5/9/2014 Disclosure The 59 th Annual LeRoy C. Abbott Society - - PowerPoint PPT Presentation

5/9/2014 1 Management of Periprosthetic Shoulder Infections: Is There a Role for Open Biopsy?

Alan Zhang, MD Brian Feeley, MD Brian Schwartz, MD Teddy Chung

• C. Benjamin Ma, MD

The 59th Annual LeRoy C. Abbott Society Scientific Program May 9th, 2014

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Disclosure

• I have no disclosures or financial relationships

related to the content of this study.

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Background

• More common than after THA or TKA
• TSA 3%, RTSA 5% [1-3]
• P. acnes common pathogen in shoulder (20%)

– Difficult to eradicate – Implicated as cause of primary shoulder OA [4]

• Gold-standard treatment

– Removal of hardware, antibiotic spacer and IV antibiotics before replant – Reinfection rate 0-37% [5]

Periprosthetic shoulder infections

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Purpose

• Decrease reinfection

rates after periprosthetic shoulder infections

• Devise a protocol for

detection of persistent infections despite previous treatment

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Methods

• Stage 1

– Removal of hardware – Irrigation & debridement – Antibiotic spacer placement

• Stage 2

– Culture-specific IV antibiotics for 6 weeks

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Methods

• Stage 3

– Open tissue biopsy in OR

• Stage 4

– If biopsy results negative

• Replant prosthesis

– If open biopsy positive for infection

• Repeat treatment

Methods

Periprosthetic Infection Remove implant, I&D, Abx Spacer Culture- specific IV Abx Antibiotic Holiday Open Biopsy Negative Culture Replant 7 Positive Culture 8

Results

• 18 patients w/ periprosthetic shoulder infection

from 2005-2012

• 14 patients- negative biopsy cultures- replanted

shortly after biopsy procedure

• 4 patients (22%)- positive culture growth during
• pen biopsy despite normal CRP, ESR, WBC and

no clinical symptoms

– All underwent repeat I&D, spacer exchange &IV abx – 3 patients- negative 2nd biopsy results and replanted – 1 patient required additional round of treatment

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Results

• Infecting pathogen for 18 pts

– P. acnes 50% – S. epidermidis 39% – S. aureus 22% – Polymicrobial 22%

• Persistent infections

– P. acnes 75%

• Risk of persistent infections found on biopsy

– 22% overall – 38% if P. acnes infection

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Results

• Final prosthesis replanted

– 15 RTSA, 1 TSA, 2 Hemi

• Mean 2 year follow-up
• All patients asymptomatic
• No recurrence of infection
• Average ASES score- 71

– FF- 142º, Abd- 140º, ER- 39º – Persistent infection group no significant difference from others

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Discussion

• Current gold-standard two-stage treatment

– Reinfection rate up to 37%

• Lack of methods to detect persistent infection

– Frozen sections at time of shoulder surgery [6]

• 67% sensitivity overall
• 50% sensitivity for P. acnes

– Needle aspiration

• 59% sensitivity in hip periprosthetic infections [7]

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Conclusion

• Open biopsy before replant of shoulder

prosthesis protocol

– Detected persistent infection rate of 22% despite normal CRP/ESR in our cohort – Detected 38% persistent infection rate in patients with P. acnes infection

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References

1. Bohsali KI, Wirth MA, Rockwood CA Jr. Complication of total shoulder

• arthroplasty. J Bone Joint Surg [Am] 2006;88-A:2279–2292.

2. Boileau P, Sinnerton RJ, Chuinard C, Walch G. Arthroplasty of the shoulder. J Bone Joint Surg Br 2006; 88(5): 562-75. 3. Cheung EV, Sperling JW, Cofield RH. Infection associated with hematoma formation after shoulder arthroplasty. Clin Orthop Relat Res 2008; 466: 1363-7. 4. Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of

• steoarthritis? J Shoulder Elbow Surg. 2013 Apr;22(4):505-11.

5. Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elbow Surg. 2012 Nov;21(11):1534-41 6. Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of Frozen Section Histology for Identifying Propionibacterium acnes Infections in Revision Shoulder Arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. 7. Cross MC1, Kransdorf MJ, Chivers FS et al. Utility of percutaneous joint aspiration and synovial biopsy in identifying culture-positive infected hip arthroplasty. Skeletal Radiol. 2014 Feb;43(2):165-8.

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