Management of the Infected Shoulder
In the abstract from his presentation at ICJR’s Pan Pacific Orthoapedic Congress, Dr. John Sperling discusses the difficulty in diagnosing and treating a shoulder infection.
By John W. Sperling, MD, MBA
Infection after shoulder surgery is an infrequent but devastating complication, with a reported incidence from 0% to 4%. A careful history is critical because many patients have a history of a “stitch abscess” or “superficial wound infection.”
Propionibacterium acnes is the organism most commonly responsible for infection following rotator cuff surgery, instability surgery, open reduction and internal fixation for proximal humerus fractures, and shoulder arthroplasty.  This organism typically does not start to grow until day 5; therefore, it is critical to keep cultures a minimum of 10 to 14 days.
The diagnosis of a shoulder infection can be challenging, principally among patients undergoing revision surgery. Most patients with a low-grade infection do not have blatant signs of infection, such as erythema or sinus tracts.
In addition, preoperative laboratory values and intraoperative pathology have been shown to be unreliable in predicting who will have positive cultures at the time of revision surgery. 
Various options are available for treating a patient with a postoperative shoulder infection. Variables that are important in determining which treatment is best for a patient include:
- Timing of infection
- Host status
- Infecting organism
- Status of implant fixation
- Status of the rotator cuff and deltoid
One of the most frequently used options for treating the infected shoulder arthroplasty is 2-stage re-implantation. However, the rate of complications with this technique, as well as residual infection, remains high. 
John W. Sperling, MD, MBA, is from Mayo Clinic, Rochester, Minnesota.
- Athwal GS, Sperling JW, Rispoli DM, Cofield RH. Acute deep infection after surgical fixation of proximal humerus fractures. J Shoulder Elbow Surg. 2007; 16:408-412
- Topolski MS, Chin PY, Sperling JW, Cofield RH. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elbow Surg. 2006; 15:402-406
- Strickland JP, Sperling JW, Cofield RH. The results of two-stage re-implantation for infected shoulder replacement. J Bone Joint Surg Br. 2008; 90:460-5