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An articulating interval spacer in the treatment of an infected total shoulder arthroplasty
An articulating interval spacer in the treatment of an infected total shoulder arthroplasty Mark I. Loebenberg, MD, and Joseph D. Zuckerman, MD, New York, NY
CASE REPORT A 67-year-old right hand– dominant man presented with a 6-year history of gradually worsening right shoulder pain without any antecedent trauma. Radiographs showed severe glenohumeral degenerative arthritis with significant posterior wear of the glenoid and posterior subluxation of the humeral head. The patient underwent total shoulder arthroplasty of the right shoulder with a cemented allpolyethylene Cofield II glenoid and a Cofield II modular humeral component inserted without cement. There were no complications in the immediate perioperative period. The postoperative course was routine until 4 months after the index procedure when the patient began to complain of increasing pain with exercises and daily activities. Active range of motion diminished from 135° of forward elevation, 25° of external rotation, and internal rotation to the L1 area to 105°, 20°, and the lumbosacral area, respectively. Radiographs were unchanged. The patient was started on an antiinflammatory medication but did not improve. An aspiration arthrogram of the right shoulder was performed. This study demonstrated tracking of dye around the glenoid component, suggestive of early loosening (Figure 1). There was no evidence of a rotator cuff tear. Cultures from the arthrogram were negative. The erythrocyte sedimentation rate was 47 (normal range, 0-20), and the C-reactive protein level was 85.3 (normal range, 0-5.0). The patient returned to the operating room 6 months after his index procedure for exploration and possible revision of the glenoid component. Clinical findings and intraoperative frozen sections obtained during surgery were suggestive of infection. All components and cement were removed, and an extensive debridement was performed. The glenoid was loose and was removed easily with the cement attached. The humeral component was removed by use of the insertion device to disimpact the stem. Tobramycin-impregnated cement was mixed, molded into a temporary articulating glenoid surface, and placed loosely in the glenoid trough. To maintain soft-tissue tension, a new smaller modular humeral stem was coated with tobramycin-impregnated cement and loosely placed in the From the Department of Orthopaedic Surgery, NYU-Hospital for Joint Diseases. Reprint requests: Joseph D. Zuckerman, MD, Department of Orthopaedic Surgery, NYU-Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003. J Shoulder Elbow Surg 2004;13:476 – 8. Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.01.016
476
Figure 1 Arthrogram of the right shoulder showed tacking of dye at the bone-cement interface of the glenohumeral component indicative of probable loosening.
humeral shaft (Figure 2). The removed humeral head was cleaned, autoclaved, and replaced on the Morse taper. The stem was then inserted into the humeral canal. A reasonable interference fit was obtained that prevented gross motion, particularly rotation. The presence of the components allowed the subscapularis to be maintained at reasonable length. It was repaired to its lateral portion with No. 2 nonabsorbable sutures. A suction drain was placed deep to the deltopectoral interval, and a standard layered closure was used. The patient was admitted to the hospital, and intravenous antibiotics were begun. Staphylococcus epidermidis grew from the intraoperative cultures. In consultation with the infectious disease service, the patient was maintained on ceftriaxone (1 g intravenously daily) for 6 weeks. During
Loebenberg and Zuckerman
J Shoulder Elbow Surg Volume 13, Number 4
Figure 2 After debridement, antibiotic-impregnated cement was placed in the trough of the glenohumeral component. In addition, a small-diameter modular humeral stem was coated with antibioticimpregnated cement and inserted into the humeral canal. The modular humeral head was used as an articulating spacer.
477
Figure 3 Twenty-seven months after reimplantation, there is no evidence suggestive of recurrent infection.
DISCUSSION this period, his erythrocyte sedimentation rate and C-reactive protein level returned to the normal range and his pain diminished significantly from preoperative levels. Three months from the first stage of the procedure, the patient had limited pain and active range of motion with a forward elevation of 135°, external rotation to 70°, and internal rotation to T12. At that time, he underwent the second stage of revision. At the time of reimplantation, the soft tissues were of good quality. Specifically, the subscapularis could be mobilized without significant difficulty. After removal of the cement spacer and the humeral component, the glenohumeral joint space showed minimal scarring and adhesions. Extensive mobilization and releases were not necessary. A cemented glenoid and noncemented humeral component was inserted. Tobramycin-impregnated cement was used for fixation of the glenoid component. There were no postoperative complications. Intraoperative frozen section showed no evidence of acute inflammation. At 27 months’ follow-up (Figure 3), active range of motion comprised forward elevation of 165°, external rotation of 50° and internal rotation to T12. The patient’s subjective complaints were limited to mild pain with more strenuous activities. There was no evidence of residual or recurrent infection.
Infection is an uncommon but devastating complication of shoulder arthroplasty, with an established incidence ranging from 0% to 3.9%.3 Patients usually present with increasing periprosthetic pain and may have radiographic evidence of progressive or early loosening of the components. Erythrocyte sedimentation rates and C-reactive protein levels are usually elevated. Aspiration arthrography of the glenohumeral joint with culture of the aspirate can be helpful, if culture results are positive. However, experience with aspiration of infected hip replacements has shown a significant incidence of false-negative results. Although data for shoulder aspiration have not been reported, it may be reasonable to expect comparable results. A variety of treatment options for infected shoulder arthroplasty ranging from antibiotic suppression to resection arthroplasty have been used. Recently, Sperling et al13 reported their experience with 32 patients diagnosed with deep infections of a shoulder prosthesis. The rate of recurrent infection varied with the administered treatment. The highest rate of recurrent infection occurred in patients who underwent debridement and retention of the prosthesis (50%) or 1-stage revision (50%). Of patients who underwent resection arthroplasty, 28% had recurrent infections.
478
Loebenberg and Zuckerman
Six patients underwent prosthesis removal and debridement with 2-stage reimplantation without any recurrent infections. These authors concluded that 2-stage reimplantation offers the best hope for eradication of infection, pain relief, and maintenance of shoulder function. Many of the techniques used in the treatment of infected shoulder prostheses have been adapted from algorithms established for the treatment of infected hip and knee arthroplasty.1,2,4 –7,10,11,15–17 The evolution of the treatment of infected hip and knee arthroplasty has resulted in the generally accepted approach that 2-stage exchange is preferable except for specific well-defined cases when 1-stage exchanges can be performed. Two-stage exchange includes a thorough debridement and removal of all components and cement—resection arthroplasty—followed by a period of antibiotic treatment. The second stage—reimplantation—is performed when the infection is considered to be resolved based on blood tests and imaging studies. The necessity to maintain the soft-tissue sleeve and minimize soft-tissue contractures led surgeons to use antibiotic-impregnated cement spacers after implant removal with the additional benefit of increasing local antibiotic concentrations. Although this technique was an improvement over previously performed resection arthroplasty, complication rates remained higher in the knee compared with the hip because of nonpliable soft tissues, and final functional outcomes were compromised because of limited range of motion as a result of residual soft-tissue contracture.8,14 These issues are only exacerbated in the shoulder because of its dependence on soft-tissue mobility to regain range of motion. To compensate for these limitations, techniques were developed in both the hip and knee to use an articulated spacer during the interim period between resection of the infected prosthesis and reimplantation. Antibiotic cement has been used in combination with either a new metal prosthesis or the original prosthesis, which was autoclaved and reimplanted. With this technique, the cement is inserted at a late stage of polymerization to ensure ease of removal at the time of revision. The articulated interval spacer allows for improved range of motion and diminished pain during the interim period before reimplantation. This is the first report in the literature of the adaptation of an articulated interval spacer in revision shoulder arthroplasty. The success of this technique in lower extremity arthroplasty encouraged us to develop a similar protocol in the shoulder. The shoulder is a well-vascularized area with only infrequent complications related to infection compared with hip and knee replacement. Our personal experience with 2-stage revision shoulder arthroplasty with and without the use of an antibiotic-implanted cement spacer has mirrored the published literature.9,12 We have been disappointed with the final functional outcomes in these patients, who often have significantly restricted range of motion. The use of an articulated spacer provides the ability to maintain
J Shoulder Elbow Surg July/August 2004
an active physical therapy regimen between procedures to preserve motion. Furthermore, the relative comfort of the articulated spacer can allow for a considerable delay in reimplantation when prolonged antibiotic treatment is required. In the hip and knee, this technique has provided significant benefit with regard to comfort and range of motion, without increasing the rate of recurrent infection. Although this case provided similar results in the shoulder, further studies are necessary to evaluate this technique on a larger scale. REFERENCES
1. Bittar ES, Petty W. Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop 1982;170:83-7. 2. Carlsson AS, Josefsson G, Lindberg L. Revision with gentamicinimpregnated cement for deep infections in total hip arthroplasties. J Bone Joint Surg Am 1978;60:1059-64. 3. Cofield RH, Edgerton BC. Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect 1990;39:449-62. 4. Duncan CP, Beauchamp C. A temporary antibiotic-loaded joint replacement system for management of complex infections involving the hip. Orthop Clin North Am 1993;24:751-9. 5. Fitzgerald RH Jr. Infected total hip arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg 1995;3:249-62. 6. Haddad FS, Masri BA, Campbell D, et al. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg Br 2000;82:807-12. 7. Hamblen DL. Diagnosis of infection and the role of permanent excision arthroplasty. Orthop Clin North Am 1993;24:743-9. 8. Hofmann AA, Kane KR, Tkach TK, Plaster RL, Camargo MP. Treatment of infected total knee arthroplasty using an articulating spacer. Clin Orthop 1995;321:45-54. 9. Ramsey ML, Fenlin JM Jr. Use of an antibiotic-impregnated bone cement block in the revision of an infected shoulder arthroplasty. J Shoulder Elbow Surg 1996;5:479-82. 10. Rand JA, Bryan RS, Morrey BF, Westholm F. Management of infected total knee arthroplasty. Clin Orthop 1986;205:75-85. 11. Salvati EA, Chekofsky KM, Brause BD, Wilson PD Jr. Reimplantation in infection: a 12-year experience. Clin Orthop 1982; 170:62-75. 12. Seitz WH Jr, Damacen H. Staged exchange arthroplasty for shoulder sepsis. J Arthroplasty 2002;17(Suppl 1):36-40. 13. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop 2001;382:206-16. 14. Whiteside LA. Treatment of infected total knee arthroplasty. Clin Orthop 1994;299:169-72. 15. Wilde AH, Ruth JT. Two-stage reimplantation in infected total knee arthroplasty. Clin Orthop 1988;236:23-35. 16. Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am 1990;72:878-83. 17. Younger AS, Duncan CP, Masri BA. Treatment of infection associated with segmental bone loss in the proximal part of the femur in two stages with use of an antibiotic-loaded interval prosthesis. J Bone Joint Surg Am 1998;80:60-9.
CASE REPORT A 67-year-old right hand– dominant man presented with a 6-year history of gradually worsening right shoulder pain without any antecedent trauma. Radiographs showed severe glenohumeral degenerative arthritis with significant posterior wear of the glenoid and posterior subluxation of the humeral head. The patient underwent total shoulder arthroplasty of the right shoulder with a cemented allpolyethylene Cofield II glenoid and a Cofield II modular humeral component inserted without cement. There were no complications in the immediate perioperative period. The postoperative course was routine until 4 months after the index procedure when the patient began to complain of increasing pain with exercises and daily activities. Active range of motion diminished from 135° of forward elevation, 25° of external rotation, and internal rotation to the L1 area to 105°, 20°, and the lumbosacral area, respectively. Radiographs were unchanged. The patient was started on an antiinflammatory medication but did not improve. An aspiration arthrogram of the right shoulder was performed. This study demonstrated tracking of dye around the glenoid component, suggestive of early loosening (Figure 1). There was no evidence of a rotator cuff tear. Cultures from the arthrogram were negative. The erythrocyte sedimentation rate was 47 (normal range, 0-20), and the C-reactive protein level was 85.3 (normal range, 0-5.0). The patient returned to the operating room 6 months after his index procedure for exploration and possible revision of the glenoid component. Clinical findings and intraoperative frozen sections obtained during surgery were suggestive of infection. All components and cement were removed, and an extensive debridement was performed. The glenoid was loose and was removed easily with the cement attached. The humeral component was removed by use of the insertion device to disimpact the stem. Tobramycin-impregnated cement was mixed, molded into a temporary articulating glenoid surface, and placed loosely in the glenoid trough. To maintain soft-tissue tension, a new smaller modular humeral stem was coated with tobramycin-impregnated cement and loosely placed in the From the Department of Orthopaedic Surgery, NYU-Hospital for Joint Diseases. Reprint requests: Joseph D. Zuckerman, MD, Department of Orthopaedic Surgery, NYU-Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003. J Shoulder Elbow Surg 2004;13:476 – 8. Copyright © 2004 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2004/$30.00 doi:10.1016/j.jse.2004.01.016
476
Figure 1 Arthrogram of the right shoulder showed tacking of dye at the bone-cement interface of the glenohumeral component indicative of probable loosening.
humeral shaft (Figure 2). The removed humeral head was cleaned, autoclaved, and replaced on the Morse taper. The stem was then inserted into the humeral canal. A reasonable interference fit was obtained that prevented gross motion, particularly rotation. The presence of the components allowed the subscapularis to be maintained at reasonable length. It was repaired to its lateral portion with No. 2 nonabsorbable sutures. A suction drain was placed deep to the deltopectoral interval, and a standard layered closure was used. The patient was admitted to the hospital, and intravenous antibiotics were begun. Staphylococcus epidermidis grew from the intraoperative cultures. In consultation with the infectious disease service, the patient was maintained on ceftriaxone (1 g intravenously daily) for 6 weeks. During
Loebenberg and Zuckerman
J Shoulder Elbow Surg Volume 13, Number 4
Figure 2 After debridement, antibiotic-impregnated cement was placed in the trough of the glenohumeral component. In addition, a small-diameter modular humeral stem was coated with antibioticimpregnated cement and inserted into the humeral canal. The modular humeral head was used as an articulating spacer.
477
Figure 3 Twenty-seven months after reimplantation, there is no evidence suggestive of recurrent infection.
DISCUSSION this period, his erythrocyte sedimentation rate and C-reactive protein level returned to the normal range and his pain diminished significantly from preoperative levels. Three months from the first stage of the procedure, the patient had limited pain and active range of motion with a forward elevation of 135°, external rotation to 70°, and internal rotation to T12. At that time, he underwent the second stage of revision. At the time of reimplantation, the soft tissues were of good quality. Specifically, the subscapularis could be mobilized without significant difficulty. After removal of the cement spacer and the humeral component, the glenohumeral joint space showed minimal scarring and adhesions. Extensive mobilization and releases were not necessary. A cemented glenoid and noncemented humeral component was inserted. Tobramycin-impregnated cement was used for fixation of the glenoid component. There were no postoperative complications. Intraoperative frozen section showed no evidence of acute inflammation. At 27 months’ follow-up (Figure 3), active range of motion comprised forward elevation of 165°, external rotation of 50° and internal rotation to T12. The patient’s subjective complaints were limited to mild pain with more strenuous activities. There was no evidence of residual or recurrent infection.
Infection is an uncommon but devastating complication of shoulder arthroplasty, with an established incidence ranging from 0% to 3.9%.3 Patients usually present with increasing periprosthetic pain and may have radiographic evidence of progressive or early loosening of the components. Erythrocyte sedimentation rates and C-reactive protein levels are usually elevated. Aspiration arthrography of the glenohumeral joint with culture of the aspirate can be helpful, if culture results are positive. However, experience with aspiration of infected hip replacements has shown a significant incidence of false-negative results. Although data for shoulder aspiration have not been reported, it may be reasonable to expect comparable results. A variety of treatment options for infected shoulder arthroplasty ranging from antibiotic suppression to resection arthroplasty have been used. Recently, Sperling et al13 reported their experience with 32 patients diagnosed with deep infections of a shoulder prosthesis. The rate of recurrent infection varied with the administered treatment. The highest rate of recurrent infection occurred in patients who underwent debridement and retention of the prosthesis (50%) or 1-stage revision (50%). Of patients who underwent resection arthroplasty, 28% had recurrent infections.
478
Loebenberg and Zuckerman
Six patients underwent prosthesis removal and debridement with 2-stage reimplantation without any recurrent infections. These authors concluded that 2-stage reimplantation offers the best hope for eradication of infection, pain relief, and maintenance of shoulder function. Many of the techniques used in the treatment of infected shoulder prostheses have been adapted from algorithms established for the treatment of infected hip and knee arthroplasty.1,2,4 –7,10,11,15–17 The evolution of the treatment of infected hip and knee arthroplasty has resulted in the generally accepted approach that 2-stage exchange is preferable except for specific well-defined cases when 1-stage exchanges can be performed. Two-stage exchange includes a thorough debridement and removal of all components and cement—resection arthroplasty—followed by a period of antibiotic treatment. The second stage—reimplantation—is performed when the infection is considered to be resolved based on blood tests and imaging studies. The necessity to maintain the soft-tissue sleeve and minimize soft-tissue contractures led surgeons to use antibiotic-impregnated cement spacers after implant removal with the additional benefit of increasing local antibiotic concentrations. Although this technique was an improvement over previously performed resection arthroplasty, complication rates remained higher in the knee compared with the hip because of nonpliable soft tissues, and final functional outcomes were compromised because of limited range of motion as a result of residual soft-tissue contracture.8,14 These issues are only exacerbated in the shoulder because of its dependence on soft-tissue mobility to regain range of motion. To compensate for these limitations, techniques were developed in both the hip and knee to use an articulated spacer during the interim period between resection of the infected prosthesis and reimplantation. Antibiotic cement has been used in combination with either a new metal prosthesis or the original prosthesis, which was autoclaved and reimplanted. With this technique, the cement is inserted at a late stage of polymerization to ensure ease of removal at the time of revision. The articulated interval spacer allows for improved range of motion and diminished pain during the interim period before reimplantation. This is the first report in the literature of the adaptation of an articulated interval spacer in revision shoulder arthroplasty. The success of this technique in lower extremity arthroplasty encouraged us to develop a similar protocol in the shoulder. The shoulder is a well-vascularized area with only infrequent complications related to infection compared with hip and knee replacement. Our personal experience with 2-stage revision shoulder arthroplasty with and without the use of an antibiotic-implanted cement spacer has mirrored the published literature.9,12 We have been disappointed with the final functional outcomes in these patients, who often have significantly restricted range of motion. The use of an articulated spacer provides the ability to maintain
J Shoulder Elbow Surg July/August 2004
an active physical therapy regimen between procedures to preserve motion. Furthermore, the relative comfort of the articulated spacer can allow for a considerable delay in reimplantation when prolonged antibiotic treatment is required. In the hip and knee, this technique has provided significant benefit with regard to comfort and range of motion, without increasing the rate of recurrent infection. Although this case provided similar results in the shoulder, further studies are necessary to evaluate this technique on a larger scale. REFERENCES
1. Bittar ES, Petty W. Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop 1982;170:83-7. 2. Carlsson AS, Josefsson G, Lindberg L. Revision with gentamicinimpregnated cement for deep infections in total hip arthroplasties. J Bone Joint Surg Am 1978;60:1059-64. 3. Cofield RH, Edgerton BC. Total shoulder arthroplasty: complications and revision surgery. Instr Course Lect 1990;39:449-62. 4. Duncan CP, Beauchamp C. A temporary antibiotic-loaded joint replacement system for management of complex infections involving the hip. Orthop Clin North Am 1993;24:751-9. 5. Fitzgerald RH Jr. Infected total hip arthroplasty: diagnosis and treatment. J Am Acad Orthop Surg 1995;3:249-62. 6. Haddad FS, Masri BA, Campbell D, et al. The PROSTALAC functional spacer in two-stage revision for infected knee replacements. Prosthesis of antibiotic-loaded acrylic cement. J Bone Joint Surg Br 2000;82:807-12. 7. Hamblen DL. Diagnosis of infection and the role of permanent excision arthroplasty. Orthop Clin North Am 1993;24:743-9. 8. Hofmann AA, Kane KR, Tkach TK, Plaster RL, Camargo MP. Treatment of infected total knee arthroplasty using an articulating spacer. Clin Orthop 1995;321:45-54. 9. Ramsey ML, Fenlin JM Jr. Use of an antibiotic-impregnated bone cement block in the revision of an infected shoulder arthroplasty. J Shoulder Elbow Surg 1996;5:479-82. 10. Rand JA, Bryan RS, Morrey BF, Westholm F. Management of infected total knee arthroplasty. Clin Orthop 1986;205:75-85. 11. Salvati EA, Chekofsky KM, Brause BD, Wilson PD Jr. Reimplantation in infection: a 12-year experience. Clin Orthop 1982; 170:62-75. 12. Seitz WH Jr, Damacen H. Staged exchange arthroplasty for shoulder sepsis. J Arthroplasty 2002;17(Suppl 1):36-40. 13. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop 2001;382:206-16. 14. Whiteside LA. Treatment of infected total knee arthroplasty. Clin Orthop 1994;299:169-72. 15. Wilde AH, Ruth JT. Two-stage reimplantation in infected total knee arthroplasty. Clin Orthop 1988;236:23-35. 16. Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am 1990;72:878-83. 17. Younger AS, Duncan CP, Masri BA. Treatment of infection associated with segmental bone loss in the proximal part of the femur in two stages with use of an antibiotic-loaded interval prosthesis. J Bone Joint Surg Am 1998;80:60-9.