Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty

Abstract

Background Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution. Methods From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection. Results Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) ( P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) ( P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection. Conclusion Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

Risk Factors for Periprosthetic Joint Infection after Shoulder Arthroplasty: Systematic Review and Meta-Analysis

“…Four studies [ 22 , 23 , 26 , 29 ] could be used for analyses with previous non arthroplasty surgery history. The results indicated that patients with surgical history are at more risk than the control group.…”

“…One study [ 22 ] included aTSA and rTSA only, and another study [ 30 ] included aTSA and HA only. Four studies [ 21 , 23 , 25 , 29 ] were recorded for only one type of operation. In the remaining three studies [ 27 , 28 , 30 ], there was no detailed description of whether TSA was anatomical or reversed.…”

“…Figure 4 shows the forest plots, pooled OR, 95% CI, and heterogeneity for comorbidities with statistically significant results. DM was reported in 6 of 10 studies [ 21 , 23 , 24 , 27 , 29 , 30 ]. Our statistical analysis evaluated DM to be a risk factor for PJI after shoulder arthroplasty (pooled OR = 1.32; 95% CI = 1.04, 1.68; I 2 = 0%).…”

“…The risk factors analyzed in the demographic subgroups include ( A ) male (vs. female), ( B ) age (≥65 years old) ( C ) obesity (BMI ≥ 30), ( D ) ASA scale I, II versus III, IV, V), and ( E ) white race versus non-white races. BMI, body mass index; ASA, American Society of Anesthesiologists [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].…”

“…The risk factors analyzed in the perioperative subgroups include ( A ) the presence of previous non-arthroplasty operation history, ( B ) acute trauma-related arthroplasty versus nontrauma-related arthroplasty, ( C ) OA as diagnosis prior to arthroplasty versus non-OA, ( D ) revision arthroplasty versus primary arthroplasty, and ( E ) total shoulder arthroplasty (aTSA and rTSA) versus hemiarthroplasty. OP Hx, operation history; OA, osteoarthritis; aTSA, anatomical total shoulder arthroplasty; rTSA, reverse total shoulder arthroplasty; HA, hemiarthroplasty [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ].…”