Propionibacterium acnes infection after shoulder arthroplasty: A diagnostic challenge

doi:10.1016/j.jse.2009.07.065

Journal of Shoulder and Elbow Surgery

Volume 19, Issue 2, March 2010, Pages 303-307

https://doi.org/10.1016/j.jse.2009.07.065 Get rights and content

Hypothesis

This study reviewed a series of patients diagnosed with Propionibacterium acnes infection after shoulder arthroplasty in order to describe its clinical presentation, the means of diagnosis, and provide options for treatment.

Materials and methods

From 2002 to 2006, 11 patients diagnosed with P acnes infection after shoulder arthroplasty were retrospectively reviewed and analyzed for (1) clinical diagnosis; (2) laboratory data, including white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP); (3) fever; (4) number of days for laboratory growth of P acnes; (5) organism sensitivities; (6) antibiotic regimen and length of treatment; and (7) surgical management. Infection was diagnosed by 2 positive cultures.

Results

Five patients had an initial diagnosis of infection and underwent implant removal, placement of an antibiotic spacer, and staged reimplantation after a course of intravenous antibiotics. In the remaining 6 patients, surgical treatment varied according to the clinical diagnosis. When infection was recognized by intraoperative cultures, antibiotics were initiated. The average initial ESR and CRP values were 33 mm/h and 2 mg/dL, respectively. The average number of days from collection to a positive culture was 9. All cultures were sensitive to penicillin and clindamycin and universally resistant to metronidazole.

Discussion

Prosthetic joint infection secondary to P acnes is relatively rare; yet, when present, is an important cause of clinical implant failure. Successful treatment is hampered because clinical findings may be subtle, many of the traditional signs of infection are not present, and cultures may not be positive for as long as 2 weeks.

Section snippets

Materials and methods

The Investigational Review Board (IRB) of the Hospital for Special Surgery, New York, approved this study (IRB #26057).

During a 4-year period (2002-2006), 11 patients (8 men, 3 women) were diagnosed with P acnes infection after shoulder arthroplasty. To ensure that a positive culture represented infection rather than specimen contamination, 2 positive intraoperative specimens were required for infection diagnosis. The medical records of these 11 patients were analyzed and retrospectively

Results

In group I, the average WBC was 7,280 cells/L (range, 6,000-9,000 cells/L), the average ESR was 44.4 mm/h (range, 13-86 mm/h), and the average CRP was 3.42 mg/dL (range, 0.8-8.8 mg/dL). The normal values at our institution for ESR are 0 to 12 mm/h for men and 0 to 27 mm/h for women, and for CRP, less than 0.7 mg/dL. No patients presented with fever.

A mean of 0.8 débridements (range, 0-3) after the reimplantation were necessary for the eradication of infection. One patient required a second

Discussion

The shoulder is thought to have has a propensity for infection with P acnes because the organism is the dominant anaerobic bacteria isolated from healthy skin in moist areas such as the axilla.1, 17, 23 Until recently, the organism was thought to be a contaminant rather than a true pathogen. P acnes is known to be a common causative organism in infections after shoulder instability surgery²² and arthroplasty.²³ Several authors have also reported that P acnes was the most common infecting

Disclaimer

No funding was necessary for this study. The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

References (24)

G.S. Athwal et al.
Deep infection after rotator cuff repair
J Shoulder Elbow Surg
(2007)
J.M. Cuckler et al.
Diagnosis and management of the infected total joint arthroplasty
Orthop Clin North Am
(1991)
M.F. Herrera et al.
Infection after mini-open rotator cuff repair
J Shoulder Elbow Surg
(2002)
Y.W. Kwon et al.
Management of early deep infection after rotator cuff repair surgery
J Shoulder Elbow Surg
(2005)
I. Brook
Anaerobic gram-positive non-sporulating bacilli
I. Brook et al.
Infections caused by Propionibacterium species
Rev Infect Dis
(1991)
R.H. Cofield et al.
Total shoulder arthroplasty: complications and revision surgery
Instr Course Lect
(1990)
N. Desplaces
Les bacteries anaerobes en pathologie osseuse
Med Mal Infect
(2000)
L.M. Dunkle et al.
Anaerobic infections in children: a prospective study
Pediatrics
(1976)
S.M. Finegold
Anaerobic bacteria in human disease
(1977)

H. Gunthard et al.

Propionibacterium acnes as a cause of aggressive aortic valve endocarditis and importance of tissue grinding-a case report and review

J Clin Microbiol

(1994)

S.L. Hillier et al.

Peptostreptoccus, Propionibacterium, Eubacterium and other nonsporeforming anaerobic gram-positive bacteria

Cited by (273)

Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis
2024, Journal of Shoulder and Elbow Surgery
There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty.
Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model.
After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I² = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I² = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03).
This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.
Revision reverse shoulder arthroplasty has similar outcomes to primary reverse shoulder arthroplasty at 5 Year average follow-up
2023, Journal of Orthopaedics
Shoulder arthroplasty is a successful procedure that provides pain relief and improvements in function and range of motion. Anatomic and reverse shoulder arthroplasty are both effective procedures, and their indications continue to expand. We look at the outcomes of revision reverse total shoulder arthroplasty and compare it to the outcomes of primary reverse and anatomic total shoulder arthroplasty.
We identified patients undergoing total shoulder arthroplasty at our institution between the years of 2010 and 2020. Data was prospectively collected and retrospectively reviewed for post-operative range of motion and strength in patients with revision surgery and compared to controls. Measurements were collected preoperatively and postoperatively including range of motion and strength in the affected and unaffected shoulder. We collected patient reported outcome measures in person and via phone to identify subjective outcomes of total shoulder arthroplasty. Average final follow-up was 5.27 years.
Our total patient sample was split between three groups: those with primary anatomic arthroplasty those who underwent primary reverse arthroplasty, and those who were revised to a reverse shoulder arthroplasty. All three groups had significant improvements in abduction and forward elevation from their pre-operative baseline to two years follow-up. Primary reverse had a significant improvement over revision reverse in abduction at one year follow-up. For all other range of motion measurements, there was no statistically significant difference at 2 years between primary and revision reverse shoulder arthroplasty. Patient reported outcomes had a significant increase from pre-op to most recent follow-up in all three groups.
Overall, our data suggest there is an improvement in outcomes with both primary and revision surgeries, and that results after revision reverse total shoulder arthroplasty may be comparable to primary reverse total shoulder arthroplasty.
Diagnostic arthroscopy for periprosthetic shoulder arthroplasty infections: a systematic review and meta-analysis
2023, JSES International
Periprosthetic joint infection of the shoulder (PJI) is a devastating complication with a reported incidence of 1%-15.4% and is often difficult to diagnose with current diagnostic tools including serologic tests and arthrocentesis. This systematic review evaluates the reliability and validity of arthroscopic biopsy in the current literature for the diagnosis of shoulder PJI.
MEDLINE, Scopus, Web of Sciences, Google Scholar, and Cochrane databases were queried electronically from inception to June 2022 for publications reporting diagnostic accuracy of shoulder arthroscopic biopsy for detecting infection after anatomic total shoulder arthroplasty, shoulder hemiarthroplasty, or reverse total shoulder arthroplasty. This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
After exclusion, our meta-analysis consisted of 7 articles with a total of 112 patients. The estimated pooled sensitivity and specificity of arthroscopic biopsy for confirmation of shoulder periprosthetic infection were 0.87 (95% confidence interval [CI]: 0.73-0.95) and 0.79 (95% CI: 0.67-0.88), respectively. The pooled positive likelihood ratio and negative likelihood ratio were 4.15 (95% CI: 2.57, 6.70) and 0.17 (95% CI: 0.08, 0.36), respectively. The aggregate positive predictive value was 73.58% (95% CI: 63.29%-81.82%), and aggregate negative predictive value was 89.83% (95% CI: 80.59%-94.95%). The diagnostic odds ratio of arthroscopic biopsy was 19.92 (95% CI: 4.96-79.99).
Arthroscopic biopsy in patients suspected of shoulder PJI has good diagnostic accuracy, with high sensitivity and specificity. Given the various biopsy protocols (such as devices, numbers, locations, etc.), further prospective studies are necessary to define the future role of arthroscopic biopsy in diagnosis and treatment.
The incidence of shoulder arthroplasty infection presents a substantial economic burden in the United States: a predictive model
2023, JSES International
Periprosthetic joint infections (PJIs) are a major cause of morbidity after shoulder arthroplasty. Prior national database studies have estimated the trends of shoulder PJI up to 2012.²¹ Since 2012, the landscape of shoulder arthroplasty has changed drastically with the expanding popularity of reverse total shoulder arthroplasty. The dramatic growth in primary shoulder arthroplasties is likely paralleled with an increase of PJI case volume. The purpose of this study is to quantify the rise in shoulder PJIs and the economic stress they currently place on the American healthcare system as well as the toll they will incur over the coming decade.
The Nationwide Inpatient Sample database was queried for primary and revision anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty from 2011-2018. Multivariate regression was used to predict cases and charges through the year 2030 adjusted to 2021 purchasing power parity.
From 2011 to 2018, PJI was found to be 1.1% shoulder arthroplasties, from 0.8% (2011) to 1.4% (2018). Anatomic total shoulder arthroplasty experienced the greatest proportion of infections at 2.0%, followed by hemiarthroplasty at 1.0% and reverse total shoulder arthroplasty at 0.3%. Total hospital charges grew 324%, from $44.8 million (2011) to $190.3 million (2018). Our regression model projects 176% growth in cases and 141% growth in annual charges by 2030.
This study demonstrates the large economic burden that shoulder PJIs pose on the American healthcare system, which is predicted to reach nearly $500 million in charges annually by 2030. Understanding trends in procedure volume and hospital charges will be critical in evaluating strategies to reduce shoulder PJIs.
Does needle penetration of the shoulder joint prior to arthroscopy increase infection risk? The effect of preoperative magnetic resonance arthrogram or corticosteroid injection
2023, Journal of Shoulder and Elbow Surgery
Prior literature has associated preoperative corticosteroid shoulder injection (CSI) with infection following shoulder surgery. A recent study found an equally elevated risk of total knee arthroplasty infection with preoperative injection of either CSI or hyaluronic acid. The implication is that violation of a joint prior to surgery, even in the absence of corticosteroid, may pose an elevated risk of infection following orthopedic surgery. The aim of the present study was to determine whether violation of the shoulder joint for magnetic resonance arthrogram (MRA) poses an elevated risk of infection following shoulder arthroscopy, and to compare this risk to that introduced by preoperative CSI.
A national, all-payer database was queried to identify patients undergoing shoulder arthroscopy between January 2015 and October 2020. Patients were stratified into the following groups: (1) no CSI or MRA within 6 months of surgery (n = 5000), (2) CSI within 2 weeks of surgery (n = 1055), (3) CSI between 2 and 4 weeks prior to surgery (n = 2575), (4) MRA within 2 weeks of surgery (n = 414), and (5) MRA between 2 and 4 weeks prior to surgery (n = 1138). Postoperative infection (septic shoulder or surgical site infection) was analyzed at 90 days, 1 year, and 2 years, postoperatively. Multivariable logistic regression analysis controlled for differences among groups.
MRA within 2 weeks prior to shoulder surgery was associated with an increased risk of infection at 1 year (odds ratio [OR], 2.17; P = .007), while MRA 2-4 weeks preceding surgery was not associated with an increased risk of postoperative infection at any time point. By comparison, CSI within 2 weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.72; P = .022), 1 year (OR, 1.65; P = .005), and 2 years (OR, 1.63; P = .002) following surgery. Similarly, CSI 2-4 weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.83; P < .001), 1 year (OR, 1.62; P < .001), and 2 years (OR, 1.79; P < .001).
Preoperative CSI within 4 weeks of shoulder arthroscopy elevates the risk of postoperative infection. Needle arthrotomy for shoulder MRA elevates the risk of infection in a more limited fashion. Avoidance of MRA within 2 weeks of shoulder arthroscopy may mitigate postoperative infection risk. Additionally, the association between preoperative CSI and postoperative infection may be more attributed to medication profile than to needle arthrotomy.
The utilization of platelet parameters as an adjunct indicator for the diagnosis of shoulder periprosthetic joint infection
2023, Seminars in Arthroplasty JSES
The diagnosis of periprosthetic joint infection (PJI) of the shoulder remains challenging. Platelet-related serum values are associated with physiological states of infection. The purpose of this study is to determine whether absolute platelet count and mean platelet volume could aid in the diagnosis of shoulder PJI.
A retrospective review of all patients undergoing revision shoulder arthroplasty at a single institution was performed. Likelihood of PJI was determined based on the International Consensus Meeting score. The ratio of absolute platelet count to mean platelet volume (PV) was calculated for each patient. This PV ratio was compared to erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels for making the diagnosis of shoulder PJI.
Four hundred sixty cases of revision shoulder arthroplasty were identified. Of these, 80 (17.4%) were diagnosed as having a definitive or probable shoulder PJI. The PV ratio was significantly higher for patients with a diagnosed PJI (28.1 vs. 25.4, P = .004). Receiver operator characteristic curve analysis for the PV ratio determined the sensitivity for diagnosing PJI is 55.3% and the specificity is 62.9% with an area under the curve of 0.60 (95% confidence interval [CI]: 0.50-0.69). There was no significant difference between the area under the curve values for PV ratio, ESR (0.61; 95% CI: 0.5117-0.7042), or CRP (0.67; 95% CI: 0.5766-0.7641). On subgroup analysis, the PV ratio demonstrated a specificity of 73.7%, compared to 18.2% for ESR and 23.8% for CRP, at recognizing PJI attributed to Cutibacterium acnes.
There is a clear association between an elevated PV ratio and patients with shoulder PJI. Although the PV ratio should not be used alone to make the diagnosis, our analysis demonstrates that this ratio performs similarly to the traditional serum biomarkers at recognizing shoulder PJI.
The PV ratio may be used as an adjunct preoperative indicator in the evaluation of patients with potential shoulder PJIs.

View all citing articles on Scopus

View full text

ShoulderPropionibacterium acnes infection after shoulder arthroplasty: A diagnostic challenge

Hypothesis

Materials and methods

Results

Discussion

Section snippets

Materials and methods

Results

Discussion

Disclaimer

J Shoulder Elbow Surg

Orthop Clin North Am

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Anaerobic gram-positive non-sporulating bacilli

Infections caused by Propionibacterium species

Rev Infect Dis

Total shoulder arthroplasty: complications and revision surgery

Instr Course Lect

Les bacteries anaerobes en pathologie osseuse

Med Mal Infect

Anaerobic infections in children: a prospective study

Pediatrics

Anaerobic bacteria in human disease

Propionibacterium acnes as a cause of aggressive aortic valve endocarditis and importance of tissue grinding-a case report and review

J Clin Microbiol

Peptostreptoccus, Propionibacterium, Eubacterium and other nonsporeforming anaerobic gram-positive bacteria

Shoulder
Propionibacterium acnes infection after shoulder arthroplasty: A diagnostic challenge