Single-Stage Revision in Shoulder Arthroplasty Patients Positive for Propionibacterium
The results of a recently published study suggest that a more-invasive 2-stage revision may not be necessary for patients with a failed shoulder arthroplasty and multiple positive cultures for a Propionibacterium infection.
Kevin Chen, MA; Samir Nayyar, MD; and Timothy G. Reish, MD
Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA 3rd. Single-stage revision is effective for failed shoulder arthroplasty with positive cultures for propionibacterium. J Bone Joint Surg Am, 2016. 98(24):2047-51.
In this retrospective case review, Hsu et al sought to evaluate the differences in clinical outcomes in patients with and without 2 or more positive cultures for Propionibacterium who received antibiotic therapy immediately following single-stage revision shoulder arthroplasty.
Specifically, the authors identified patients of a single surgeon who fit the following inclusion criteria:
- Underwent revision shoulder arthroplasty between November 2009 and May 2013
- Had no clinically obvious evidence of infection before surgery
- Were indicated for revision shoulder arthroplasty due to pain, stiffnes, or component loosening
- Had at least 2 years of clinical follow-up
Of the 55 patients fitting these criteria, 27 had multiple positive cultures (culture-positive group) and 28 had 1 or no positive cultures (control group).
The authors compared these groups using the following outcomes at an overall mean follow-up of 47.8 years:
- Simple Shoulder Test (SST)
- Number of revision surgical procedures required
- Single Assessment Numeric Evaluation (SANE)
- Visual Analog Scale (VAS) pain scores
At a mean follow-up of 45.8 months, SST scores in the culture positive group improved from 3.2±2.8 points to 7.8±3.3 points (P < 0.001), representing a mean improvement of 48% of the maximum possible improvement.
At a mean follow-up of 49.6 ± 11.8 months, mean SST scores in the culture positive group improved from 2.6 ± 1.9 points to 6.1 ± 3.4 points (P < 0.001), representing a mean improvement of 37% of the maximum possible improvement.
Differences in postoperative SANE and VAS pain scores were not statistically significant between groups (P=0.711 and P=0.971, respectively).
The need for subsequent procedures was similar, with 3 patients (11%) in each group undergoing additional procedures (P=1.0).
More than 40% of shoulders needing revision shoulder arthroplasty are found to be culture-positive for Propionibacterium. [1-3] However, diagnosing a Propionibacterium infection often takes significant time, and the tests utilized for this purpose have limited diagnostic sensitivity and specificity.
Further complicating this problem is that the affected patient population tends to lack the clinical symptoms typically associated with infection (eg, erythema, drainage) and instead present with signs of vague pain, stiffness, and component loosening. [1,4]
In obvious cases of periprosthetic shoulder infection, 2-stage revision is often considered the procedure of choice and has been shown to be an effective treatment option.  However, this procedure is thought to come with increased morbidity to the patient.
This study by Hsu et al has shown that the use of a standard single-stage revision arthroplasty followed by immediate antibiotic therapy can be just as efficacious in Propionibacterium culture-positive shoulders as in culture-negative shoulders. Both groups had statistically significant improvement in SST and had similar SANE and VAS pain scores at final follow-up.
If true, this suggests that regardless of Propionibacterium infection status, patients without clinically obvious signs of periprosthetic shoulder infection may be safely and effectively treated with the simpler single-stage revision shoulder arthroplasty procedure and avoid the increased morbidity associated with the 2-stage procedure.
It should be noted that 14 of the 33 patients who were asked about side effects did experience some form of adverse event, including gastrointestinal complications, dermatologic complications, and leukopenia. This must be factored into the decision about utilizing such a protocol and weighed against the potential benefits of avoiding a more-invasive treatment protocol.
This study was not without limitations, including the retrospective nature of its design and the methodology for selecting the patient population, which focused only on stealthy-type periprosthetic infections.
Overall, although more research needs to be performed to elucidate the full clinical and economic benefits of this approach, the study by Hsu et al sheds light on the possible role of single-stage revision arthroplasty in patients with this stealthy-type periprosthetic shoulder infection.
Kevin Chen, MA, is a Research Fellow for the Division of Adult Reconstruction, Department of Orthopaedic Surgery at NYU Langone Medical Center – Hospital for Joint Diseases New York, New York. Samir Nayyar, MD, is a Clinical Fellow for the Division of Adult Reconstruction, Department of Orthopaedic Surgery at NYU Langone Medical Center – Hospital for Joint Diseases New York, New York. Timothy G. Reish, MD, is a Clinical Assistant Professor, Division of Sports Medicine, Department of Orthopaedic Surgery, NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.
- Pottinger, P., et al., Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am, 2012. 94(22): p. 2075-83.
- Cofield, R.H. and B.C. Edgerton, Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect, 1990. 39: p. 449-62.
- Singh, J.A., et al., Periprosthetic infections after shoulder hemiarthroplasty. J Shoulder Elbow Surg, 2012. 21(10): p. 1304-9.
- Dodson, C.C., et al., Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. J Shoulder Elbow Surg, 2010. 19(2): p. 303-7.
- Buchalter, D.B., et al., Two-stage revision for infected shoulder arthroplasty. J Shoulder Elbow Surg, 2016.