Treating a Periprosthetic Shoulder Infection
Vincenzo Franceschini and Claudio Chillemi
The authors have no disclosure relevant to this article.
Editor’s Note: This article is an except of the authors’ article, Periprosthetic Shoulder Infection, published in The Open Orthopaedics Journal. The full article can be found here.
Shoulder arthroplasty is considered the most effective surgical procedure for end-stage shoulder pain from different causes, including osteoarthritis, cuff-tear arthropathy, trauma, and tumors. [1,2] During the last decade the number of shoulder arthroplasty procedures more than doubled, and it has been estimated that more than 46,000 shoulder replacements are performed annually in the United States. 
In most cases, this procedure provides significant pain relief and functional improvement with satisfactory longevity.  However, a number of potential complications may be associated with this surgery, the most frequent of which include implant loosening, shoulder instability, periprosthetic fracture, rotator cuff tear, nerve injury, deltoid dysfunction and infection .
Although uncommon and less frequent than knee or hip periprosthetic infection,  periprosthetic shoulder infection (PSI) remains a devastating complication and, despite treatment, is associated with unsatisfactory results.  We have previously discussed diagnosis of PSI. [Franceschini V, Chillemi C. Periprosthetic shoulder infection.  The Open Orthopaedics Journal, 2013, 7, (Suppl 2: M10) 243-249. © Franceschini and Chillemi; Licensee Bentham Open.] In this article, we address treatment options.
The treatment strategies for a PSI are similar to those used for other periprosthetic joint infections:
- Antibiotic therapy
- Debridement with retention of the prosthesis
- Direct prosthesis exchange (one-stage exchange)
- Staged prosthesis exchange with temporary placement of an antibiotic-impregnated spacer (two-stage exchange)
- Resection arthroplasty
In each case, the choice of treatment depends on the virulence of the pathogens, sensitivity to antibiotics, stability of the implant, and the time interval between primary implantation and clinical manifestation of the infection. The treatment algorithms for PSI at present reflect the standard protocols for periprosthetic hip and knee infections.
Antibiotic therapy was demonstrated to be ineffective in the management of PSI, confirming the results of antibiotic suppression for periprosthetic knee infections.
Failure rates of 60% to 75% have been reported with this treatment modality. [7,9] Antibiotic treatment alone should only be contemplated for seriously ill patients or those who refuse to have surgery. 
Debridement with Prosthesis Retention
Retention of a shoulder prosthesis can be feasible if:
- The infection is identified acutely
- After less than 30 days from implantation, or
- After less than 3 weeks from the start of infectious symptoms
- The implant is stable
- A low-virulence organism is isolated
- Complete debridement has been achieved 
In select cases, debridement may also be performed arthroscopically.  However, Sperling et al  reported a 50% failure rate with this treatment, and Romanò et al,  in a multicenter study, reported less-satisfactory results with debridement in terms of infection eradication rate compared with the other treatments.
A retrospective review of 49 cases of PSI by Coste et al  found that neither antibiotics nor debridement alone was effective. They suggested treating acute PSI with aggressive debridement and exchange of the implant associated with an appropriate intravenous antibiotic therapy.
Formed mainly from the experiences gained in hip and knee surgery, one-stage prosthesis exchange is not as popular as two-stage prosthesis exchange. Sperling et al  reported failure in one of two shoulders treated for subacute PSI with direct prosthesis exchange.
Coste et al,  however, detected improvement in Constant scores and no recurrence of infection in three patients treated with one-stage prosthesis exchange. Ince et al.  also reported no recurrence of infection in 16 patients managed with one-stage revision using an antibiotic-impregnated cement.
Although two-stage exchange is generally regarded as the gold standard, Cuff et al,  in a retrospective analysis of 22 cases, reported that a single-stage revision was statistically no different from a two-stage procedure with regard to outcome and the eradication of infection.
The one-stage reimplantation guarantees better functional outcome but carries a higher risk of infection recurrence. Other benefits of one-stage exchange over a two-stage exchange involve lower cost and the requirement for only one procedure.
Nonetheless, failure to eradicate the infection during the one-stage reimplantation will require additional procedures.
More investigation is needed to establish guidelines and identify the appropriate conditions for using a one-stage exchange. 
Two-stage exchange involves:
- Removal of the infected implant
- Extensive debridement of periprosthetic tissues
- Placement of a temporary antibiotic spacer (Figure 1)
- Antibiotic treatment prior to reimplantation of new prosthetic components
Figure 1. Intraoperative images of an infected shoulder arthroplasty (top) before the removal of the prosthesis, (middle) after performing irrigation and debridement, and (bottom) after the implantation of an antibiotic-impregnated cement spacer.
Various authors have suggested discontinuing antibiotics and monitoring the C-reactive protein level erythrocyte sedimentation rate before going ahead with revision surgery.  One-stage and two-stage reimplantation show high rates of infection control, although the most reproducible results have been obtained from two-stage revision surgery. [16,17]
Moreover, two-stage reimplantation appears to encompass the goals of dependable eradication of the infection and functionality after surgery.
Sperling et al  examined 32 PSI cases:
- Group I (21 cases) underwent resection arthroplasty
- Group II (six cases), underwent debridement and retention of the implant
- Group III (two cases) was treated with one-stage exchange
- Group IV (three cases), was treated with two-stage exchange
Reinfection occurred in six patients treated with resection arthroplasty, in three patients with the retained implant, in one patient treated with one-stage reimplantation, and in none of the patients treated with two-stage reimplantation.
At the time of final follow-up, the authors concluded that two-stage exchange gives the best results in terms of eradication of infection, pain relief, and shoulder function, particularly when compared with resection arthroplasty.
Sabesan et al  also reported a low recurrence rate after a two-stage reimplantation procedure, with substantial improvement in function and pain.
Strickland et al,  however, described less-successful outcomes with two-stage exchange. In their group of 19 patients, the infection was eradicated in only 63% of cases (12); in 13 cases the outcomes were unsatisfactory.
Antibiotic-impregnated cement spacers have proven to be of use in staged reimplantation [19,20]. The spacer:
- Maintains soft-tissue tension
- Reduces pain
- Enhances the patient’s functional status
- Enables the patient to do physical therapy prior to reimplantation of the prosthesis
- Permits local antibiotic administration
- Induces the development of a pseudocapsule that can be mobilized with the cuff during ensuing surgeries
In a recent study, nine of 11 patients who had a spacer implanted for sepsis or PSI were satisfied and put off removal of the spacer. Other authors also support prolonged or even permanent retention of the spacer as a possible substitute for reimplantation in complicated patients who are at increased surgical risk.
A viable option for patients with cuff-tear arthropathy and a working deltoid is reverse shoulder arthroplasty. Reverse shoulder arthroplasty could permit improved function in patients who have undergone debridement of periprosthetic tissues.
In the case of infection, the quality of debridement is deemed a crucial factor for the eradication of infection. An aggressive debridement of suspicious soft and bone tissue can be carried out with less apprehension for decreased functionality when a reverse shoulder replacement is planned. [15,17]
One-stage and two-stage reimplantation provide the greatest chance of restoring function, but in some cases, this may not be possible.
In the older, debilitated patient with high-virulence organisms, significant loss of soft tissue, or poor health, a reimplantation may be unwise. Resection arthroplasty represents an acceptable alternative, offering the opportunity to eradicate the infection and provide good pain relief with just one surgical procedure. The only downside is limited function. 
Many studies have indicated that resection arthroplasty provides excellent eradication rates, although, often at the price of significant functional deficits.  In particular, loss of internal and external rotation may hinder patients during activities of daily living. [19,23] Resection arthroplasty, therefore, is generally reserved for older, low-demand patients.
Codd et al  compared the treatment results for PSI after resection arthroplasty with those after prosthesis reimplantation. Pain reduction was achieved with approximately the same efficacy in both procedures. Patients who had resection arthroplasty, however, had significantly reduced shoulder motion and difficulties with every-day activities.
Rispoli et al.  reported substantial functional impairments despite good pain relief in 18 patients treated with resection arthroplasty for PSI or failed shoulder replacement.
PSI is a rare but catastrophic complication that continues to be both a diagnostic and treatment challenge. Patients who develop a PSI will have worse outcomes compared with patients who have an uncomplicated procedure, even if appropriately treated for the infection.
Preventive measures are, therefore, of primary importance and include:
- Adequate surgical site preparation with an effective antiseptic
- Intraoperative prophylactic antibiotic administration
- Preoperative blood glucose control for patients with diabetes
- Minimization of immunosuppressive medication whenever is possible
- Reducing operating times
Vincenzo Franceschini is from the Department of Orthopaedics and Traumatology, Sapienza University of Rome, Latina, Italy. Claudio Chillemi is from the Department of Orthopaedics and Traumatology, Istituto Chirurgico Ortopedico Traumatologico Latina, Italy.
Excerpted from: Franceschini V, Chillemi C. Periprosthetic shoulder infection. The Open Orthopaedics Journal, 2013, 7, (Suppl 2: M10) 243-249. © Franceschini and Chillemi; Licensee Bentham Open. This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.
The entire article can be found at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731811/
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