Shoulder and Elbow Cases to Consider.
Last updated Friday, August 22, 2008
Propionibacterium acnes (P. Acnes) infection after total shoulder arthroplasty Clinical presentation A 67 year-old male presented with
severe pain, stiffness, and loss of function of the left shoulder after a total
shoulder arthroplasty 5 years previously for advanced degenerative changes in
the glenohumeral joint.
He was initially comfortable after his TSA and did well for two years. Two
years after his shoulder arthroplasty he had a left rotator cuff repair after
which his shoulder remained stiff and painful with limited function. He
presented to our service five years after his total shoulder arthroplasty. Plain radiographs suggested glenoid loosening
with medial erosion, and resorption of the medial portion of the humerus (Figure
1a). Bone scan showed increased uptake
around the glenoid component. Pre-operative complete blood count, sedimentation
rate, and C reactive protein values were all within normal range. Clinically
there was no swelling or erythema around the shoulder.
Our concerns included: - Infection
- Loosening of components
- Poor glenoid bone stock
- Poor humeral bone stock
- Intra-operative fracture
- Access to glenoid if humeral component well fixed
- Axillary nerve injury due to multiply
operated, altered surgical field
Management Due to the patient’s severe loss
of shoulder function with persistent pain and stiffness, we recommended revision
surgery to include cultures before antibiotic administration, removal of the glenoid
component, possible revision of the humeral component, and debridement with
lysis of adhesions.
At surgery the glenoid component
was loose. There was a substantial amount of osteolysis of the proximal humerus
and glenoid. The glenoid bone was eroded medially. There was no evidence of
acute inflammation.
After removal of both the glenoid
and humeral components, the remaining glenoid bone was reamed to a conforming
concavity after
debridement of all fibrous tissue and cement. No prosthetic glenoid component
was inserted. No bone graft was performed. A new humeral component was secured
in proper position using impaction allograft
with Vancomycin-impregnated allograft. (Figure 1b)
Multiple soft tissue and fluid
specimens were sent for culture and microscopic examination. The pathology revealed clusters of gram-positive
bacteria. (Figure 2). 5 out of 5
cultures became positive. Four specimens
became positive at 5 days after surgery and one specimen 8 days after surgery. The patient was started on Ceftriaxone 2 gm
IV q24 hours for six weeks via a PICC line followed by amoxicillin 1gm po tid
for six weeks.
While the long-term outcome
remains to be seen, the patient is making excellent progress with his
rehabilitation.
References
1. Acute deep infection after surgical fixation of proximal
humeral fractures
Journal of Shoulder and Elbow Surgery, Volume 16, Issue 4, July-August
2007, Pages 408-412
George S. Athwal, John W. Sperling, Damian M. Rispoli, Robert H. Cofield
2. Propionibacterium acnes: An agent
of prosthetic joint infection and colonization
Journal of Infection, Volume 55, Issue 2, August
2007, Pages 119-124
Valérie Zeller, Ali Ghorbani, Christophe Strady, Philippe Leonard, Patrick
Mamoudy, Nicole Desplace
3. Revision shoulder arthroplasty for glenoid component
loosening
Journal of Shoulder and Elbow Surgery, Volume 17, Issue 3, May-June
2008, Pages 371-375
Emilie V. Cheung, John W. Sperling, Robert H. Cofield
4. Deep infection after rotator cuff repair
Journal of Shoulder and Elbow Surgery, Volume 16, Issue 3, May-June
2007, Pages 306-311
George S. Athwal, John W. Sperling, Damian M. Rispoli, Robert H. Cofield
5. Revision shoulder arthroplasty with positive
intraoperative cultures: The value of preoperative studies and intraoperative
histology
Journal of Shoulder and Elbow Surgery, Volume 15, Issue 4, July-August
2006, Pages 402-406
Mark S. Topolski, Patrick Y.K. Chin, John W. Sperling, Robert H. Cofield
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