Published online Oct 18, 2019. doi: 10.5312/wjo.v10.i10.356
Peer-review started: April 4, 2019
First decision: July 31, 2019
Revised: September 3, 2019
Accepted: September 15, 2019
Article in press: September 15, 2019
Published online: October 18, 2019
Septic arthritis of the glenohumeral joint is a relatively rare entity representing 3% to 15% of septic arthritis. It can nonetheless lead to major complications such as bone and cartilage destruction if treatment is delayed. Early treatment is therefore mandatory to alleviate pain and restore optimal function. Open or arthroscopic irrigation and debridement associated with targeted intravenous antibiotic therapy is effective to eradicate the infection. However, in patients with advanced osteoarthritic changes and/or massive rotator cuff tendon tears, infection eradication can be challenging to achieve and the functional outcome is often not satisfying even after successful infection eradication.
The motivation behind this study was to evaluate a two-stage approach with initial resection of the native infected articular surfaces, implantation of a cement spacer before final treatment with a total shoulder arthroplasty in a second stage. While this treatment option is gaining popularity in recent years, the evidence in the literature remains limited.
The available studies which deal with the topic of two-stage revision are focused on infected total shoulder arthroplasty. The results of patients with native advanced septic arthritis which are merged in theses cohorts, with no separate analysis provided for this specific subgroup. The aim of our study was reported our results of a short interval two-stage arthroplasty approach for septic arthritis with concomitant advanced degenerative changes of the shoulder joint.
We retrospectively included five consecutive patients over a five-year period and evaluated the therapeutic management and the clinical outcome assessed by disability of the arm, shoulder and hand (DASH) score and subjective shoulder value (SSV). All procedures were performed through a deltopectoral approach and consisted in a debridement and synovectomy, articular surface resection and insertion of a custom made antibiotic enriched cement spacer. Shoulder arthroplasty was performed in a second stage.
Mean age was 61 years (range, 47-70 years). Four patients had previous surgeries ahead of the septic arthritis. All patients had a surgical debridement ahead of the index procedure. Mean follow-up was 13 mo (range, 6-24 mo). Persistent microbiological infection was confirmed in all five cases at the time of the first stage of the procedure. The shoulder arthroplasties were performed 6 to 12 wk after insertion of the antibiotic-loaded spacer. There were two hemi and three reverse shoulder arthroplasties. Infection was successfully eradicated in all patients. The clinical outcome was satisfactory with a mean DASH score and SSV of 18.4 points and 70%, respectively.
Our study indicates that short interval two-stage approach for septic glenohumeral arthritis is a valid alternative treatment option for patient with advanced degenerative condition and/or irreparable rotator cuff tears. The main advantage of this novel approach is that by treating the underlying bony pathology in terms of resecting the arthritic bone the chances of successful infection eradication are increased and at the same time it allows for adequate pain control and improvement of functional outcomes. In our opinion, it should be reserved for selected patients with higher stage of infection, who failed to heal with arthroscopic or open lavage and debridement
The rising number of shoulder procedures performed in aging population with inherent higher risk factors could potentially lead to a growing number of septic glenohumeral arthritis. Multicenter studies are necessary to achieve a higher case load and evidence regarding these rare indications.