Management of periprosthetic joint infection of the shoulder: A narrative review

Abstract

Evidence for management of shoulder periprosthetic joint infection (PJI) has traditionally originated from the hip and knee literature. The differing microbiome, anatomy and implants used in the shoulder mean this evidence is not always directly transferrable. The 2018 Philadelphia International Consensus Meeting for the first-time produced evidence-based guidelines and diagnostic criteria relating specifically to PJI of the shoulder. These guidelines and criteria recognize the pathogenicity of lower virulence organisms in the shoulder which often means clinical presentation is less obvious than other joints. The role of Cutibacterium acnes in shoulder PJI is the subject of increasing basic science and clinical research and advances in microbiological research may help to understand the pathology behind shoulder infections. There is new evidence that outcomes after revision shoulder arthroplasty are dependent on the virulence of the causative organism. An individualised approach to treatment considering host factors, organism, soft tissues and bone stock is recommended. Debate continues in the literature regarding the indications of one- or two-stage revision and the latest evidence is discussed and synthesized in this review article. We advocate careful multidisciplinary team decision making for cases of shoulder PJI and recognize a limited role for debridement and implant retention in acute shoulder PJI (<6 weeks). There appears to be a role for one-stage revision in lower risk cases with low virulence organisms but caution against its' universal adoption. In higher risk or complex cases, there remains a clear role for two-stage revision arthroplasty, and we detail the specifics of this protocol and procedure from our tertiary shoulder and elbow unit.

Fig. 1

(a) Pre-revision surgery radiographs of an infected rTSR demonstrating periosteal scalloping, scapular notching and lucency around the humeral implant. (b) Post-operative first-stage radiographs showing antibiotic laden bone cement (ALBC) spacer.

Fig. 2

Our treatment pathway for management of shoulder PJI at The Royal National Orthopaedic Hospital Shoulder and Elbow Unit. After all revision cases, microbiology results and antimicrobial therapy are re-discussed in the MDT. *Patient carefully counselled of potential need to proceed to on table two-stage in presence of gross signs of infection. Updated and adapted from BESS PJI guidelines..