Undergoing Revision Shoulder Arthroplasty Research Articles

Incidence of Shoulder Prosthetic Joint Infection Throughout the COVID-19 Pandemic

Introduction1-2% of patients who undergo anatomic and reverse total shoulder arthroplasty are diagnosed with a prosthetic joint infection which requires revision surgery, prolonged recovery and rehabilitation, and antibiotic treatment. During the COVID-19 pandemic, anecdotal evidence suggested an increased rate of PJI among all patient populations. However, there have been no studies characterizing PJI incidence following shoulder arthroplasty during the COVID-19 pandemic. In the present study, we sought to evaluate the incidence of shoulder PJI during the COVID-19 pandemic. Materials & MethodsPatients undergoing revision shoulder arthroplasty for PJI at an academic medical center between 2017-2021 were identified: patients before COVID-19 (2017-2019) and patients during COVID-19 (2020-2021). Patient demographics, laboratory data, history of COVID-19 infection and vaccination, antibiotic treatment, and final surgical treatment were collected. Patient-reported outcome measures (PROMs) (ASES, SANE, SAS, PROMIS (Physical Function, Pain Intensity, Upper Extremity, Global 10), and VR/SF12) were collected. PJI incidence was calculated from a retrospective chart review which identified patients with PJI as defined by the International Consensus meeting (ICM) on Musculoskeletal Infection in 2018 and who underwent revision surgery and antibiotic treatment. Incidence rate analysis and independent t-tests were conducted to compare mean baseline PROMs. Descriptive analysis of the collected data included means and standard deviations for continuous variables and frequencies and percentages for discrete variables. Statistical significance was set at a p-value < 0.05. Results46 patients were identified with 20 patients undergoing a revision surgery for a PJI during the pre-COVID-19 time interval and 26 during the COVID-19 time interval. 20% underwent single stage revision (4 pre-COVID-19 and 5 during COVID-19), 50% underwent two stage revision (10 pre-COVID-19 and 13 during COVID-19), and 30% underwent a DAIR procedure (6 pre-COVID-19 and 8 during COVID-19). There was a significant increase in shoulder PJI infections between the pre-COVID-19 time interval and during COVID-19, with PJI incidence rates of 1.1% and 2.1%, respectively (p = .028). There was no significant difference in any outcome scores, microbes on aspiration, inflammatory markers, or duration of treatment between the two time intervals. ConclusionWhile this study does not show clear evidence to an underlying mechanism explaining the increased PJI incidence observed during the COVID-19 pandemic, this study does show a significant increase in the rate of shoulder PJI status post shoulder arthroplasty during COVID-19. Further investigation into how the vaccine and COVID-19 infection may affect the body’s immune system may provide insight into this increase.

Allograft Prosthetic Composite (APC) for Proximal Humeral Bone Deficiency in Revision Reverse Shoulder Arthroplasty: A Technical Note and Systematic Review.

Background: Proximal humeral bone deficiency in revision shoulder arthroplasty is an emerging and challenging problem as the use of reverse shoulder arthroplasty (RSA) increases. This paper presents a technical note discussing our detailed preoperative planning steps, surgical techniques, and their rationale in carrying out the use of an allograft prosthetic composite (APC) to address proximal humeral bone deficiency in revision RSA. The outcomes of this technique are also presented. This paper also presents a systematic review to further discuss the existing literature on RSA with APCs. Methods: The preoperative surgical planning and the surgical technique employed to execute proximal humeral reconstruction using APC during revision arthroplasty are discussed in the technical note. The preliminary clinical and radiological results of five patients who underwent revision shoulder arthroplasty with proximal humeral reconstruction using APCs are presented. The PRISMA guidelines were followed to perform the systematic review. A systematic search using PubMed, Embase, and Cochrane databases was conducted. All studies involving RSA and APCs were pooled, and the data were extracted and analyzed. Results: A total of 14 studies were eligible for inclusion in the systematic review, with a total of 255 patients and a mean follow-up of 57 months. All studies in the systematic review and the patients included in the author's case series showed improvements in the level of pain, range of motion, function, and satisfaction. Graft incorporation in the systematic review was 84%. Conclusions: Based on the available literature and the results of our case series, the use of an APC construct is a viable option for proximal humeral bone deficiency in revision shoulder arthroplasty.

Diagnostic accuracy of preoperative percutaneous synovial biopsy and aspirate compared with open biopsy for prosthetic shoulder infections

BackgroundShoulder arthroplasty revision is associated with a high prevalence of prosthetic infection, and diagnosis remains difficult. The primary aim of the study was to determine the diagnostic accuracy of percutaneous synovial biopsy (PSB) and joint aspiration compared with open culture results in detecting infection in revision shoulder arthroplasty. The second aim was to determine whether biopsy location within the shoulder was associated with culture status. MethodsThis was a multicenter prospective cohort study involving four sites and 69 patients undergoing revision shoulder arthroplasty. The cohort was 57% female with a mean age of 64 years. Preoperative fluoroscopic-guided PSB’s and aspirates were carried out by a musculoskeletal radiologist prior to revision shoulder arthroplasty. The original prostheses consisted of hemiarthroplasties, total shoulder arthroplasties (TSA), resurfacing TSA, reverse shoulder arthroplasties (RSA), and antibiotic spacers. Six synovial tissue biopsies from separate regions in the shoulder were obtained both preoperatively and intra-operatively. The shoulder joint was aspirated, and synovial fluid collected, if available. Infection was considered positive in the setting of two or more matching positive cultures. The PSB cultures were considered “true positive” if the PSB cultures matched the open biopsy cultures. ResultsNineteen percent had positive infection based on PSB and 23% had confirmed culture positive infections based on intra-operative biopsy. The diagnostic accuracy of PSB compared with open biopsy was as follows: sensitivity 0.37 (95% CI 0.13-0.61), specificity 0.81 (95% CI 0.7-0.91), positive predictive value 0.37 (95% CI 0.13 – 0.61), negative predictive value 0.81 (95% CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77. Of the 71 patients, aspiration yielded synovial fluid in 33 patients. Preoperative aspirates detected no infections confirmed positive by open biopsy and correctly identified 81% of absent infections. The diagnostic accuracy of aspirates compared with open biopsy was as follows: sensitivity 0%, specificity 0.81 (95% CI 0.66-0.96), positive predictive value 0%, negative predictive value 0.78 (95% CI 0.63-0.93). Biopsy location within the shoulder was not associated with infection status. DiscussionPreoperative aspiration detected none of the infections proven positive via open biopsy. Although PSB was superior to synovial fluid aspirate, poor likelihood ratios suggests that PSB is not useful as an isolated test in the preoperative workup of the potentially infected patient.Biopsy location was not associated with culture status suggesting that the capsule is uniformly infected, and the location of tissue biopsies does not appear to matter.

Early diagnosis and revision repair of lesser tuberosity osteotomy failure after anatomic total shoulder arthroplasty

BackgroundLesser tuberosity osteotomy (LTO) in total shoulder arthroplasty (TSA) has a relatively high success rate owing to bone-to-bone healing and modern repair techniques. Failure of the LTO repair has been associated with poorer outcomes, decreased patient satisfaction, and the potential need for revision arthroplasty. Despite this, few studies closely examined outcomes for revision LTO repair in the setting of prior TSA. MethodsA retrospective review of all TSAs performed by a single surgeon from 2016 until 2023 was performed to identify all cases with LTO failure who underwent acute revision LTO repair. Baseline characteristics, postoperative complications including infection, need for revision surgery, and time to revision surgery were collected and reported on all TSA patients. All patients were followed for a minimum of 1 year after their TSA and revision LTO fixation if required. Subgroup analysis was performed on the LTO revision cohort to evaluate for potential risk factors. ResultsA total of 166 patients underwent TSA with LTO. Of these, eight patients were diagnosed with an acute LTO failure at a mean of 5.7 weeks after surgery and underwent revision LTO fixation at a mean of 6.3 weeks after surgery. At a mean follow-up of 147.9 weeks (standard deviation: 90.3; range: 52.1-284.9), seven of eight patients (87.5%) demonstrated healing of their LTO and had no complaints, complications, or reoperations at the latest follow-up. One patient developed a periprosthetic infection requiring two-stage revision. No patients in the overall cohort underwent revision shoulder arthroplasty due to subscapularis failure. ConclusionEarly identification of subscapularis failure is important to optimize outcomes of revision fixation. Use of LTO for subscapularis repair is beneficial by allowing early radiographic detection of subscapularis failure. Revision LTO repair can be successful when performed acutely and appears to minimize the need for revision shoulder arthroplasty due to subscapularis failure.

Complications after primary and revision shoulder arthroplasty: a matched cohort study

BackgroundPatients who undergo total shoulder arthroplasty typically have excellent clinical outcomes, though some patients require revision shoulder arthroplasty to address complications such as infection, instability, and persistent pain. The purpose of this study was to compare the rates and types of complications, as well as patient-reported outcomes, following primary and revision shoulder arthroplasty. MethodsRetrospective chart review was conducted for patients who underwent revision anatomic or reverse shoulder arthroplasty between January 2015 and May 2021 (N = 152). A cohort of patients who underwent primary shoulder arthroplasty in the same period was generated by matching 1:1 for implant type (anatomic/reverse), age, and surgery date. Demographic data, patient-reported outcomes, surgical details, surgical complications, and reoperations were collected for both cohorts (N = 304). Chi-square, t-test, Fisher’s exact test, and Mann-Whitney test were used as appropriate. ResultsThe revision cohort had a significantly higher rate of surgical complications than the primary cohort (N = 58, 38.2% vs. N = 22, 14.5%; P < .0001). The distribution of complication types differed significantly between the primary and revision cohorts (P = .018). Revision patients reported less improvement in Single-Assessment Numeric Evaluation score from baseline to 2-year follow-up compared to primary patients (postoperative and preoperative scores 33.9 ± 35.9 vs. 52.3 ± 32.5; P = .036). Patients in the primary cohort who underwent a previous shoulder surgery before their shoulder arthroplasty were more likely to experience complications than those who did not (P < .001). The most common surgical complications in the revision cohort were persistent pain (N = 20) and periprosthetic joint infection (N = 10), while the most common complications in the primary cohort were persistent pain (N = 6) and instability (N = 4). 63.6% of complications in primary patients and 55.2% of complications in revision patients necessitated reoperation. Total procedure time was higher on average in revision patients (120 ± 68 min) than primary patients (94 ± 31 min; P < .0001). Revision patients were more likely than primary patients to have had cemented humeral stems in their primary arthroplasty (P = .043). ConclusionPatients undergoing revision shoulder arthroplasty are at an increased risk for subsequent surgical complications and worse clinical improvement compared to primary shoulder arthroplasty patients. The differing profiles of postoperative complication types following primary and revision shoulder arthroplasty should be considered when advising patients on the risks of surgery and creating preoperative surgical plans to minimize these risks.

Functionality, complications, and survivorship of total shoulder arthroplasty in patients under 60 years old

BackgroundAs total shoulder arthroplasty (TSA) expands to younger patients, it is crucial to weigh the benefits of early intervention against potential complications and implant longevity in patients under 60 years of age. This study examines mid-term outcomes in this patient subset. MethodsBetween 2009 and 2019, a retrospective analysis was conducted on 50 patients (25 male, 25 female) who underwent anatomic TSA (TSA) under the age of 60 with minimum 5 years follow-up. Demographic and baseline variables were extracted from medical records. Pre-operative and post-operative outcomes of range of motion (ROM) and strength were recorded. Patient-reported outcomes (PROs) were obtained. ResultsFifty patients were followed for an average of 8.7 ± 2.4 years, having a mean age of 54.1 ± 8.4 years. Comparison of pre-operative and post-operative measurements revealed significant improvements in active ROM, including external rotation (ER) (p < 0.0001), forward elevation (FE) (p < 0.0001), and internal rotation (IR) (p = 0.0001). There were significant improvements in functional strength scores, including ER (p = 0.0005) and FE (p = 0.0002). PROs included visual analog scale (VAS) (2.2 ± 2.6), Single Assessment Numeric Evaluation (SANE) (80.3 ± 17.6), American Shoulder and Elbow Surgeons (ASES) score (76.4 ± 22.8), and Simple Shoulder Test (SST) (8.9 ± 3.2). The 5-year and 10-year implant survival rates were found to be 98.0 % and 83.3 %, respectively. There were 7 postoperative complications in 5 patients (14.0 %), including glenoid loosening (n = 2), infection (n = 1), atraumatic instability (n = 1), lesser tuberosity avulsion (n = 1), painful arthroplasty (n = 1) and traumatic rotator cuff insufficiency (n = 1). Subsequently, all 5 patients underwent revision shoulder arthroplasty at an average of 6.5 years after the initial procedure. ConclusionPositive mid to long-term outcomes, including significant improvements in ROM and strength, along with high 5-year and 10-year implant survival rates support TSA as an effective treatment option for patients under the age of 60.

Single-stage revision for total shoulder arthroplasty infection. Results at a minimum 2 years follow-up

IntroductionSimilar to the management of periprosthetic joint infections of the lower limb, one-stage revision in total shoulder arthroplasty (TSA) infections is an option that has been highlighted in scientific publications since the early 2010s. However, there are only a few studies which validate this treatment and determine its scope of application in relation to two-stage treatment. HypothesisSingle-stage revision for infected TSA is a reliable treatment allowing good infection control and satisfactory functional results. MethodsThis single-center retrospective series of 34 consecutive patients operated on between 2014 and 2020 for a one-stage prosthetic revision was evaluated at a minimum of 2 years of follow-up. All of the patients included underwent revision shoulder arthroplasty during this period with the diagnosis of infection confirmed by microbiological analysis of surgical samples. Patients who did not benefit from a bipolar revision were excluded. All patients were followed at least 2 years after the intervention. Clinically suspected recurrence of infection was confirmed by a periprosthetic sample under radiographic guidance. Functional clinical outcomes as well as mechanical complications were also reported. ResultsThe average follow-up was 40.4 months (24–102±21.6). A septic recurrence was observed in three patients (8.8%). A mechanical complication was present in four patients (14.7%), and three (11.8%) required at least one surgical revision. The mean Constant-Murley score at the last follow-up was 49 (42–57±21.83). DiscussionSingle-stage revision for shoulder periprosthetic joint infection results in a success rate of 91.2% with satisfactory functional results after more than 2 years of follow-up. Level of evidenceIV; retrospective study.

Oral and intravenous tranexamic acid administration demonstrate no significant difference in objective measures of blood loss in primary total shoulder arthroplasty

IntroductionThe routine use of tranexamic acid (TXA) in shoulder arthroplasty has grown in popularity due to the perceived benefits of reduction in intra-operative blood loss and the related adverse sequelae. Both intravenous (IV) and oral (PO) formulations of TXA exist and there is minimal data regarding the optimal route of administration. This study aimed to assess whether there was a significant difference in efficacy between the administration of PO vs. IV TXA prior to total shoulder arthroplasty. We hypothesized equivalence in preoperative (preop) to postoperative change in hemoglobin (Hg) and hematocrit (Hct) as well as the length of stay (LOS), 90-day readmission, transfusion rates and adverse events between the two routes. Materials and methodsA single-center retrospective chart review was conducted between May 2022 and January 2023. All patients undergoing primary anatomic or reverse total shoulder arthroplasty during this period were included. Patients undergoing revision shoulder arthroplasty or arthroplasty for fracture were excluded. The primary outcome of interest was the change (Δ) in preop to postoperative day 1 Hg and Hct reported as ΔHg and ΔHct. Intraoperative estimated blood loss (EBL), transfusion rates, patient demographics, LOS, and adverse event data were also collected. ResultsTwo hundred and thirty patients who underwent shoulder arthroplasty met the inclusion criteria. A total of 176 patients received preoppreop IV TXA and 54 patients received preop PO TXA. There was no significant difference between groups in the mean ΔHg (1.69 in the IV group and 2.52 in the PO group, P = .11) or ΔHct (5.19 in the IV group and 5.04 in the PO group, P = .42). There was no significant difference in LOS, transfusion rates, or 90-day readmission between groups. There was a significant difference in the mean EBL between the two groups (123.78cc in the IV group and 173.06cc in the PO group, P < .001). Our study was adequately powered at 0.95. ConclusionThere was no statistically significant difference between the IV and PO TXA groups when comparing preop to postoperative day 1 change in Hg and Hct, LOS, transfusion rates, surgical site infections, and 90-day readmission indicating similar efficacy between the two routes of administration. EBL was found to be significantly higher in the PO TXA group, though the clinical significance of this finding is indeterminate. Given these findings, however, PO TXA may be a reliable alternative to IV TXA in primary shoulder arthroplasty.

Shoulder Periprosthetic Joint Infection is Associated with Increased Mortality.

Periprosthetic joint infections (PJI) are a catastrophic complication after shoulder arthroplasty and may be associated with an increased mortality risk, as seen in hip and knee arthroplasty. Shoulder PJI organisms differ from hip and knee infections, as lower virulence organisms, such as Cutibacterium acnes (C. acnes), are more commonly encountered. This study evaluated the association between shoulder PJI and mortality. We retrospectively identified 411 patients who underwent revision shoulder arthroplasty from 2007 to 2020 at a single institution. 2018 ICM criteria were used to categorize each case as definite, probable, possible, or unlikely PJI. Mortality rate was assessed by performing chart reviews and an obituary search. Revision cases were grouped into a septic cohort (definite and probable PJI) and an aseptic cohort (possible and unlikely PJI). Kaplan-Meier analyses were performed to compare survival between septic and aseptic groups. The log-rank test was used to compare cumulative survival distributions and survival rates at ninety days, six months, one year, two years and five years. Demographic information, Charlson Comorbidity Index (CCI), and culture data were collected. PJI organisms were categorized as virulent or non-virulent per an infectious disease specialist and predictors of mortality were determined by performing stepwise logistic regression analyses. The overall mortality rate was significantly greater (p<0.001) in the septic group (20.5%) than in the aseptic group (6.6%). When evaluating time from revision surgery to death, patients with PJI had significantly greater mortality compared to those undergoing aseptic revision at two years (7.7% vs 2.1%, p=0.01) and five years (17% vs 5.1%, p<0.001). BMI, CCI, race, sex, and age were not significantly different between groups. Groups differed in utilization of two-staged procedures (65% septic, 9% aseptic, p<0.001). Multivariate regression analysis found that the variables most associated with mortality were septic revision, two-staged procedures and CCI. In the septic group, patients with C. acnes PJI had a significantly lower mortality rate when compared to PJI from any other offending organism (3.1% versus 48.4%, p=0.001). Revision shoulder arthroplasty in the setting of PJI not only carries severe functional consequences for patients, but is also associated with an increased mortality risk. Furthermore, C. acnes infections are associated with a more favorable survival profile than PJI resulting from other organisms. Continued efforts to decrease shoulder arthroplasty infection rates are warranted and may influence long-term survival.

The utilization of platelet parameters as an adjunct indicator for the diagnosis of shoulder periprosthetic joint infection

BackgroundThe diagnosis of periprosthetic joint infection (PJI) of the shoulder remains challenging. Platelet-related serum values are associated with physiological states of infection. The purpose of this study is to determine whether absolute platelet count and mean platelet volume could aid in the diagnosis of shoulder PJI. MethodsA retrospective review of all patients undergoing revision shoulder arthroplasty at a single institution was performed. Likelihood of PJI was determined based on the International Consensus Meeting score. The ratio of absolute platelet count to mean platelet volume (PV) was calculated for each patient. This PV ratio was compared to erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels for making the diagnosis of shoulder PJI. ResultsFour hundred sixty cases of revision shoulder arthroplasty were identified. Of these, 80 (17.4%) were diagnosed as having a definitive or probable shoulder PJI. The PV ratio was significantly higher for patients with a diagnosed PJI (28.1 vs. 25.4, P = .004). Receiver operator characteristic curve analysis for the PV ratio determined the sensitivity for diagnosing PJI is 55.3% and the specificity is 62.9% with an area under the curve of 0.60 (95% confidence interval [CI]: 0.50-0.69). There was no significant difference between the area under the curve values for PV ratio, ESR (0.61; 95% CI: 0.5117-0.7042), or CRP (0.67; 95% CI: 0.5766-0.7641). On subgroup analysis, the PV ratio demonstrated a specificity of 73.7%, compared to 18.2% for ESR and 23.8% for CRP, at recognizing PJI attributed to Cutibacterium acnes. DiscussionThere is a clear association between an elevated PV ratio and patients with shoulder PJI. Although the PV ratio should not be used alone to make the diagnosis, our analysis demonstrates that this ratio performs similarly to the traditional serum biomarkers at recognizing shoulder PJI. ConclusionThe PV ratio may be used as an adjunct preoperative indicator in the evaluation of patients with potential shoulder PJIs.

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?

Shoulder Periprosthetic Joint Infection and All-Cause Mortality: A Worrisome Association.

Background:Periprosthetic joint infection (PJI) can be a devastating complication following shoulder arthroplasty. PJI following hip and knee arthroplasties has been found to increase mortality. However, anatomical and bacteriologic differences could potentially result in a different trend after shoulder arthroplasties. Thus, the purpose of the present study was to determine whether there is an association between shoulder PJI and all-cause mortality.Methods:Our institutional Total Joint Registry Database was queried to identify patients who underwent revision shoulder arthroplasty procedures between 2000 and 2018. A total of 1,160 procedures were then classified as either septic (21.8%) or aseptic (78.2%). Septic revisions were further subdivided into (1) debridement, antibiotics, irrigation, and implant retention (9.1%); (2) 2-stage reimplantation for deep infection (61.3%); (3) implant resection without reimplantation (3.6%); and (4) unexpected positive cultures at revision surgery (26.1%). The most common bacterium isolated was Cutibacterium acnes (64.4%). All-cause patient mortality was determined with use of our registry and confirmed with use of a nationwide mortality database. All-cause crude and adjusted mortality rates were then compared between groups.Results:The 1-year crude mortality rate was 1.8% (95% confidence interval [CI], 0.9% to 2.6%) for the aseptic group and 2.8% (95% CI, 0.7% to 4.8%) for the septic group (p = 0.31). Multivariate Cox regression analysis demonstrated an elevated but statistically similar adjusted hazard ratio for 1-year all-cause mortality of 1.9 (95% CI, 0.8 to 4.6) when comparing the septic to the aseptic group (p = 0.17). The risk of 2-year all-cause mortality was significantly higher in the septic group, with a hazard ratio of 2.2 (95% CI, 1.1 to 4.5; p = 0.029). In univariate analyses, increased 5-year mortality in the septic revision group was associated with age, Charlson Comorbidity Index, and methicillin-resistant Staphylococcus aureus infection, whereas C. acnes infection was associated with lower mortality.Conclusions:Shoulder PJI is associated with an adjusted 2-year all-cause mortality rate that is double that of aseptic patients. The results of the present study should be utilized to appropriately counsel patients who are considered to be at risk for infection following shoulder arthroplasty.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

654 Outcome and Complications Following Revision Shoulder Arthroplasty. A Systematic Review and Meta-Analysis

Abstract Introduction It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on (i) shoulder outcome scores, (ii) complication and reoperation rates and (iii) comparison of anatomic and reverse prostheses when used in revision surgery. Method A PRISMA systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analysed using a meta-analysis of proportion and continuous variables underwent comparative subgroup analysis. Results 107 studies (5,010 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (n = 584/2872), instability 20% (n = 577/2872), rotator cuff failure 18% (n = 528/2872) and infection 17% (n = 490/2872). Revision surgery resulted in a clinically important improvement in patient-reported outcome measures (PROMs). Intraoperative complication, postoperative complication and reoperation rates were 3% (n = 205/4919), 22% (n = 722/3474) and 15% (n = 533/3474) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (n = 134/205, 65%) and instability (n = 209/772, 27%). Revision to reverse TSA, rather than revision to anatomic TSA from any index prosthesis resulted in lower complication rates (22% vs. 29%, p &amp;lt; 0.001 odds ratio 1.5) and superior Constant scores (59.9 vs. 53.8, p &amp;lt; 0.001), although no difference in ASES scores. Conclusions Satisfactory improvement in PROMs are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA.

Periprosthetic joint infections of the shoulder: A 10-year retrospective analysis outlining the heterogeneity among these patients.

Diagnosis and treatment of shoulder periprosthetic joint infection is a difficult problem. The purpose of this study was to utilize the 2018 International Consensus Meeting definition of shoulder periprosthetic joint infection to categorize revision shoulder arthroplasty cases and determine variations in clinical presentation by presumed infection classification. Retrospective review of patients undergoing revision shoulder arthroplasty at a single institution. Likelihood of periprosthetic joint infection was determined based on International Consensus Meeting scoring. All patients classified as definitive or probable periprosthetic joint infection were classified as periprosthetic joint infection. All patients classified as possible or unlikely periprosthetic joint infection were classified as aseptic. The periprosthetic joint infection cohort was subsequently divided into culture-negative, non-virulent microorganism, and virulent microorganism cohorts based on culture results. Four hundred and sixty cases of revision shoulder arthroplasty were reviewed. Eighty (17.4%) patients were diagnosed as definite or probable periprosthetic joint infection, of which 29 (36.3%), 39 (48.8%), and 12 (15.0%) were classified as virulent, non-virulent, or culture-negative periprosthetic joint infection, respectively. There were significant differences among periprosthetic joint infection subgroups with regard to preoperative C-reactive protein (p = 0.020), erythrocyte sedimentation rate (p = 0.051), sinus tract presence (p = 0.008), and intraoperative purulence (p < 0.001). The total International Consensus Meeting criteria scores were also significantly different between the periprosthetic joint infection cohorts (p < 0.001). While the diagnosis of shoulder periprosthetic joint infection has improved with the advent of International Consensus Meeting criteria, there remain distinct differences between periprosthetic joint infection classifications that warrant further investigation to determine the accurate diagnosis and optimal treatment.

Outcome and complications following revision shoulder arthroplasty : a systematic review and meta-analysis.

AimsIt is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.MethodsA Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis.ResultsA total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores.ConclusionSatisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA.Cite this article: Bone Jt Open 2021;2(8):618–630.

Minimum clinically important difference for the American Shoulder and Elbow Surgeons score after revision shoulder arthroplasty

BackgroundPatients undergoing revision total shoulder arthroplasty (TSA) typically achieve smaller improvements in outcome measurements than those undergoing primary TSA. The minimum clinically important difference (MCID) in the American Shoulder and Elbow Surgeons (ASES) questionnaire for primary shoulder arthroplasty ranges from 13.6 to 20.9, but the MCID for revision shoulder arthroplasty remains unclear. This study aims to define the MCID in ASES score for revision TSA and ascertain patient factors that affect achieving the MCID threshold. MethodsPatients were identified from an institutional shoulder arthroplasty database. Prospective data collected included demographic variables, prior shoulder surgeries, primary and revision implants, indication for revision, and pre- and postoperative ASES scores. All patients provided informed consent to participate. An anchor-based method was used with a binary answer choice. The MCID was calculated using the receiver-operator curve (ROC) method, and the sensitivity, specificity, and area under the curve were obtained from the ROC. MCID values were compared between groups using Student's t-test. Multivariate logistic regression modeling was used to determine significant predictors for reaching MCID. Significance was defined as P< .05. ResultsA total of 46 patients underwent revision TSA with minimum 2-year follow-up. The MCID using ROC method was 16.7 with 71% sensitivity and 62% specificity. There was a trend toward males being more likely to reach MCID after revision arthroplasty (P= .058). There were also trends toward increased forward flexion and abduction range of motion in patients who met MCID (P= .08, P= .07). Multivariate logistic regression modeling demonstrated male sex to be associated with achieving MCID (P= .03), while younger age and fewer prior shoulder surgeries demonstrated a trend to association with achieving MCID (P= .06, P= .10). ConclusionThe MCID for ASES score in patients undergoing revision shoulder arthroplasty is similar to previously reported MCID values for patients undergoing primary shoulder arthroplasty. Younger, male patients with fewer prior shoulder surgeries were more likely to achieve MCID after revision TSA. Level of EvidenceLevel III; Retrospective Comparative Treatment Study

Symptomatic aseptic loosening of a short humeral stem following anatomic total shoulder arthroplasty.

The rate of aseptic humeral component loosening with standard-length stems is historically so low (0.3%) that presence of humeral loosening was given substantial weight in defining periprosthetic shoulder infection by the International Consensus Meeting (ICM) in 2018. This study aims to confirm that the historically low rate of humeral stem aseptic loosening is not affected by the adoption of a novel short humeral stem. Following institutional review board approval, this retrospective multi-institutional study was undertaken. A review of anatomic total shoulder arthroplasty (TSA) cases at 3 institutions provided 184 shoulders that received TSA with a grit-blasted, rectangular short humeral stem without ingrowth coating (Univers Apex; Arthrex). The average patient age was 62.1 years (range: 30-84), and 57.1% (105/184) were male. One-year radiographic follow-up was achieved in 64.7%. Patient clinical charts were reviewed for onset of newly painful shoulders, radiographic evidence of loosening, and return to the operating room for any reason. All patients with concern for clinically significant humeral loosening underwent workup for periprosthetic shoulder infection. Immediate postoperative films were reviewed to identify any differences in prosthetic canal fit. The definition of periprosthetic shoulder infection used was provided by the recent ICM shoulder guidelines. Twenty-three (12.5%) patients presented with a painful shoulder and radiographic concern for potential humeral loosening at a mean follow-up of 1.5 years (range: 1.5 months-3.4 years). Thirteen (7.1%) of these underwent revision shoulder arthroplasty where a loose stem was confirmed. All revisions underwent tissue culture, and 3 cases were consistent with probable or possible periprosthetic infection at the time of revision arthroplasty. The rate of symptomatic aseptic humeral loosening in this series was 10.9% (20/184), with 5.4% undergoing revision surgery. Patients with symptomatic aseptic humeral loosening were more likely to be male (90.5%) than those patients without symptoms (52.8%, P < .001). There were no differences in canal fit between patients with concern for symptomatic loosening and those with pain-free, stable implants. In this multisurgeon, multicenter study, the early humeral loosening rate for this stem design far outpaces previously reported rates, and this study likely under-reports the true incidence of clinically significant loosening as it only contains limited short-term follow-up. The perception that humeral loosening is nearly pathognomonic for periprosthetic shoulder infection should be reconsidered for certain short humeral stem designs.

Cutibacterium subtype distribution on the skin of primary and revision shoulder arthroplasty patients

The skin of healthy shoulders is known to harbor multiple different subtypes of Cutibacterium (formerly Propionibacterium) acnesat the same time. C acnes can often be isolated from deep tissue and explant samples obtained during revision of a failed shoulder arthroplasty, presumably because the shoulder was inoculated with organisms from the patient's skin at the time of the index arthroplasty. It is possible that specific subtypes or distributions of subtypes may be associated with an increased pathogenic potential and that the skin of patients undergoing revision arthroplasty contains different distributions of the subtypes than in patients undergoing primary arthroplasty. We analyzed the subtype distribution of Cutibacterium from the skin of shoulders undergoing revision arthroplasty vs. primary arthroplasty. Preoperative skin swabs were collected from 25 patients who underwent primary shoulder arthroplasty and 27 patients who underwent revision shoulder arthroplasty. The results of semiquantitative cultures of the skin and deep tissues were reported as specimen Cutibacteriumvalues, and scores from all deep tissue samples were added to report the total shoulder Cutibacteriumscore. Single-locus sequence typing (SLST) of Cacnes from the skin swabs was used to determine the subtype distribution for each patient. The percentage of each subtype for each patient was averaged in patients undergoing revision arthroplasty and then compared with that in patients undergoing primary arthroplasty. The C acnes subtype distribution on the skin of revision arthroplasty patients was different from that of primary shoulder arthroplasty patients, with a significantly higher percentageof SLST subtype A (36.9% vs. 16.0%, P = .0018). The distribution of SLST subtypes was similar between revision arthroplasty patients with strongly positive culture findings vs. those with weakly positive or negative culture findings. Significant differences in the skin Cutibacterium subtype distributions were found between shoulders undergoing revision shoulder arthroplasty and those undergoing primary shoulder arthroplasty. Future studies are needed to determine whether certain Cutibacterium subtype distributions are associated with an increased risk of arthroplasty revision.

The Use and Adverse Effects of Oral and Intravenous Antibiotic Administration for Suspected Infection After Revision Shoulder Arthroplasty

When performing revision shoulder arthroplasty, surgeons do not have access to the results of intraoperative culture specimens and will administer empiric antibiotics to cover for the possibility of deep infection until the culture results are finalized. The purpose of this study was to report the factors associated with the initiation, modification, and adverse events of 2 different postoperative antibiotic protocols in a series of revision shoulder arthroplasties. In this study, 175 patients undergoing revision shoulder arthroplasty were treated with either a protocol of intravenous (IV) antibiotics if there was a high index of suspicion for infection or a protocol of oral antibiotics if the index of suspicion was low. Antibiotics were withdrawn if cultures were negative and were modified as indicated if the cultures were positive. Antibiotic course, modification, and adverse effects to antibiotic administration were documented. On univariate analysis, factors significantly associated with the initiation of IV antibiotics were male sex (p < 0.001), history of infection (p < 0.001), intraoperative humeral loosening (p = 0.003), and membrane formation (p < 0.001). On multivariate analysis, male sex (p = 0.003), history of infection (p = 0.003), and membrane formation (p < 0.001) were found to be independent predictors of the initiation of IV antibiotics. On the basis of preoperative and intraoperative characteristics, surgeons anticipated the culture results in 75% of cases, and modification of antibiotic therapy was required in 25%. The modification from oral to IV antibiotics due to positive culture results was made significantly more often in male patients (p < 0.001). Adverse effects of antibiotic administration occurred in 19% of patients. The rates of complications were significantly lower in the patients treated with oral antibiotics and a shorter course of antibiotics (p < 0.001). Complications associated with antibiotic administration after revision shoulder arthroplasty are not infrequent and are more common in patients whose initial protocol is IV antibiotics. Further study is needed to balance the effectiveness and risks of post-revision antibiotic treatment given the frequency of antibiotic-related complications. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cutibacterium acnes Isolates from Deep Tissue Specimens Retrieved during Revision Shoulder Arthroplasty: Similar Colony Morphology Does Not Indicate Clonality.

Cutibacterium acnes is the most common bacterium associated with periprosthetic shoulder infections. Sequencing of C. acnes has been proposed as a potential rapid diagnostic tool and a method of determining subtypes associated with pathogenicity and antibiotic resistance patterns. When multiple deep samples from the same surgery are culture positive for the same species and the isolates show the same culture phenotype, it is typically assumed that these isolates are clonal. However, it is well-known that C. acnes is not clonal on the skin of most individuals. We hypothesized that the C. acnes bacteria recovered at the time of revision shoulder arthroplasty would often represent more than one subtype, and we tested this hypothesis in this work. For patients undergoing revision shoulder arthroplasty, multiple samples from the surgical field were taken. For those patients with multiple samples that were culture positive for C. acnes, isolates from each sample were subjected to full genome sequencing. Of 11 patients, 5 (45%) had different subtypes of C. acnes within the deep tissues even though the colony morphology was similar. One patient had four subtypes in the deep tissues, while four patients had two different subtypes. Up to four different subtypes of C. acnes were observed in the deep tissues of a single patient. Clonality of C. acnes isolates from deep specimens from a potential periprosthetic shoulder infection cannot be assumed. Sequence-based characterization of virulence and antibiotic resistance may require testing of multiple deep specimens.