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Workup and Management of Infection in Shoulder Arthroplasty

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Abstract

Prosthetic joint infection (PJI) is an important complication after shoulder arthroplasty and is often associated with significant morbidity. However, clear signs and symptoms of infection are not always present. As such, it is mandatory to consider each painful shoulder arthroplasty as potentially infected until proven otherwise and to perform a systematic diagnostic investigation. However, the exact diagnostic and therapeutic strategies are still a matter of open debate. The authors present a critical review of the management of infection in shoulder arthroplasty considering their own experience.

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References

  1. Beekman PD, Katusic D, Berghs BM, Karelse A, Wilde L, De Wilde L. One-stage revision for patients with a chronically infected reverse total shoulder replacement. J Bone Joint Surg Br. 2010;92(6):817–22.

    Article  CAS  PubMed  Google Scholar 

  2. Singh JA, Sperling J, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elb Surg. 2012;21(11):1534–41.

    Article  Google Scholar 

  3. Hudek R, Gohlke F. [Endoprosthesis infections of the shoulder: diagnosis and therapy algorithm]. Orthopade. 2013;42(7):552–9.

    Google Scholar 

  4. Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elb Surg. 2015;24(5):741–6.

    Article  Google Scholar 

  5. Richards J, Inacio M, Beckett M, Navarro RA, Singh A, Dillon MT, et al. Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty. Clin Orthop Relat Res. 2014;472(9):2809–15.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, et al. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am. 2012;94(22):2075–83.

    Article  PubMed  Google Scholar 

  7. Bohsali KI, Wirth MA. Complications of shoulder arthroplasty. J Bone Joint Surg Am. 2017;99(3):256–69.

    Article  PubMed  Google Scholar 

  8. Piper KE, Jacobson MJ, Cofield RH, Sperling JW, Sanchez-Sotelo J, Osmon DR, et al. Microbiologic diagnosis of prosthetic shoulder infection by use of implant sonication. J Clin Microbiol. 2009;47(6):1878–84.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Fink B, Sevelda F. Periprosthetic joint infection of shoulder arthroplasties: diagnostic and treatment options. Biomed Res Int. 2017;2017:4582756.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Weber P, Utzschneider S, Sadoghi P, Andress H-J, Jansson V, Muller PE. Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature. Int Orthop. 2011;35(3):365–73.

    Article  PubMed  Google Scholar 

  11. Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, Garvin KL, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469(11)(1528-1132 (Electronic)):2992–4.

    Google Scholar 

  12. Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1–e25.

    Article  PubMed  Google Scholar 

  13. Renz N, Yermak K, Perka C, Trampuz A. Alpha defensin lateral flow test for diagnosis of periprosthetic joint infection: not a screening but a confirmatory test. J Bone Joint Surg Am. 2018;100(9):742–50.

    Article  PubMed  Google Scholar 

  14. Gehrke T, Parvizi J. Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection. 2013. https://www.efort.org/wp-content/uploads/2013/10/Philadelphia_Consensus.pdf.

  15. Garrigues GE, Zmistowski B, Cooper AM, Green A. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elb Surg. 2019;28(6S):S8–S12.

    Article  Google Scholar 

  16. Moroder P, Gerhardt C, Renz N, Trampuz A, Scheibel M. Diagnostik und Management des Endoprotheseninfekts am Schultergelenk. Obere Extrem. 2016;11(2):78–87.

    Article  Google Scholar 

  17. Sousa R, Massada M, Pereira A, Fontes F, Amorim I, Oliveira A. Diagnostic accuracy of combined 99mTc-sulesomab and 99mTc-nanocolloid bone marrow imaging in detecting prosthetic joint infection. Nucl Med Commun. 2011;32(9):834–9.

    Article  PubMed  Google Scholar 

  18. Piper KE, Fernandez-Sampedro M, Steckelberg KE, Mandrekar JN, Karau MJ, Steckelberg JM, et al. C-reactive protein, erythrocyte sedimentation rate and orthopedic implant infection. PLoS One. 2010;5(2):e9358.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  19. Dodson CC, Craig E, Cordasco FA, Dines DM, Dines JS, Dicarlo E, et al. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elb Surg. 2010;19(2):303–7.

    Article  Google Scholar 

  20. Grosso MJ, Frangiamore SJ, Saleh A, Kovac MF, Hayashi R, Ricchetti ET, et al. Poor utility of serum interleukin-6 levels to predict indolent periprosthetic shoulder infections. J Shoulder Elb Surg. 2014;23(9):1277–81.

    Article  Google Scholar 

  21. Marcheggiani Muccioli GM, Guerra E, Roberti di Sarsina T, Alesi D, Fratini S, Cammisa E, et al. Diagnosis and treatment of infected shoulder arthroplasty: current concepts review. Joints. 2018;6(3):173–6.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Colvin OC, Kransdorf MJ, Roberts CC, Chivers FS, Lorans R, Beauchamp CP, et al. Leukocyte esterase analysis in the diagnosis of joint infection: can we make a diagnosis using a simple urine dipstick? Skeletal Radiol. 2015;44(5):673–7.

    Article  PubMed  Google Scholar 

  23. Shafafy R, McClatchie W, Chettiar K, Gill K, Hargrove R, Sturridge S, et al. Use of leucocyte esterase reagent strips in the diagnosis or exclusion of prosthetic joint infection. Bone Joint J. 2015;97-B(9):1232–6.

    Article  CAS  PubMed  Google Scholar 

  24. Tischler EH, Cavanaugh PK, Parvizi J. Leukocyte esterase strip test: matched for musculoskeletal infection society criteria. J Bone Joint Surg Am. 2014;96(22)(1535-1386 (Electronic)):1917–20.

    Google Scholar 

  25. Wetters NG, Berend KR, Lombardi AV, Morris MJ, Morris MJ, Tucker TL, Della Valle CJ. Leukocyte esterase reagent strips for the rapid diagnosis of periprosthetic joint infection. J Arthroplasty. 2012;27(8 Suppl)(1532–8406 (Electronic)):8–11.

    Google Scholar 

  26. Shahi A, Parvizi J, Kazarian GS, Higuera C, Frangiamore S, Bingham J, et al. The alpha-defensin test for periprosthetic joint infections is not affected by prior antibiotic administration. Clin Orthop Relat Res. 2016;474(7):1610–5.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Kasparek MF, Kasparek M, Boettner F, Faschingbauer M, Hahne J, Dominkus M. Intraoperative diagnosis of periprosthetic joint infection using a novel alpha-defensin lateral flow assay. J Arthroplasty. 2016;31(12):2871–4.

    Article  PubMed  Google Scholar 

  28. Sigmund IK, Holinka J, Gamper J, Staats K, Bohler C, Kubista B, et al. Qualitative alpha-defensin test (Synovasure) for the diagnosis of periprosthetic infection in revision total joint arthroplasty. Bone Joint J. 2017;99-B(1):66–72.

    Article  CAS  PubMed  Google Scholar 

  29. Frangiamore SJ, Saleh A, Grosso MJ, Kovac MF, Higuera CA, Iannotti JP, et al. alpha-Defensin as a predictor of periprosthetic shoulder infection. J Shoulder Elb Surg. 2015;24(7):1021–7.

    Article  Google Scholar 

  30. Ince A, Seemann K, Frommelt L, Katzer A, Loehr JF. One-stage exchange shoulder arthroplasty for peri-prosthetic infection. J Bone Joint Surg Br. 2005;87(6):814–8.

    Article  CAS  PubMed  Google Scholar 

  31. Ali F, Wilkinson JM, Cooper JR, Kerry RM, Hamer AJ, Norman P, et al. Accuracy of joint aspiration for the preoperative diagnosis of infection in total hip arthroplasty. J Arthroplasty. 2006;21(2):221–6.

    Article  PubMed  Google Scholar 

  32. Parvizi J, Ghanem E, Menashe S, Barrack RL, Bauer TW. Periprosthetic infection: what are the diagnostic challenges? J Bone Joint Surg Am. 2006;88(Suppl 4)(0021-9355 (Print)):138–47.

    Google Scholar 

  33. Qu X, Zanjing Z, Wu C, Jin F, Li H, Wang L, et al. Preoperative aspiration culture for preoperative diagnosis of infection in total hip or knee arthroplasty. J Clin Microbiol. 2013;51(11)(1098-660X (Electronic)):3830–4.

    Google Scholar 

  34. Spangehl MJ, Masri BA, O’Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81(5)(0021-9355 (Print)):672–83.

    Google Scholar 

  35. Gollwitzer H, Diehl P, Gerdesmeyer L, Mittelmeier W. [Diagnostic strategies in cases of suspected periprosthetic infection of the knee. A review of the literature and current recommendations]. Orthopade. 2006;35(9):904, 6–8, 10–6.

    Google Scholar 

  36. Costerton JW. Biofilm theory can guide the treatment of device-related orthopaedic infections. Clin Orthop Relat Res. 2005;(437):7–11.

    Google Scholar 

  37. Neut D, van Horn JR, van Kooten TG, van der Mei HC, Busscher HJ. Detection of biomaterial-associated infections in orthopaedic joint implants. Clin Orthop Relat Res. 2003;(413)(0009-921X (Print)):261–8.

    Google Scholar 

  38. Holmes S, Pena Diaz AM, Athwal GS, Faber KJ, O’Gorman DB. Neer Award 2017: a rapid method for detecting Propionibacterium acnes in surgical biopsy specimens from the shoulder. J Shoulder Elb Surg. 2017;26(2):179–85.

    Article  Google Scholar 

  39. Dilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am. 2014;96(23):1952–8.

    Article  PubMed  Google Scholar 

  40. Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty. A retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am. 1999;81(10):1434–45.

    Article  CAS  PubMed  Google Scholar 

  41. Sousa R, Abreu MA. Treatment of prosthetic joint infection with debridement, antibiotics and irrigation with implant retention—a narrative review. J Bone Jt Infect. 2018;3(3):108–17.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25(7):1022–7.

    Article  PubMed  Google Scholar 

  43. Holmberg A, Thorhallsdottir VG, Robertsson O, W-Dahl A, Stefansdottir A. 75% success rate after open debridement, exchange of tibial insert, and antibiotics in knee prosthetic joint infections. Acta Orthop. 2015;86(4):457–62.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Wouthuyzen-Bakker M, Sebillotte M, Lomas J, Taylor A, Palomares EB, Murillo O, et al. Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention. J Infect. 2019;78(1):40–7.

    Article  PubMed  Google Scholar 

  45. Choong PF, Dowsey MM, Carr D, Daffy J, Stanley P. Risk factors associated with acute hip prosthetic joint infections and outcome of treatment with a rifampinbased regimen. Acta Orthop. 2007;78(6):755–65.

    Article  PubMed  Google Scholar 

  46. Lora-Tamayo J, Murillo O, Iribarren JA, Soriano A, Sanchez-Somolinos M, Baraia-Etxaburu JM, et al. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis. 2013;56(2):182–94.

    Article  PubMed  Google Scholar 

  47. Morata L, Senneville E, Bernard L, Nguyen S, Buzele R, Druon J, et al. A retrospective review of the clinical experience of linezolid with or without rifampicin in prosthetic joint infections treated with debridement and implant retention. Infect Dis Ther. 2014;3(2):235–43.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Peel TN, Buising KL, Dowsey MM, Aboltins CA, Daffy JR, Stanley PA, et al. Outcome of debridement and retention in prosthetic joint infections by methicillin-resistant staphylococci, with special reference to rifampin and fusidic acid combination therapy. Antimicrob Agents Chemother. 2013;57(1):350–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Puhto AP, Syrjala H. Short-course antibiotics for prosthetic joint infections treated with prosthesis retention. Clin Microbiol Infect. 2012;18(11):1143–8.

    Article  CAS  PubMed  Google Scholar 

  50. Tornero E, Morata L, Martinez-Pastor JC, Angulo S, Combalia A, Bori G, et al. Importance of selection and duration of antibiotic regimen in prosthetic joint infections treated with debridement and implant retention. J Antimicrob Chemother. 2016;71(5):1395–401.

    Article  PubMed  Google Scholar 

  51. Vilchez F, Martinez-Pastor JC, Garcia-Ramiro S, Bori G, Macule F, Sierra J, et al. Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement. Clin Microbiol Infect. 2011;17(3):439–44.

    Article  CAS  PubMed  Google Scholar 

  52. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16)(1533–4406 (Electronic)):1645–54.

    Google Scholar 

  53. Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PFM, et al. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect. 2011;17(6):862–7.

    Article  CAS  PubMed  Google Scholar 

  54. Rodriguez-Pardo D, Pigrau C, Lora-Tamayo J, Soriano A, del Toro MD, Cobo J, et al. Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study. Clin Microbiol Infect. 2014;20(11):911–9.

    Article  CAS  Google Scholar 

  55. Grossi O, Asseray N, Bourigault C, Corvec S, Valette M, Navas D, et al. Gram-negative prosthetic joint infections managed according to a multidisciplinary standardized approach: risk factors for failure and outcome with and without fluoroquinolones. J Antimicrob Chemother. 2016;71(9):2593–7.

    Article  CAS  PubMed  Google Scholar 

  56. Piso RJ, Elke R. Antibiotic treatment can be safely stopped in asymptomatic patients with prosthetic joint infections despite persistent elevated C-reactive protein values. Infection. 2010;38(4):293–6.

    Article  CAS  PubMed  Google Scholar 

  57. Bejon P, Byren I, Atkins BL, Scarborough M, Woodhouse A, McLardy-Smith P, et al. Serial measurement of the C-reactive protein is a poor predictor of treatment outcome in prosthetic joint infection. J Antimicrob Chemother. 2011;66(7):1590–3.

    Article  CAS  PubMed  Google Scholar 

  58. Lora-Tamayo J, Euba G, Cobo J, Horcajada JP, Soriano A, Sandoval E, et al. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents. 2016;48(3):310–6.

    Article  CAS  PubMed  Google Scholar 

  59. Magnan B, Bondi M, Vecchini E, Samaila E, Maluta T, Dall’Oca C. A preformed antibiotic-loaded spacer for treatment for septic arthritis of the shoulder. Musculoskelet Surg. 2014;98(1):15–20.

    Article  CAS  PubMed  Google Scholar 

  60. Haddad S, Corona PS, Reverte MM, Amat C, Flores X. Antibiotic-impregnated cement spacer as a definitive treatment for post-arthroscopy shoulder destructive osteomyelitis: case report and review of literature. Strategies Trauma Limb Reconstr. 2013;8(3):199–205.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Wouthuyzen-Bakker M, Kheir MM, Moya I, Rondon AJ, Kheir M, Lozano L, et al. Failure after 2-stage exchange arthroplasty for treatment of periprosthetic joint infection: the role of antibiotics in the cement spacer. Clin Infect Dis. 2019;68(12):2087–93.

    Article  PubMed  Google Scholar 

  62. Klatte TO, Junghans K, Al-Khateeb H, Rueger JM, Gehrke T, Kendoff D, et al. Single-stage revision for peri-prosthetic shoulder infection: outcomes and results. Bone Joint J. 2013;95-B(3):391–5.

    Article  PubMed  Google Scholar 

  63. Nelson GN, Davis DE, Namdari S. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elb Surg. 2016;25(8):1337–45.

    Article  Google Scholar 

  64. Cuff DJ, Virani NA, Levy J, Frankle MA, Derasari A, Hines B, et al. The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics. J Bone Joint Surg Br. 2008;90(3):336–42.

    Article  CAS  PubMed  Google Scholar 

  65. George DA, Volpin A, Scarponi S, Haddad FS, Romano CL. Does exchange arthroplasty of an infected shoulder prosthesis provide better eradication rate and better functional outcome, compared to a permanent spacer or resection arthroplasty? A systematic review. BMC Musculoskelet Disord. 2016;17:52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Pellegrini A, Legnani C, Macchi V, Meani E. Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections. Orthop Traumatol Surg Res. 2019;105(2):237–40.

    Article  PubMed  Google Scholar 

  67. Coste JS, Reig S, Trojani C, Berg M, Walch G, Boileau P. The management of infection in arthroplasty of the shoulder. J Bone Joint Surg Br. 2004;86(1):65–9.

    Article  CAS  PubMed  Google Scholar 

  68. Romano CL, Borens O, Monti L, Meani E, Stuyck J. What treatment for periprosthetic shoulder infection? Results from a multicentre retrospective series. Int Orthop. 2012;36(5):1011–7.

    Article  PubMed  PubMed Central  Google Scholar 

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Claro, R., Barros, L., Sampaio Gomes, N., Sousa, R. (2020). Workup and Management of Infection in Shoulder Arthroplasty. In: Sampaio Gomes, N., Kovačič, L., Martetschläger, F., Milano, G. (eds) Massive and Irreparable Rotator Cuff Tears. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-61162-3_35

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