Periprosthetic Infections of the Shoulder

Diagnosis and Management

E. Scott Paxton, MD; Andrew Green, MD; Van S. Krueger, MD, MBA

Disclosures

J Am Acad Orthop Surg. 2019;27(21):e935-e944. 

In This Article

Abstract and Introduction

Abstract

The use of shoulder arthroplasty is continuing to expand. Periprosthetic joint infection of the shoulder is a devastating complication occurring in approximately 1% of cases. The most common organisms responsible for the infection are Cutibacterium acnes (formerly Propionibacterium acnes) (~39%) and coagulase-negative Staphylococcus (~29%). Evaluation of patients includes history and physical examination, serologic testing, imaging, possible joint aspiration, and tissue culture. Diagnosing infections caused by lower virulence organisms (eg, C acnes) poses a challenge to the surgeon because traditional diagnostic tests (erythrocyte sedimentation rate, C-reactive protein, and joint aspiration) have a low sensitivity due to the lack of an inflammatory response. Periprosthetic joint infections of the shoulder due to Staphylococcus aureus and other highly virulent organisms are often easy to diagnose and are usually treated with two-stage revisions. However, for infections with C acnes and coagulase-negative Staphylococcus, single- and two-stage revision surgeries have shown similar ability to clear the infection. Unexpected positive cultures for C acnes during revision surgery are not uncommon; the proper management is still under investigation and remains a challenge.

Introduction

In 2011, orthopaedic surgeons performed more than 60,000 shoulder arthroplasty procedures in the United States.[1] Shoulder arthroplasty is the third most common large joint arthroplasty and has a faster growth rate than hip or knee replacements.[2,3] Periprosthetic joint infection of the shoulder (PJIS), which occurs in roughly 1% of cases, is one of the most devastating complications of shoulder arthroplasty and has a significant negative impact on the outcome.[4] The economic and social costs are substantial.[4] Whereas early and subacute infections are often clinically obvious, later cases often have a nonspecific presentation and present diagnostic challenges. In addition, the unique microbiology of the shoulder may render the application of the diagnostic criteria for hip and knee periprosthetic joint infection (PJI), and management approaches too, inappropriate. Last, the dependence of shoulder function on the rotator cuff can dictate the type of revision surgical reconstruction undertaken to restore the function.

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