5/9/2014 Disclosure The 59 th Annual LeRoy C. Abbott Society - PowerPoint PPT Presentation

5/9/2014 Disclosure The 59 th Annual LeRoy C. Abbott Society Scientific Program • I have no disclosures or financial relationships May 9 th , 2014 related to the content of this study. Management of Periprosthetic Shoulder Infections: Is There a Role for Open Biopsy? Alan Zhang, MD Brian Feeley, MD Brian Schwartz, MD Teddy Chung C. Benjamin Ma, MD 2 Background Purpose Periprosthetic shoulder infections • Decrease reinfection rates after • More common than after THA or TKA periprosthetic shoulder infections • TSA 3%, RTSA 5% [1-3] • P. acnes common pathogen in shoulder (20%) • Devise a protocol for – Difficult to eradicate detection of – Implicated as cause of primary shoulder OA [4] persistent infections despite previous • Gold-standard treatment treatment – Removal of hardware, antibiotic spacer and IV antibiotics before replant – Reinfection rate 0-37% [5] 3 4 1

5/9/2014 Methods Methods • Stage 1 • Stage 3 – Removal of hardware – Open tissue biopsy in OR – Irrigation & debridement – Antibiotic spacer placement • Stage 4 – If biopsy results negative • Stage 2 • Replant prosthesis – Culture-specific IV antibiotics for 6 weeks – If open biopsy positive for infection • Repeat treatment 5 6 Methods Results • 18 patients w/ periprosthetic shoulder infection Positive Culture from 2005-2012 • 14 patients- negative biopsy cultures- replanted shortly after biopsy procedure Remove Periprosthetic Culture- Antibiotic Open Biopsy implant, I&D, Infection specific IV Abx Holiday Abx Spacer • 4 patients (22%)- positive culture growth during open biopsy despite normal CRP, ESR, WBC and no clinical symptoms Negative Culture – All underwent repeat I&D, spacer exchange &IV abx – 3 patients- negative 2nd biopsy results and replanted – 1 patient required additional round of treatment Replant 7 8 2

5/9/2014 Results Results • Infecting pathogen for 18 pts • Final prosthesis replanted – P. acnes 50% – 15 RTSA, 1 TSA, 2 Hemi – S. epidermidis 39% • Mean 2 year follow-up – S. aureus 22% • All patients asymptomatic – Polymicrobial 22% • No recurrence of infection • Persistent infections • Average ASES score- 71 – P. acnes 75% – FF- 142º, Abd- 140º, ER- 39º • Risk of persistent infections found on biopsy – Persistent infection group no significant difference – 22% overall from others – 38% if P. acnes infection 9 10 Discussion Conclusion • Current gold-standard two-stage treatment • Open biopsy before replant of shoulder prosthesis protocol – Reinfection rate up to 37% – Detected persistent infection rate of 22% despite • Lack of methods to detect persistent infection normal CRP/ESR in our cohort – Frozen sections at time of shoulder surgery [6] – Detected 38% persistent infection rate in patients with P. acnes infection • 67% sensitivity overall • 50% sensitivity for P. acnes – Needle aspiration • 59% sensitivity in hip periprosthetic infections [7] 11 12 3

5/9/2014 Thank you References 1. Bohsali KI, Wirth MA, Rockwood CA Jr. Complication of total shoulder arthroplasty. J Bone Joint Surg [Am] 2006;88-A:2279–2292. 2. Boileau P, Sinnerton RJ, Chuinard C, Walch G. Arthroplasty of the shoulder. J Bone Joint Surg Br 2006; 88(5): 562-75. 3. Cheung EV, Sperling JW, Cofield RH. Infection associated with hematoma formation after shoulder arthroplasty. Clin Orthop Relat Res 2008; 466: 1363-7. 4. Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg. 2013 Apr;22(4):505-11. 5. Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elbow Surg. 2012 Nov;21(11):1534-41 6. Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of Frozen Section Histology for Identifying Propionibacterium acnes Infections in Revision Shoulder Arthroplasty. J Bone Joint Surg Am. 2014 Mar 19;96(6):442-7. 7. Cross MC1, Kransdorf MJ, Chivers FS et al. Utility of percutaneous joint aspiration and synovial biopsy in identifying culture-positive infected hip arthroplasty. Skeletal Radiol. 2014 Feb;43(2):165-8. 13 4