Periprosthetic joint infections of the shoulder: A 10-year retrospective analysis outlining the heterogeneity among these patients

Abstract

Background

Diagnosis and treatment of shoulder periprosthetic joint infection is a difficult problem. The purpose of this study was to utilize the 2018 International Consensus Meeting definition of shoulder periprosthetic joint infection to categorize revision shoulder arthroplasty cases and determine variations in clinical presentation by presumed infection classification.

Methods

Retrospective review of patients undergoing revision shoulder arthroplasty at a single institution. Likelihood of periprosthetic joint infection was determined based on International Consensus Meeting scoring. All patients classified as definitive or probable periprosthetic joint infection were classified as periprosthetic joint infection. All patients classified as possible or unlikely periprosthetic joint infection were classified as aseptic. The periprosthetic joint infection cohort was subsequently divided into culture-negative, non-virulent microorganism, and virulent microorganism cohorts based on culture results.

Results

Four hundred and sixty cases of revision shoulder arthroplasty were reviewed. Eighty (17.4%) patients were diagnosed as definite or probable periprosthetic joint infection, of which 29 (36.3%), 39 (48.8%), and 12 (15.0%) were classified as virulent, non-virulent, or culture-negative periprosthetic joint infection, respectively. There were significant differences among periprosthetic joint infection subgroups with regard to preoperative C-reactive protein (p = 0.020), erythrocyte sedimentation rate (p = 0.051), sinus tract presence (p = 0.008), and intraoperative purulence (p < 0.001). The total International Consensus Meeting criteria scores were also significantly different between the periprosthetic joint infection cohorts (p < 0.001).

Discussion

While the diagnosis of shoulder periprosthetic joint infection has improved with the advent of International Consensus Meeting criteria, there remain distinct differences between periprosthetic joint infection classifications that warrant further investigation to determine the accurate diagnosis and optimal treatment.

Keywords

Shoulder arthroplasty revision shoulder arthroplasty periprosthetic joint infection

Get full access to this article

View all access options for this article.

References

Ahsan

Somerson

Matsen

. Characterizing the propionibacterium load in revision shoulder arthroplasty: a study of 137 culture-positive cases. J Bone Joint Surg Am 2017; 99: 150–154.

Dodson

Craig

Cordasco

, et al. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg 2010; 19: 303–307.

Falconer

Baba

Kruse

, et al. Contamination of the surgical field with propionibacterium acnes in primary shoulder arthroplasty. J Bone Joint Surg Am 2016; 98: 1722–1728.

Foruria

Fox

Sperling

, et al. Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty. J Shoulder Elbow Surg 2013; 22: 620–627.

Garrigues

Zmistowski

Cooper

, et al. ICM Shoulder Group. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elbow Surg 2019; 28: S8–12.

Hsu

Somerson

, et al. What is a “periprosthetic shoulder infection”? A systematic review of two decades of publications. Int Orthop 2017; 41: 813–822.

Hudek

Sommer

Kerwat

, et al.

Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue?

J Shoulder Elbow Surg 2014; 23: 1763–1771.

Kelly

Hobgood

. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res 2009; 467: 2343–2348.

Lucas

Hsu

Whitney

, et al.

Loose glenoid components in revision shoulder arthroplasty: is there an association with positive cultures?

J Shoulder Elbow Surg 2016; 25: 1371–1375.

10.

McGoldrick

McElvany

Butler-Wu

, et al. Substantial cultures of propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty. J Shoulder Elbow Surg 2015; 24: 31–35.

11.

Grosso

Sabesan

, et al. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elbow Surg 2012; 21: 754–758.

12.

Padegimas

Lawrence

Narzikul

, et al. Future surgery after revision shoulder arthroplasty: the impact of unexpected positive cultures. J Shoulder Elbow Surg 2017; 26: 975–981.

13.

Boyle

Wood

Tarity

. Low-virulence organisms and periprosthetic joint infection-biofilm considerations of these organisms. Curr Rev Musculoskelet Med 2018; 11: 409–419.

14.

Horneff

Hsu

Voleti

, et al. Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. J Shoulder Elbow Surg 2015; 24: 838–843.

15.

Cooper

Trivedi

Sivasundaram

, et al. Diagnosis and management of periprosthetic joint infection after shoulder arthroplasty. JBJS Rev 2019; 7: e3–e3.

16.

Nelson

Davis

Namdari

. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2016; 25: 1337–1345.

17.

Millett

Yen

Y-M

Price

, et al. Propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res 2011; 469: 2824–2830.

18.

Tarabichi

Shohat

Goswami

, et al. Diagnosis of periprosthetic joint infection: the potential of next-generation sequencing. J Bone Joint Surg Am 2018; 100: 147–154.

19.

Casadevall

Pirofski

. The damage-response framework of microbial pathogenesis. Nat Rev Microbiol 2003; 1: 17–24.

20.

Casadevall

. The pathogenic potential of a microbe. mSphere 2017; 2: e00015–00017.

21.

Gries

Kielian

. Staphylococcal biofilms and immune polarization during prosthetic joint infection. J Am Acad Orthop Surg 2017; 25 Suppl 1: S20–24.

22.

Jenul

Horswill

. Regulation of Staphylococcus aureus virulence. Microbiol Spectr 2019; 7: 1–34.

23.

Achermann

Goldstein

EJC

Coenye

, et al. Propionibacterium acnes: from commensal to opportunistic biofilm-associated implant pathogen. Clin Microbiol Rev 2014; 27: 419–440.

24.

Vuong

Otto

. Staphylococcus epidermidis infections. Microbes Infect 2002; 4: 481–489.

25.

Cheung

GYC

Rigby

Wang

, et al. Staphylococcus epidermidis strategies to avoid killing by human neutrophils. PLoS Pathog 2010; 6: e1001133–e1001133.

26.

Namdari

Nicholson

Parvizi

. Cutibacterium acnes is isolated from air swabs: time to doubt the value of traditional cultures in shoulder surgery? Arch Bone Jt Surg 2020; 8: 506–510.

27.

Wong

Schoch

Lee

, et al. Culture positivity in primary total shoulder arthroplasty. J Shoulder Elbow Surg 2018; 27: 1422–1428.

28.

Topolski

Chin

PYK

Sperling

, et al. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elbow Surg 2006; 15: 402–406.

29.

Zmistowski

Della Valle

Bauer

, et al. Diagnosis of periprosthetic joint infection. J Orthop Res Off Publ Orthop Res Soc 2014; 32 Suppl 1: S98–107.

30.

Tan

Kheir

Shohat

, et al. Culture-negative periprosthetic joint infection: an update on what to expect. JBJS Open Access 2018; 3: e0060–e0060.

31.

Baré

MacDonald

Bourne

. Preoperative evaluations in revision total knee arthroplasty. Clin Orthop 2006; 446: 40–44.

32.

Gomez

Cazanave

Cunningham

, et al. Prosthetic joint infection diagnosis using broad-range PCR of biofilms dislodged from knee and hip arthroplasty surfaces using sonication. J Clin Microbiol 2012; 50: 3501–3508.

33.

Goswami

Parvizi

Maxwell Courtney

. Current recommendations for the diagnosis of acute and chronic PJI for hip and knee-cell counts, alpha-defensin, leukocyte esterase, next-generation sequencing. Curr Rev Musculoskelet Med 2018; 11: 428–438.

34.

Pandey

Berendt

Athanasou

. Histological and microbiological findings in non-infected and infected revision arthroplasty tissues. The OSIRIS Collaborative Study Group. Oxford Skeletal Infection Research and Intervention Service. Arch Orthop Trauma Surg 2000; 120: 570–574.

35.

Parvizi

Erkocak

Della Valle

. Culture-negative periprosthetic joint infection. J Bone Joint Surg Am 2014; 96: 430–436.

36.

Shanmugasundaram

Ricciardi

Briggs

TWR

, et al. Evaluation and management of periprosthetic joint infection-an international, multicenter study. HSS J Musculoskelet J Hosp Spec Surg 2014; 10: 36–44.

37.

Stone

Clark

O’Brien

, et al. Surgical management of periprosthetic shoulder infections. J Shoulder Elbow Surg 2017; 26: 1222–1229.

38.

McLawhorn

Nawabi

Ranawat

. Management of resistant, atypical and culture-negative periprosthetic joint infections after hip and knee arthroplasty. Open Orthop J 2016; 10: 615–632.