ICJR DEBATES: 1-Stage vs. 2-Stage Revision for an Infected Shoulder Arthroplasty
When a shoulder arthroplasty patient is diagnosed with a periprosthetic joint infection (PJI), surgeons should strongly consider a 1-stage revision, April D. Armstrong, MD, MSc, FRCSC, told attendees at ICJR’s 8th Annual Shoulder Course.
Compared with a 2-stage revision, a 1-stage revision is associated with reduced patient morbidity, including only 1 exposure to anesthesia, and lower costs for the patient, health system, and third-party payers, Dr. Armstrong said. What’s more, outcomes are similar, with Nelson et al  reporting 90% eradication of infection with 1- and 2-stage revisions.
So, Dr. Armstrong asked, why would a surgeon want to do 2 surgeries when only 1 is needed?
Because the answer may not be clear-cut, countered John M. Itamura, MD, with multiple factors determining the procedure chosen, such as:
- Patient age and comorbidities
- Acute versus chronic infection
- Infecting organism(s)
- Number of prior surgeries
- Type of arthroplasty: anatomic versus reverse
The indications for 1-stage versus 2-stage are unclear, Garrigues et al  concluded. Although data in their systematic review favored 1-stage revision, some selection bias may have occurred.  In a systematic review on reverse shoulder arthroplasty, Stone and Namdari  postulated that the infecting organism could be the determining factor in the chosen treatment, with 2-stage revision for virulent organisms and 1-stage revision for less-virulent organisms.
Click here to watch Dr. Armstrong’s presentation, including her tips and pearls for improving the success of a 1-stage revision.
Click here to watch Dr. Itamura’s presentation, including his review of the literature on treating PJIs in shoulder arthroplasty patients.
April D. Armstrong, MD, MSc, FRCSC, is the James Bobb Professor of Orthopaedics, Interim Chair for the Department of Orthopaedics and Rehabilitation, and Chief of the Shoulder and Elbow Service at Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
John M. Itamura, MD, is the Director of the Kerlan-Jobe Adult Shoulder and Elbow Reconstruction Fellowship at the Cedars Sinai Kerlan-Jobe Institute in Los Angeles California. He is also a team physician for the Los Angeles Dodgers.
Disclosures: Dr. Armstrong has disclosed that she is a paid consultant for Aevumed, Globus Medical, and Zimmer Biomet. Dr. Itamura has disclosed that he receives royalties and research support from and is a paid consultant and presenter/speaker for Acumed; that he receives royalties from Advanced Orthopedic Solutions; that he is a paid consultant and paid presenter/speaker for Arthrex; that he is a paid consultant and paid presenter/speaker for DJO; that he receives royalties from Shoulder Innovations; and that he is a paid presenter/speaker for Tornier.
- Nelson GN, Davis DE, Namdari S. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2016 Aug;25(8):1337-45. doi: 10.1016/j.jse.2015.11.064. Epub 2016 Mar 21.
- Garrigues GE, Zmistowski B, Cooper AM, Green A; ICM Shoulder Group. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection. J Shoulder Elbow Surg. 2019 Jun;28(6S):S67-S99. doi: 10.1016/j.jse.2019.04.015.
- Stone MA, Namdari S. Reverse shoulder arthroplasty: diagnostic and treatment options for the infected reverse. Annals of Joint. 13 November 2018;3:91.