Background
Methods
Results
Author | Year | Number of patients | Infections eradicated | Rate (%) | Follow-up (months) | ||
---|---|---|---|---|---|---|---|
Min | Max | Mean | |||||
Resection arthroplasty | |||||||
Sperling [27] | 2001 | 21 | 15 | 71.4 | 33.6 | 157.2 | 78 |
Coste [21] | 2004 | 10 | 7 | 70.0 | 12 | 96 | 32 |
Maynou [28] | 2006 | 10 | 10 | 100.0 | 44 | ||
Braman [2] | 2006 | 7 | 7 | 100.0 | 12 | 42 | 20.4 |
Rispoli [29] | 2007 | 13 | 13 | 100.0 | 8.3 | ||
Verhelst [9] | 2011 | 11 | 9 | 81.8 | 46.4 | ||
Weber [10] | 2011 | 5 | 5 | 100.0 | 14.4 | 120 | 48 |
Romanò [30] | 2012 | 6 | 6 | 100.0 | 24 | 98 | 41.1 |
Total Mean (SD) | 83 | 72 | 86.7 |
19.2 (9.4)
|
102.6 (41.9)
|
39.8 (20.8)
| |
Single-stage arthroplasty | |||||||
Sperling [27] | 2001 | 2 | 1 | 50 | 9 | 120 | 57.6 |
Coste [21] | 2004 | 3 | 3 | 100 | 12 | 96 | 32.0 |
Ince [16] | 2005 | 14 | 14 | 100 | 13 | 159 | 69.6 |
Cuff [7] | 2007 | 10 | 10 | 100 | 25 | 66 | 43.0 |
Beekman [14] | 2010 | 11 | 10 | 90.9 | 12 | 36 | 22.4 |
Klatte [31] | 2013 | 35 | 33 | 94.3 | 13.2 | 159 | 56.4 |
Total Mean (SD) | 75 | 71 | 94.7 |
14.0 (5.6)
|
106 (49.8)
|
46.8 (17.6)
| |
Two-stage arthroplasty | |||||||
Sperling [27] | 2001 | 3 | 3 | 100 | 26.4 | 106.8 | 57.6 |
Seitz [32] | 2002 | 8 | 8 | 100 | 36 | 96 | 56 |
Jerosh [3] | 2003 | 8 | 8 | 100 | 6 | 30 | |
Coste [21] | 2004 | 10 | 6 | 60 | 12 | 96 | 32 |
Cuff [7] | 2007 | 12 | 12 | 100 | 25 | 66 | 43 |
Strickland [8] | 2008 | 19 | 12 | 63.2 | 24 | 80 | 35 |
Themistocleous [33] | 2008 | 2 | 2 | 100 | 15 | 26 | 22 |
Coffey [34] | 2010 | 12 | 12 | 100 | 10 | 29 | 18.3 |
Stine [35] | 2010 | 15 | 15 | 100 | 27.6 | ||
Jawa [36] | 2011 | 15 | 14 | 93.3 | 12 | 69 | 27.6 |
Sabesan [37] | 2011 | 17 | 16 | 94.1 | 22 | 80 | 46.2 |
Weber [10] | 2011 | 4 | 4 | 100 | 14.4 | 120 | 48 |
Romanò [30] | 2012 | 17 | 17 | 100 | 24 | 98 | 41.1 |
Total Mean (SD) | 142 | 129 | 90.8 |
18.9 (8.7)
|
74.7 (31.8)
|
37.9 (12.8)
| |
Permanent spacer | |||||||
Jerosh [3] | 2003 | 2 | 2 | 100 | 6 | 30 | 18 |
Coste [21] | 2004 | 1 | 1 | 100 | 12 | 96 | 32 |
Themistocleous [33] | 2008 | 9 | 9 | 100 | 15 | 26 | 22 |
Coffey [34] | 2010 | 4 | 4 | 100 | 16 | 25 | 19.25 |
Stine [35] | 2010 | 15 | 15 | 100 | 28.8 | ||
Jawa [36] | 2011 | 12 | 10 | 83.3 | 12 | 69 | 27.6 |
Verhelst [9] | 2011 | 10 | 10 | 100 | 46.4 | ||
Romanò [30] | 2012 | 15 | 14 | 93.3 | 24 | 98 | 41.1 |
Total Mean (SD) | 68 | 65 | 95.6 |
14.2 (5.9)
|
57.3 (34.8)
|
31 (9.8)
|
Quality indicators | Resection arthroplasty (n = 7, %) | Single-stage (n = 6, %) | Two-stage (n = 13, %) | Permanent spacer (n = 8, %) | ||||
---|---|---|---|---|---|---|---|---|
Age | 7 |
100
| 6 |
100
| 13 |
100
| 8 |
100
|
Gender | 7 |
100
| 6 |
100
| 13 |
100
| 8 |
100
|
Indication for primary shoulder arthroplasty | 7 |
100
| 5 |
83.3
| 10 |
76.9
| 5 |
62.5
|
Isolated pathogen | 6 |
85.7
| 6 |
100
| 13 |
100
| 8 |
100
|
Indication for type of revision procedure | 3 |
42.9
| 3 |
50
| 4 |
30.8
| 3 |
37.5
|
Length of antibiotic therapy | 1 |
14.3
| 4 |
66.7
| 6 |
46.2
| 4 |
50
|
Duration of interim period between stages | - | - | 6 |
46.2
| 3 |
37.5
| ||
Implant type used at exchange arthroplasty | - | 5 |
83.3
| 7 |
53.8
| 4 |
50
| |
Number of reinfections | 7 |
100
| 6 |
100
| 13 |
100
| 8 |
100
|
Functional outcome scores | 5 |
71.4
| 5 |
83.3
| 9 |
69.2
| 6 |
75
|
Number of patients lost to follow-up | 7 |
100
| 6 |
100
| 12 |
92.3
| 7 |
87.5
|
Mean (%, SD) | 64.94 | 8.18 | 78.79 | 13.69 | 74.13 | 8.17 | 73.73 | 9.72 |
Revision arthroplasty | Infection status at follow-up (n, %) | Significance (p-value)* | ||||
---|---|---|---|---|---|---|
Eradicated | Recurrence | |||||
Permanent Spacer | 65 |
95.6
| 3 |
4.4
| ||
Resection arthroplasty | 72 |
86.7
| 11 |
13.3
|
0.0897
| |
Single-stage | 71 |
94.7
| 4 |
5.3
|
1.0000
| |
Two-stage | 129 |
90.8
| 13 |
9.15
|
0.2771
| |
Single-stage | 71 |
94.7
| 4 |
5.3
| ||
Resection arthroplasty | 72 |
86.7
| 11 |
13.3
|
0.1080
| |
Two-stage | 129 |
90.8
| 13 |
9.15
|
0.4291
| |
Two-stage | 129 |
90.8
| 13 |
9.15
| ||
Resection arthroplasty | 72 |
86.7
| 11 |
13.3
|
0.3743
|
Functional scores | Frequency | Percentage |
---|---|---|
Constant-Murley | 11 |
64.70
|
UCLA Shoulder Score | 2 |
11.76
|
Simple Shoulder Test (SST) | 6 |
35.29
|
American Shoulder and Elbow Surgeons (ASES) | 3 |
17.65
|
Neer-Score | 3 |
17.65
|
Pennsylvania (PENN) shoulder score | 2 |
11.76
|
Disabilities of the Arm, Shoulder and Hand (DASH) | 6 |
35.29
|
Author | Year | Number of patients | Follow-up (months) | Constant score | ||||
---|---|---|---|---|---|---|---|---|
Min | Max | Mean | Pre-op | Post-op | Difference | |||
Resection arthroplasty | ||||||||
Coste [21] | 2004 | 10 | 12 | 96 | 32 | 16 | 30 | 14 |
Weber [10] | 2011 | 5 | 14 | 120 | 48 | - | 33 | |
Debeer [38] | 2006 | 7 | 9 | - | 26 | |||
Verhelst [9] | 2011 | 11 | 17 | 101 | 46 | - | 46 | |
Romano [30] | 2012 | 6 | 24 | 98 | 41 | - | 32 | |
Ghijselings [39] | 2013 | 6 | 18 | 97 | 49 | - | 28 | |
Total Mean (SD) | 45 |
17 (5)
|
102 (10)
|
38 (15)
|
32 (7)
| |||
Single-stage arthroplasty | ||||||||
Coste [21] | 2004 | 3 | 12 | 96 | 32 | 35 | 66 | 31 |
Ince [16] | 2005 | 9 | 13 | 159 | 70 | - | 34 | |
Beekman [14] | 2010 | 11 | 12 | 36 | 22 | 39 | 51 | 12 |
Klattle [31] | 2013 | 35 | 13 | 159 | 56 | - | 51 | |
Total Mean (SD) | 58 |
13 (1)
|
113 (59)
|
45 (22)
|
37 (3)
|
51 (13)
|
21 (14)
| |
Two-stage arthroplasty | ||||||||
Jerosch [3] | 2003 | 8 | 6 | 30 | - | 48 | ||
Coste [21] | 2004 | 10 | 12 | 96 | 32 | 15 | 35 | 20 |
Weber [10] | 2004 | 4 | 14 | 120 | 48 | - | 40 | |
Coffey [34] | 2010 | 12 | 10 | 29 | 18 | 16 | 57 | 41 |
Romano [30] | 2012 | 17 | 24 | 98 | 41 | - | 38 | |
Total Mean (SD) | 51 |
13 (7)
|
75 (42)
|
35 (13)
|
16 (1)
|
44 (9)
|
31 (15)
| |
Permanent spacer | ||||||||
Coste [21] | 2004 | 3 | 12 | 96 | 32 | 26 | 38 | 12 |
Romano [30] | 2012 | 15 | 24 | 98 | 41 | - | 34 | |
Ghijselings [39] | 2013 | 4 | 67 | 87 | 78 | - | 21 | |
Total Mean (SD) | 22 | 34 (29) | 94 (6) | 50 (24) |
31 (9)
|
Revision arthroplasty | Post-operative constant score | Significance (p-value)* | ||
---|---|---|---|---|
Score (mean) | SD | |||
Permanent spacer | 31.0 | 8.89 | ||
Resection arthroplasty | 32.5 | 7.09 |
0.7895
| |
Single-stage | 50.5 | 13.08 |
0.0787
| |
Two-stage | 43.6 | 8.91 |
0.1006
| |
Single-stage | 50.5 | 13.08 | ||
Resection arthroplasty | 32.5 | 7.09 |
0.0214
| |
Two-stage | 43.6 | 8.91 |
0.3764
| |
Two-stage | 43.6 | 8.91 | ||
Resection arthroplasty | 32.5 | 7.09 |
0.0465
| |
Difference in constant scorea | ||||
Mean | SD | |||
Two-stage | 30.5 | 14.85 | ||
Resection arthroplastyb | 14.00 | - |
-
| |
Single-stage | 21.50 | 13.44 |
0.5901
| |
Permanent Spacerb | 12.00 | - |
-
|
Discussion
-
Omission of patient-related variables that may directly influence outcome; including patient co-morbidities, ASA grade, number of previous shoulder procedures, indication for primary procedure;
-
Omission of surgeon-related variables that may directly influence outcome; including type of implant, type of spacer, use of antibiotic-impregnated cement, duration and use of antibiotics, quality and timing of initial debridement;
-
No subgroup analysis comparing the type of antibiotic spacers (custom-made, molded or preformed), time interval between stages of a two-stage exchange, use of antibiotic-loaded cement and respective dose and type used
-
No subgroup analysis comparing the outcome based upon the primary procedure (i.e. proximal humeral fracture, osteoarthritis, rotator cuff arthropathy, rheumatoid arthritis, or avascular necrosis) as the clinical course of infections may be very different in these subgroups;
-
Outcome measures did not include quality of life scores, complication rates or aseptic revision rate;
-
Inclusion of very few studies that directly compare changes in Constant scores, and therefore demonstrate an improvement or worsening in their patient cohort. It is well known that good pre-operative function is a predictor of good post-operative function, likewise pre-operative stiffness is a negative predictor [14]
-
Inclusion of only papers published with either an abstract or full text in English
-
Socioeconomic impact for each treatment