease, chronic lung disease, chronic liver disease, chronic kidney disease, use of hemodialysis, major depression, hypothyroidism and chronic anemia. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were calculated for each risk factor, with P < 0.05 considered statistically significant.Results:422,245 patients met all inclusion and exclusion criteria. There were 883 infections within 90 days postoperatively (0.21%). Intraoperative steroid injection was an independent risk factor for postoperative infection (OR 1.3, P = 0.001). There were also numerous independent patient-related risk factors for infection, which are provided in Table 1. The most significant were: chronic anemia (OR 1.7, P < 0.0001), age < 65 years (OR 1.5), P < 0.0001), obesity (OR 1.5, P < 0.0001) and depression (OR 1.5, P < 0.0001) [Table 1].Conclusion:The risk of infection following shoulder arthroscopy in the present series of over 420,000 patients was 0.21%, similar to reported numbers from other large series. Intraoperative steroid injection was a significant, independent risk factor for postoperative infection. There were also numerous significant patient-related risk factors for postoperative infection, including obesity, younger age, chronic anemia, depression and alcohol use among others.Table 1.Significant Risk Factors for Infection after Shoulder ArthroscopyVariableOdds Ratio95% CIP Demographics age < 651.50[1.36 - 1.65]< 0.0001male gender1.41[1.27 - 1.56]< 0.0001Obesity (BMI 30-40)1.50[1.35 - 1.67]< 0.0001Morbid Obesity (BMI 40+)1.37[1.19 - 1.58]< 0.0001Alcohol Use1.47[1.27 - 1.71]< 0.0001 Comorbidities Diabetes Mellitus1.28[1.17 - 1.40]0.001Inflammatory Arthritis1.19[1.03 - 1.38]0.020Hypertension1.37[1.20 - 1.56]< 0.0001Congestive Heart Failure1.20[1.07 - 1.35]0.002Chronic Lung Disease1.13[1.02 - 1.24]0.017Chronic Liver Disease1.29[1.13 - 1.48]< 0.0001Chronic Anemia1.68[1.49 - 1.88]< 0.0001Depression1.48[1.34 - 1.62]< 0.0001 Intraoperative Intraop Steroid Injection1.34[1.12 - 1.60]0.001

Prognostic Factors Affecting the Clinical Outcome of Septic Arthritis of the Shoulder.

The objective of this study was to determine prognostic factors affecting the clinical outcome of septic arthritis of the shoulder. We retrospectively reviewed 34 shoulders from 32 patients, two of which had bilateral involvement. Arthroscopic (22 shoulders) or open surgery (12 shoulders) was performed by a single surgeon. The mean follow-up period was 32.4 ± 17.0 months. Clinical outcomes according to the University of California at Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, and Subjective Shoulder Value (SSV) were assessed at the final follow-up period. Various factors were included for statistical analysis. The mean UCLA, ASES scores, and SSV were 28.9 ± 7.2, 81.3 ± 21.0, 79.7 ± 2.5%, respectively. Positive culture was observed in only 13 shoulders (38.2%) and the most common organism was Staphylococcus aureus (seven shoulders). Five shoulders (14.7%) required two or three operations. Age and comorbidity were negatively correlated with the UCLA, ASES score, and/or SSV (p < 0.05). There was no correlation between clinical outcome and various parameters, including gender, location of lesion, history of previous steroid injection, interval between onset of symptoms and surgical intervention, bacterial organisms, operative method, and presence of rotator cuff tear and reoperation (p > 0.05). Both arthroscopic and open surgery for septic shoulders showed satisfactory clinical outcomes. Old age and comorbidity were poor prognostic factors of clinical outcomes after treatment.

A case of shoulder jointStreptobacillus moniliformisseptic arthritis with severe subdeltoid bursitis

AbstractObjective and importancePeople in close contact with rodents, particularly those with rodents as pets, may become infected with the Streptobacillus moniliformis organism. Such patients may present with a triad of fever, rash, and arthritis. This medical condition is also known as rat-bite fever. It is imperative for the clinician to consider and recognize rat-bite fever in cases of septic arthritis in order to prevent delay in treatment. Severe involvement of the bursa requiring its excision during joint irrigation and debridement surgery has not been reported in the literature.Clinical presentationWe are reporting on a recent case of septic shoulder arthritis and severe subdeltoid bursitis due to rat-bite fever in a 19-year-old female. Pre-operative magnetic resonance imaging scans demonstrated severe bursal involvement.InterventionIn addition to antibiotics, excision of the bursa was necessary in this case in combination with irrigation and debridement of the joint.ConclusionThe bursa adjacent t...