Functional antibiotic spacer can be used to treat shoulder prosthetic joint infection
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Surgical management of shoulder prosthetic joint infection typically involves one- or two-stage revision shoulder arthroplasty.
For shoulder reconstruction, various options exist to deliver antibiotic therapy to the joint while maintaining an articulation at the glenohumeral joint.
Source: Jonathan C. Levy, MD
In 2015, we published patient outcomes of a maintained functional antibiotic hemiarthroplasty spacer which incorporates a metal-bone articulation at the joint space. This surgical technique maintains the ability to deliver antibiotics to the joint, while providing a smooth articular hemiarthroplasty surface, potentially limiting the need for revision surgery. The surgical technique and updated patient outcomes are described here.
Methods
A retrospective query of our institution’s shoulder and elbow repository between September 2007 and September 2018 identified 31 patients treated with a functional hemiarthroplasty spacer for a prosthetic joint infection (PJI). Of these, eight patients were revised to a second stage. The surgical procedure and rate of culture positivity at the time of second stage were reported.
Among the 23 patients who did not undergo a second stage, follow-up data were available for 21 patients (91%). Outcomes of these patients, including the American Shoulder and Elbow Surgeons score, simple shoulder test (SST) score, VAS function score, single assessment numerical evaluation (SANE) score and active range of motion were analyzed. Central tendency and variability were reported as means and standard deviations. Overall patient satisfaction with surgery was reported.
Surgical technique
The patient is positioned in the beach chair position and the deltopectoral interval is developed to gain access to the joint. Once the implants are exposed, these are sequentially removed, cultures are obtained from multiple sites and a thorough debridement is performed. When present, the glenoid implant is removed, and the glenoid bone is reamed. This allows for glenoid surface debridement and any necessary version correction to create a concentric socket for the humeral head. Antibiotic pulse irrigation together with dilute betadine and dilute peroxide are used to complete the debridement stage.
Source: Jonathan C. Levy, MD
New instruments, drapes and gloves are introduced for the spacer implantation stage. The functional spacer is then fashioned with the use of any small-diameter humeral stem and appropriate diameter humeral head. This is typically done using a thicker option to create humeral offset. When a subscapularis repair is possible, multiple number 1 Proline monofilament sutures (Ethicon) are placed along the humeral neck for later repair. Antibiotic cement is mixed on the back table consisting of a single dose of Simplex P with tobramycin (Stryker) mixed with an additional 2.2 g of tobramycin and 3 g vancomycin. Once the cement becomes moldable, the cement is added to the humeral stem. The cement is formed to the stem in a fashion to facilitate a metaphyseal fit whereby the thickness of the cement tapers from proximal to distal. As the cement becomes doughy, it is introduced into the humeral canal to mold to the irregularities of the remaining proximal humeral bone. The spacer is then pistoned (Figure 1) in and out of the humerus at a 2 mm to 3 mm distance to prevent the cement from curing to the humerus. Once the cement is fully hardened, it can withstand rotational stress while remaining easily removable. The shoulder is then reduced. The subscapularis is repaired when present.
Patients are kept in a shoulder immobilizer for 6 weeks and perform pendulum exercises only, followed by an active-assisted stretching program and strengthening after 3 months. Patients with persistent pain or loss of function are offered a second-stage revision.
Results
Of the patients who were treated with a functional hemiarthroplasty spacer, 23 patients (74%) did not undergo a second-stage surgery. At the time of first-stage surgery, the mean age of these patients was 69 years ±10 years, mean BMI was 30 kg/m2 ± 7 kg/m2 and 15 patients (65%) were men. At a mean follow up of 47.8 months, patients demonstrated mean ASES scores of 62.4, SST scores of 6.7, VAS function scores of 5.9 and SANE scores of 60.6. Satisfactory results were reported in 86% of cases (Figure 2, page 4). Active range of motion and outcome data are presented (Table).
Eight (26%) patients went on to undergo a second-stage surgery (four second hemiarthroplasty spacer; three patients had reverse shoulder arthroplasty; one patient had anatomic total shoulder arthroplasty). The rate of culture positivity at the second stage was 25% (2/8). One patient was positive for candida albicans and one patient was positive for Pasteurella dagmatis.
Discussion
PJI is a devastating surgical complication associated with shoulder arthroplasty. The primary goal of surgical management of PJI is eradication of the infection, however an important secondary goal is pain relief and restoration of function. Revision arthroplasty is the most common method to accomplish these goals with controversy existing about the benefit of a two-stage compared with a one-stage procedure. The surgical technique presented utilizes a two-stage approach to PJI using a functioning hemiarthroplasty humeral head surface with no obligation for a second stage. However, when a second stage is indicated, the antibiotic functional hemiarthroplasty spacer is easy to remove.
Two-stage revision procedures have been shown to be successful in eradicating infection, traditionally utilizing all-cement spacers, creating a cement-bone articulation at the glenohumeral joint. Several reports have demonstrated long-term positive outcomes with traditional spacers. However, concern regarding the high friction and pain that is often generated by such an articulation led to the utilization of a metallic cobalt-chrome humeral head. The metallic head produces a low-friction articulation which may decrease the need for repeat revision procedures that may be plagued with marginal outcomes and high costs. Furthermore, by utilizing a metallic humeral head, reaming of the glenoid can be performed to aid in debridement and restoration of more normal glenoid version and inclination. Glenoid reaming together with use of a hemiarthroplasty has been a well-documented method for achievement of pain relief and functional outcomes.
When performed with a thorough debridement, placement of a spacer that may function as a metallic hemiarthroplasty takes advantage of the benefits of both one-stage and two-stage revision arthroplasty for PJI. In cases of maintained pain relief and acceptable function, the spacer can remain indefinitely, as observed in nearly 75% of cases. However, when a second stage is needed, removal of the spacer is easy and facilitates transition to the definitive implant.
Click here to watch video of this technique.
- References:
- Brodt S, et al. Strategies Trauma Limb Reconstr. 2010;5:111-114.
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- Levy JC, et al. Orthopedics. 2015;doi:10.3928/01477447-20150603-60.
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- For more information:
- Andrew Boltuch, DO, a shoulder and elbow fellow; Gagan Grewal, MD, a clinical research fellow; and Jonathan C. Levy, MD, chief of orthopedics and program director of the Holy Cross Shoulder & Elbow Fellowship, and medical director of the Holy Cross Orthopedic Research Institute, can be reached at Holy Cross Orthopedic Institute, 5597 N. Dixie Highway, Fort Lauderdale, FL 33334. Boltuch’s email: andrew.boltuch@gmail.com. Grewal’s email: ggrewal747@gmail.com. Levy email: jonlevy123@yahoo.com.
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Brodt S, et al. Strategies Trauma Limb Reconstr. 2010;5:111-114.
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