Study finds high rate of morbidity, mortality associated with native shoulder joint sepsis
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Multiple underlying risk factors, such as IV drug use, and increased mortality rates were found in patients with native shoulder joint sepsis who are treated with surgical irrigation and debridement, according to recently presented results.
Tyler Henry, BS, on behalf on the Sidney Kimmel Medical College and Rothman Orthopaedic Institute, presented findings on shoulder joint sepsis at the Musculoskeletal Infection Society Annual Meeting, which was held virtually.
“We sought to characterize the demographics in patients presenting with native shoulder joint sepsis, assess the efficacy of utilized treatment strategies and identify variables that may affect outcomes,” Henry said in his presentation.
“Shoulder joint sepsis is a relatively rare but serious condition that carries a high risk of morbidity and mortality. It commonly occurs in medically complex patients and those who have identifiable risk factors,” Henry said. “Treatment most often involves a combination of surgical debridement, followed by a course of IV and oral antibiotics, and their reported outcomes are highly variable.”
From 2007 to 2017, Henry and colleagues identified 79 patients with native shoulder sepsis, following up with the final study population of 23 patients for an average of 3.2 years.
“Looking at the study population, it is worth noting that at the time of data collection, 16 of the initially queried 79 patients were deceased,” Henry said. “This, in conjunction with the low rate of post-surgical follow-up, underscore the unique challenges of treating shoulder joint sepsis and the medical complexity of many infected patients,” he added.
Henry and colleagues found open irrigation and debridement was associated with a higher number of surgeries required and was reserved for more virulent organisms such as MRSA, he said.
“Five patients experienced infection recurrence requiring reoperation, and seven patients underwent unplanned reoperation, including one conversion arthroplasty 5 months after initial presentation,” Henry said. “At final follow-up, the mean American Shoulder and Elbow Surgeons shoulder score was 55.3 and was significantly lower in IV drug users,” he said.
“Overall, IV drug use carried a poorer functional prognosis in our cohort. The high rate of IV drug users within our cohort also challenges prior studies that have reported no increased risk for shoulder joint sepsis among IV drug users,” Henry said.
With a mortality rate of 20.3% throughout the cohort, Henry highlighted the severity of the disease, stressing the need for prompt, aggressive management.
“Surgical debridement and postoperative antibiotics [are] relatively effective, but reinfection rates are high,” Henry said. “Underlying risk factors and comorbidities should be identified and addressed to the greatest extent possible.”
Perspective
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Jonathan Barlow, MD
We certainly appreciate the contribution by the Rothman Group to the surgical literature regarding native shoulder infections. In many cases, these infections are associated with substantial medical comorbidities and IV drug abuse.
Henry and colleagues were able to compile a relatively large group of patients (79 patients). Follow-up was limited – only 30% (23/79). Even more striking was a 20% mortality rate in this population (similar to hip fractures). This number is likely related to host factors rather than the infection itself.
The authors showed slightly lower rates of revision with arthroscopic debridement, although the authors note that open surgery was reserved for the more severe infections (there was a 30% reoperation rate). In addition, the average shoulder SANE score was 53, which indicates substantial ongoing difficulties for these patients.
The 20% mortality, 30% reoperation rate and SANE scores of 53 are sobering statistics that can be used to help council patients with native shoulder infections preoperatively.
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Henry T, et al. Presentation 10. Presented at: Musculoskeletal Infection Society Annual Meeting; Aug. 7-8, 2020 (virtual meeting).
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