The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics

Abstract

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1 degrees (sd 27.8) pre-operatively to 75.7 degrees (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1 degrees (sd 33.5) to 79.5 degrees (sd 43.2) (p = 0.0003), and mean external rotation from 10.2 degrees (sd 18.7) to 25.4 degrees (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.

Two-stage Reimplantation for Treating Prosthetic Shoulder Infections

“…Seventeen of the 27 patients were revised to a reverse total shoulder arthroplasty in the second-stage surgery and are the focus of this study. The diagnosis of infection was based on a combination of clinical suspicion, positive intraoperative frozen sections, positive culture treated at an outside referring institution, positive preoperative aspiration cultures, or positive intraoperative tissue cultures (Table 1) [4]. Fourteen patients had their initial diagnosis and treatment at our institution, while three were initially diagnosed and treated for infection at an outside hospital and then referred to our institution for treatment.…”

“…Patients had a median of Values are expressed as mean, with 95% confidence interval in brackets, or as number/total number of patients, with percentage in parentheses and 95% confidence intervals in brackets; TSA = total shoulder arthroplasty; WBC = white blood cell; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein; poly = polymorphonuclear leukocytes; org = organisms. 4.0 months (range, 1.8-61 months) between explant of the infected prosthetic to second-stage reconstruction. All patients who underwent second-stage reverse total shoulder arthroplasty had major damage to the rotator cuff at the time of second-stage reconstruction.…”

“…They concluded two-stage reimplantation for infected shoulder arthroplasty provided marginal success in controlling infection and low patient satisfaction with high complication rates. Cuff et al [4] reported substantially different findings, with no recurrence of infection for patients treated with a single-or two-stage revision. They reported major improvements in postoperative shoulder ROM when compared to preoperative levels (abduction, 36.1°preoperatively to 75.7°postoperatively; forward flexion, 43.1°to 79.5°; mean external rotation, 10.2°to 25.4°).…”

“…However, few studies report function, particularly when the secondstage reconstruction used a reverse total shoulder arthroplasty. Two case series report function after twostage reimplantation [4,14] but used different functional scores and reported differing reinfection rates. Strickland et al [14] reported 17 patients treated with two-stage reimplantation for infected shoulder arthroplasty and found 37% had persistent infection.…”

Management of complications after revision shoulder arthroplasty

“…Cuff et al compared outcomes of single vs. two-stage exchange with conversion to a reverse total shoulder arthroplasty and found no difference in outcomes between the two methods. They believed successful eradication of infection between the two methods were a result of the quality of the debridement since RSA was anticipated, and there was little concern for resecting suspicious rotator cuff, capsule, and bone tissue [82].…”