lima corporate
IT | EN
You are here: News&Events - Lima News
Lima News

Two-Stage Revision for infected Shoulder Arthroplasty










Infection after shoulder replacement is a painful and potentially devastating complication, occurring in up to 3,9% of cases and its management is still controversial. Two stage revision procedures are the most accepted treatment. Despite this, the procedural technique has not been standardised. We present 8 cases of infected shoulder implants treated between 2007 and 2009 by two stage revision with re-implantation of a modular, non cemented (SMR,
Lima Corporate) hemiarthroplasty, focusing on the importance of a standardized diagnostic and therapeutic protocol. Patients were clinically evaluated with the Constant score. Diagnosis of infection was diagnosed in collaboration with the Department of Infectious Disease of the research institution, on clinical signs and symptoms (painful decrease of shoulder motion, pain at rest, presence of fever, presence of  sinus, elevation of leucocytes count, erythrocytes sedimentation rate and CRP), in association with signs of component loosening on standard radiographs (>1mm lucent lines), and CT scan. We performed a pre operative culture of the fluid only in the two cases presenting a draining sinus. Subacute infection was diagnosed in 4 patients, chronic in 3, acute in one patient. Staphylococcus aureus was the bacterium responsible of the infection in four cases (50%) and Propionibacterium acnes in 2 cases (25%). In two cases (25%) no bacteria were isolated from the cultures. Any broad spectrum antibiotic treatment was suspended at least two weeks before surgery. Intra-operatively, prior to administration of antibiotic prophylaxis, at least 3 biopsies for culture and hysto-pathological study were taken from the bone and soft tissue around the prosthesis, and joint fluid aspiration was performed for culturing. Previous implants were removed, and an antibiotic-loaded cement spacer was inserted. 
Patients received broad spectrum antibiotic therapy until obtaining the results of the cultures. In the cases of presenceofthebacterium patients received a specific treatment for six weeks minimum. Otherwise they continued the same broad spectrum antibiotic treatment. Values of leucocytes count, erythrocytes sedimentation rate and CRP were checked every 3 weeks. In two consecutive cases normal results were seen, treatment was suspended and a three-phase bone isotope scanning was performed. 
Patients were re-operated, with a mean interval of 7.5 months (5-14) between surgeries. Intra operative biopsies and joint fluid were taken for culture. The cement spacer was removed, and a modular non cemented hemiarthroplasty (SMR,
Lima Corporate) was implanted, in order to restore biomechanics and deal with bone loss. In 6 cases (75%) a simple hemiarthroplasty was implanted and in two cases a CTA hemiarthroplasty. In the last two cases, the quality of the cuff was very poor and the subacromial space was significantly reduced. After surgery, all patients followed a similar rehabilitation programme of between 10 and 14 weeks.
The mean clinical and radiological follow up was 20 months (14-39). In all cases infection was eradicated, as biopsies and fluid cultures were negative. No major complications were observed. Medium value of the Constant Score improved from a pre operative value of 21 (7-30) points to a value of 43 (40-48) at follow up. Radiological evaluation did not show pathologic changes of the implants. No case required revision surgery.
The correct management of infected shoulder prostheses is not standardised. A proper diagnostic work up, as a multidisciplinary approach can lead to eradication of the infection and satisfactory results. The use of a modular CTA (SMR,
Lima Corporate) prosthetic system at re-implantation time can optimally deal with the possible situation of compromised biomechanics and bone loss.

G. Porcellini¹, MD, F. Campi¹, MD, P. Paladini¹, MD,
G. Merolla¹, MD, A. Pellegrini¹, MD, V. Bellotti², MD
 
¹ Shoulder Surgery Unit, “D. Cervesi” Hospital Cattolica, (Italy)
²  ICATME USP Dexeus, Barcelona (Spain)
“Federico II” Orthopaedic Clinic, University of Naples,
Naples (Italy)



References
 
  1. Weber P, Utzschneider S, Sadoghi P, Andress Hj, Jansson V, Müller Pe.  Management Of The Infected Shoulder Prosthesis: A Retrospective Analysis And Review Of The Literature.  Int Orthop. 2011 Mar;35(3):365-73
  2. Hattrup Sj, Renfree Kj.  Two-Stage Shoulder Reconstruction For Active Glenohumeral Sepsis. Orthopedics. 2010 Jan;33(1):20.
  3. Strickland Jp, Sperling Jw, Cofield Rh. The Results Of Two-Stage Re-Implantation For Infected Shoulder Replacement. J Bone Joint Surg Br. 2008 Apr;90(4):460-5.


 Download .pdf