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

Abstract

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.

Short-term outcomes of two-stage reverse total shoulder arthroplasty with antibiotic-loaded cement spacer for shoulder infection

“…A two-stage approach with use of a temporary antibiotic-loaded cement spacer has been also used in infected shoulders as a common procedure proven by numerous studies for treatment of hip and knee infections [7][8][9][10][11][12]. The first stage in this approach consists of thorough irrigation and extensive debridement with implant removal if present, followed by subsequent insertion of a temporary antibiotic-loaded cement spacer with intravenous antibiotic therapy.…”

“…Among these variety of options, the two-stage approach with temporary antibiotic-loaded cement spacer is well known as one of the standard options in hip and knee infections, and has become a procedure of interest for the treatment of shoulder infection [7,8]. Recently, several studies reported promising results using a two-stage reverse total shoulder arthroplasty (RTSA) with antibiotic-loaded cement spacers in the treatment of primary pyogenic arthritis, as well as PJI of the shoulder [9][10][11][12]. However, reports about the treatment of primary pyogenic arthritis using this modality are limited with a small number of patients [9].…”

“…Recently, several studies reported promising results using a two-stage reverse total shoulder arthroplasty (RTSA) with antibiotic-loaded cement spacers in the treatment of primary pyogenic arthritis, as well as PJI of the shoulder [9][10][11][12]. However, reports about the treatment of primary pyogenic arthritis using this modality are limited with a small number of patients [9].…”

Artroplastia de resección de hombro como salvamento para infecciones recalcitrantes. Estado actual de la técnica a propósito de dos casos

“…Además, la tasa de insatisfacción tras el tratamiento en dos tiempos es elevada, alcanzando hasta el 40% de los pacientes en alguna serie. 19 El mayor problema radica en los fracasos de esas revisiones, en aflojamientos e infecciones de PRH, en pacientes frágiles o en situaciones de infecciones recalcitrantes u osteomielitis, donde la preservación de los implantes implica un alto riesgo de fracaso o incluso el compromiso de la vida del paciente por sepsis. Además, la revisión de las PRH es complicada y las opciones son muy limitadas, debido a la pérdida de en cursiva óseo y a la tensión de los tejidos blandos.…”

“…Se realiza un desbridamiento amplio y retirada de la prótesis y del cemento si están presentes, asociado a abundantes lavados. Para la extracción del cemento se recomienda el uso de múltiples osteotomos e incluso un dispositivo de ultrasonidos, para asegurar que no permanecen elementos que puedan perseverar la infección 19 . En ocasiones, una osteotomía puede ser necesaria para la extracción del vástago de la prótesis 20 como en uno de nuestros casos en los que fue necesario realizar un sarcófago para la extracción del vástago cementado.…”