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Chronic shoulder arthroplasty infection is amenable to two-stage reimplantation
Identifying the type of infection, patient factors may help surgeons determine the best course of treatment.
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The type of infectious organism, patient factors and timing of a revision procedure play critical roles in appropriate treatment of infection after shoulder arthroplasty, according to a presenter.
“The diagnosis of infection after shoulder arthroplasty can be challenging,” John W. Sperling, MD, told Orthopedics Today. “Integration of the history, physical examination, radiographic studies, as well as laboratory investigations, is important due to the fact preoperative blood tests, such as [C-reactive protein] CRP and sedimentation rate, are frequently normal in patients with a low-grade infection.”
Infection treatment
Infection after shoulder arthroplasty ranges from 0% to 4% and can be a devastating complication, Sperling noted. He said patients with an acute or early postoperative infection and a well-functioning prosthesis could undergo debridement and polyethylene exchange.
One-stage or two-stage reimplantation also can be performed, although deciding which reimplantation surgery is appropriate in each case has become controversial, Sperling noted.
According to Sperling, when deciding between a one-stage or two-stage reimplantation following shoulder arthroplasty, the type of organism, the patient’s medical comorbidities and whether the patient can withstand a two-stage operation should all be considered. One-stage reimplantation is extensive debridement with placement of new components fixed with antibiotic-impregnated cement and the use of IV antibiotics based on the organism, he said.
Two-stage reimplantation is the most accepted approach for chronic infection. It involves component removal, debridement, placement of an antibiotic spacer, IV antibiotics and placing the new implant typically 8 weeks later, Sperling said.
“We have shifted toward using more uncemented components at the time of reimplantation,” Sperling said.
Operative tips for surgeons
The surgeon must know the type of infection the patient has when deciding on a course of treatment. Sperling said infections can be categorized into four types: positive cultures found at revision surgery (type 1); acute infection within 30 days of surgery (type 2); acute hematogenous infection (type 3); and chronic infection (type 4).
He noted type 1 infections should be treated with IV antibiotics and be watched closely.
“With Type 2 early postoperative infection, there is more of a tendency now to do a debridement with prosthetic retention, particularly with a reverse arthroplasty,” Sperling said. “With the thought of trying to avoid removal of a well-fixed baseplate, we will consider more of a debridement in these patients.”
Patients with hematogenous or type 3 infections should undergo debridement, however patients at this institution with chronic infections are typically treated with two-stage reimplantation, he said.
Sperling recommended orthopedic surgeons preoperatively template the size of the spacer when performing a two-stage shoulder arthroplasty revision for infection.
“The spacer can be made with the specific antibiotics chosen by the surgeon while the patient undergoes anesthesia. This can save considerable operative time,” Sperling said. “The spacer can enable early passive motion, which can help minimize scarring and facilitate future reimplantation surgery.” – by Casey Tingle
- Reference:
- Sperling JW. Paper #15. Presented at: Current Concepts in Joint Replacement Spring Meeting; May 21-24, 2017; Las Vegas.
- For more information:
- John W. Sperling, MD, can be reached at Mayo Clinic, 200 1st St. SW, Rochester, MN 55902; email: madson.rhoda@mayo.edu.
Disclosure: Sperling reports he receives royalties from Zimmer Biomet.