Shoulder:Sepsis of the Shoulder - Revision history

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← Older revision		Revision as of 08:52, 14 July 2021
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−	==~~=85/~~Bullet Points===	+	==Bullet Points==

	*Periprosthetic shoulder infection is rare but potentially devastating. The rate of periprosthetic shoulder infection is increased in cases of revision procedures, reverse shoulder implants and comorbidities. One specific type of periprosthetic shoulder infection is the occurrence of low-grade infections caused by non-suppurative bacteria such as Cutibaterium acnes or Staphylococcus epidemermidis.		*Periprosthetic shoulder infection is rare but potentially devastating. The rate of periprosthetic shoulder infection is increased in cases of revision procedures, reverse shoulder implants and comorbidities. One specific type of periprosthetic shoulder infection is the occurrence of low-grade infections caused by non-suppurative bacteria such as Cutibaterium acnes or Staphylococcus epidemermidis.

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 Blood supply to the joint comes from the articular branches of the suprascapular and internal thoracic arteries.<ref name=":27" />[1] The nerve to the subclavius muscle and the medial suprascapular nerves provide innervation to the sternoclavicular joint.<ref name=":27" />[1]
-Septic arthritis of the sternoclavicular joint is rare and represents less than 1% of all bone and joint infections.<ref name=":29" /><ref name=":30">Bar-Natan M, Salai M, Sidi Y, Gur H. Sternoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum. 2002;32:189-95.</ref>[5][6] A sternoclavicular joint infection is, in the majority of cases, associated with other systemic illnesses and/or general poor health status. Common concurrent issues include diabetes, intravenous drug use, immunosuppression, and rheumatoid arthritis.<ref name=":31">Nusselt T, Klinger HM, Freche S, Schultz W, Baums MH. Surgical management of sternoclavicular septic arthritis. Arch Orthop Trauma Surg. 2011;131:319-23.</ref>[7] While rare, prompt diagnosis and treatment are essential to prevent spread into the posteriorly located great vessels, mediastinum, and pleural space.<ref name=":31" />[7]
+Septic arthritis of the sternoclavicular joint is rare and represents less than 1% of all bone and joint infections.<ref name=":29" /><ref name=":30">Bar-Natan M, Salai M, Sidi Y, Gur H. Sternoclavicular infectious arthritis in previously healthy adults. Semin Arthritis Rheum. 2002;32:189-95.</ref>[5][6] In the majority of cases a sternoclavicular joint infection is associated with other systemic illnesses and/or general poor health status. Common concurrent issues include diabetes, intravenous drug use, immunosuppression, and rheumatoid arthritis.<ref name=":31">Nusselt T, Klinger HM, Freche S, Schultz W, Baums MH. Surgical management of sternoclavicular septic arthritis. Arch Orthop Trauma Surg. 2011;131:319-23.</ref>[7] While rare, prompt diagnosis and treatment are essential to prevent spread into the posteriorly located great vessels, mediastinum, and pleural space.<ref name=":31" />[7]
 ==Etiology==
-Ross et al. reviewed 180 cases of sternoclavicular joint septic arthritis and found that the most common offending bacteria were Staphylococcus aureus (49%) followed by Pseudomonas aeruginosa (10%) and Brucella melitensis (7%)<ref name=":29" />.[5] In a similarly designed study, Brancos et al. reported on sternoclavicular joint infections in a population of heroin addicts. They confirmed S. aureus and P. aeruginosa as the most common isolates.<ref>Brancós MA, Peris P, Miró JM, Monegal A, Gatell JM, Mallolas J, Mensa J, García S, Muñoz-Gomez J. Septic arthritis in heroin addicts. Semin Arthritis Rheum. 1991;21:81-7.</ref>[8] In 2015, Jain et al. described tuberculosis (TB) as an unusual cause of sternoclavicular septic arthritis. They reported a small series of 9 men and 4 women who eventually received a diagnosis of sternoclavicular septic arthritis secondary to TB.<ref name=":32">Jain A, Jajodia N, Aggarwal A, Singh J, Gupta S. Tuberculosis of the sternoclavicular joint. J Orthop Surg (Hong Kong). 2015;23:315-8.</ref>[9]
+Ross et al. reviewed 180 cases of sternoclavicular joint septic arthritis and found that the most common offending bacteria were Staphylococcus aureus (49%), followed by Pseudomonas aeruginosa (10%) and Brucella melitensis (7%)<ref name=":29" />.[5] In a similarly designed study, Brancos et al. reported sternoclavicular joint infections in a population of heroin addicts. They confirmed S. aureus and P. aeruginosa as the most common isolates.<ref>Brancós MA, Peris P, Miró JM, Monegal A, Gatell JM, Mallolas J, Mensa J, García S, Muñoz-Gomez J. Septic arthritis in heroin addicts. Semin Arthritis Rheum. 1991;21:81-7.</ref>[8] In 2015, Jain et al. described tuberculosis (TB) as an unusual cause of sternoclavicular septic arthritis. They reported a small series of 9 men and 4 women, who eventually received a diagnosis of sternoclavicular septic arthritis secondary to TB.<ref name=":32">Jain A, Jajodia N, Aggarwal A, Singh J, Gupta S. Tuberculosis of the sternoclavicular joint. J Orthop Surg (Hong Kong). 2015;23:315-8.</ref>[9]
 ==Epidemiology==
-In the general population, sternoclavicular septic arthritis accounts for less than 1% of bone and joint infections.<ref name=":30" />[6]  Interestingly, it accounts for 17% of septic arthritis cases amongst intravenous drug users.<ref name=":29" />[5] The classic involved patient demographic consists of males in the fourth to fifth decade of life. In the previously mentioned case series by Ross et al., 73% of sternoclavicular joint infections involved males with a mean age of 45.<ref name=":29" />[5]  Interestingly, no risk factor for infection was identifiable in almost a quarter of the patients in the study.<ref name=":29" />[5] Von Glinski et al. reported 13 cases of sternoclavicular joint infection involving eight men with a mean age of 37 years.<ref name=":33">von Glinski A, Yilmaz E, Rausch V, Koenigshausen M, Schildhauer TA, Seybold D, Geßmann J. Surgical management of sternoclavicular joint septic arthritis. J Clin Orthop Trauma. 2019;10:406-13.</ref>[10]
+In the general population, sternoclavicular septic arthritis accounts for less than 1% of bone and joint infections.<ref name=":30" />[6]  Interestingly, it accounts for 17% of septic arthritis cases amongst intravenous drug users.<ref name=":29" />[5] The classic involved patient demographic consists of males in the fourth to fifth decade of life. In the previously mentioned case series by Ross et al., 73% of sternoclavicular joint infections involved males with a mean age of 45 years .<ref name=":29" />[5]  Interestingly, no risk factor for infection was identifiable in almost a quarter of the patients in the study.<ref name=":29" />[5] Von Glinski et al. reported 13 cases of sternoclavicular joint infection involving eight men with a mean age of 37 years.<ref name=":33">von Glinski A, Yilmaz E, Rausch V, Koenigshausen M, Schildhauer TA, Seybold D, Geßmann J. Surgical management of sternoclavicular joint septic arthritis. J Clin Orthop Trauma. 2019;10:406-13.</ref>[10]
 ==Pathophysiology==
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 A healthy patient may be able to contract a spontaneous sternoclavicular joint infection. Sanelli et al. describe a case os staphylococcal septic arthritis that is associated with no known predisposing risk factor. That patient was able to be managed with medical therapy alone.<ref name=":34">Zanelli G, Sansoni S, Migliorini L, Donati E, Cellesi C. Sternoclavicular joint infection in an adult without predisposing risk factors. Infez Med. 2003;11:105-7. </ref>[12]
-There have been reports of patients contracting sternoclavicular joint infections in association with dialysis. Renoult et al. first reported on the association of hemodialysis and sternoclavicular joint infection.  They reported on two patients who were able to be treated non-operatively after addressing the condition.<ref name=":35">Renoult E, Lataste A, Jonon B, Testevuide P, Kessler M. Sternoclavicular joint infection in hemodialysis patients. Nephron.1990;56:212-3.</ref>[13] Renal failure may further immunosuppress and predispose such patients to a sternoclavicular joint infection.
+There have been reports of patients contracting sternoclavicular joint infections in association with dialysis. Renoult et al. first reported on the association of hemodialysis and sternoclavicular joint infection. They reported two patients who were able to be treated non-operatively after addressing the condition.<ref name=":35">Renoult E, Lataste A, Jonon B, Testevuide P, Kessler M. Sternoclavicular joint infection in hemodialysis patients. Nephron.1990;56:212-3.</ref>[13] Renal failure may further immunosuppress and predispose such patients to a sternoclavicular joint infection.
 ==History and Physical==
-An extensive history involving the assessment of systemic symptoms is vital as many of the conditions that affect the sternoclavicular joint are systemic. The clinician should question the patient regarding a family history of sternoclavicular arthritis, intravenous drug use, and systemic complaints such as subjective fevers, chills, night sweats, and malaise. Pain localized to the sternoclavicular joint or medial clavicle is a high-risk patient, or an individual with systemic symptoms should raise suspicion for infection.
+An extensive history involving the assessment of systemic symptoms is vital, as many of the conditions that affect the sternoclavicular joint are systemic. The clinician should question the patient regarding a family history of sternoclavicular arthritis, intravenous drug use, and systemic complaints such as subjective fevers, chills, night sweats, and malaise. Pain localized to the sternoclavicular joint or medial clavicle is a high-risk patient, or an individual with systemic symptoms should raise suspicion for infection.
 On physical examination, an infected sternoclavicular joint is likely to be swollen, warm, tender, and erythematous. Patients are painful both with direct palpation of the joint as well as passive/active range of motion of the ipsilateral shoulder. Typically, sternoclavicular joint septic arthritis is a unilateral condition, while inflammatory arthritis such as rheumatoid arthritis affects both joints simultaneously. One should pay attention to any fluctuance, joint translation, joint asymmetry, and bony enlargement. Joint asymmetry should raise concern for a sternoclavicular joint dislocation, which may represent a surgical emergency if directed posteriorly with neurovascular changes.<ref>Morell DJ, Thyagarajan DS. Sternoclavicular joint dislocation and its management: A review of the literature. World J Orthop. 2016;7:244-50.</ref>[14]

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 In a medically stable patient with a high demand, a two stage revision procedure is generally accepted (''Table'').<ref name=":9" /><ref name=":16" /><ref name=":18" /><ref name=":17" /><ref>Strickland JP, Sperling JW, Cofield RH. The results of two-stage reimplantation for infected shoulder replacement. J Bone Joint Surg Br. 2008;90:460-5</ref><ref>Ortmaier R, Resch H, Hitzl W, Mayer M, Stundner O, Tauber M. Treatment strategies for infection after reverse shoulder arthroplasty. Eur J Orthop Surg Traumatol 2014;24:723-31</ref><ref>Sabesan VJ, Ho JC, Kovacevic D, Iannotti JP. Two-stage reimplantation for treating prosthetic shoulder infections. Clin Orthop Relat Res 2011;469:2538-43</ref> It is highly recommended when the microorganism responsible for the infection is unknown. The first step consists of infection eradication after prosthetic removal: an antibiotic-loaded cement spacer is often implanted and general antibiotics are administrated, secondarily adapted to the micro-organism(s) identified. Antibiotics are generally continued for six to eight weeks. Markers such as C-reactive protein or interleukin-6 have been shown to be valuable to predict the eradication of infection and, so, the time of re-implantation.<ref name=":23">Coffey MJ, Ely EE, Crosby LA. Treatment of glenohumeral sepsis with a commercially produced antibiotic-impregnated cement spacer. J Shoulder Elbow Surg. 2010;19:868-73</ref><ref>Villacis D, Merriman JA, Yalamanchili R, Omid R, Itamura J, Rick Hatch 3rd GF. Serum interleukin-6 as a marker of periprosthetic shoulder infection. J Bone Joint Surg Am. 2014;96:41-5</ref> However, interleukin-6 seems to be normalized faster than C-reactive protein and allows earlier revision for better outcomes.<ref name=":23" /> An iterative irrigation and debridement could be proposed in case of persistent infection. For re-implantation reverse shoulder arthroplasty has been gaining ground in recent years as the implant of choice. First, it allows a larger debridement at the first stage with less concern for soft-tissue preservation. Secondly, it offers the possibility of addressing the glenoid bone defect with or without bone graft. Shirwaiker et al. reported that there is still uncertainty whether two-stage revision is superior to one-stage (Figure 1)<ref>Shirwaiker RA, Springer BD, Spangehl MJ, Garrigues GE, Lowenberg DW, Garras DN, Yoo JU, Pottinger PS. A clinical perspective on musculoskeletal infection treatment strategies and challenges. J Am Acad Orthop Surg. 2015;23:S44-S54</ref>.
-[[File:Eor-2-104.jpg|thumb|''Figure 1.'' A) Radiograph of a 73-year-old man with a chronic periprosthetic shoulder infection of a reverse shoulder arthroplasty (RSA). B) A two-stage revision was decided with a cement spacer implantation for eight weeks. C) Propionibacterium acnes was identified on peri-operative samples taken from the back of the glenosphere. D) After four weeks free of antibiotics, a new RSA was implanted with a proximal humeral allograft. From Bonnevialle et al.,<ref name=":24" /> with permission.|alt=]]
+[[File:Eor-2-104.jpg|thumb|''Figure 1.'' A) Radiograph of a 73-year-old man with a chronic periprosthetic shoulder infection of a reverse shoulder arthroplasty (RSA). B) A two-stage revision was decided with a cement spacer implantation for eight weeks. C) Propionibacterium acnes was identified on peri-operative samples taken from the back of the glenosphere. D) After four weeks free of antibiotics, a new RSA was implanted with a proximal humeral allograft. From Bonnevialle et al.,<ref name=":24" /> with permission.|alt=|center]]
 ===Resection arthroplasty===
 Shoulder resection should remain a salvage procedure for frail or low-demand patients and recalcitrant infection. It offers the option of a single definitive procedure for infection eradication (Figure 2). It has been shown that functional results are poor, but pain relief is achieved in more than 50% of cases.<ref name=":15" /><ref name=":26">Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Pain relief and functional results after resection arthroplasty of the shoulder.J Bone Joint Surg Br. 2007;89:1184-7</ref> Rispoli et  al. reported a mean active elevation of 70 degrees at long-term follow-up after anatomical shoulder arthroplasty removal.<ref name=":26" /> Verhelst et al. demonstrated that preservation of the tuberosities is a predictive factor for better results, because it can avoid antero-superior subluxation of the humerus.<ref name=":25" /> In cases of reverse shoulder arthroplasty, Jacquot et al. did not improve functional outcomes after removal of the implant and identified a high rate of post-operative complications.<ref name=":14" /> Bone loss and soft-tissue impairment after such constrained prostheses could partly explain these findings. Despite Jacquot<ref name=":14" /> and Coste’s<ref name=":16" /> studies, the literature reports a high rate of infection eradication reaching more than 90% of cases.<ref name=":25" /><ref name=":15" /><ref name=":16" /><ref name=":17" /> <ref>Weber P, Utzschneider S, Sadoghi P, Andress HJ, Jansson V, Müller PE. Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature. Int Orthop 2011;35:365-73</ref><ref>Atkins BL, Athanasou N, Deeks JJ, Crook DW, Simpson H, Peto TE, McLardy-Smith P, Berendt AR. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol. 1998;36:2932-9</ref>
-[[File:Eor-2-104 2.jpg|thumb|''Figure 2.'' Radiographs (A and B) of an 86-year-old woman, with a loose implant secondary to chronic periprosthetic shoulder infection. C) Because of numbers of co-morbidities and huge bone loss on glenoid side, a simple resection arthroplasty was performed.From Bonnevialle et al.,<ref name=":24" /> with permission.|alt=]]
+[[File:Eor-2-104 2.jpg|thumb|''Figure 2.'' Radiographs (A and B) of an 86-year-old woman, with a loose implant secondary to chronic periprosthetic shoulder infection. C) Because of numbers of co-morbidities and huge bone loss on glenoid side, a simple resection arthroplasty was performed.From Bonnevialle et al.,<ref name=":24" /> with permission.|alt=|center]]<br />
 ==Sternoclavicular Joint Infection==
 Cover of StatPearls
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 ==References==

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 *Periprosthetic shoulder infection is rare but potentially devastating. The rate of periprosthetic shoulder infection is increased in cases of revision procedures, reverse shoulder implants and comorbidities. One specific type of periprosthetic shoulder infection is the occurrence of low-grade infections caused by non-suppurative bacteria such as Cutibaterium acnes or Staphylococcus epidemermidis.
-*Success of treatment depends on micro-organism identification, appropriate surgical procedures and antibiotic administration efficiency. Post-operative early periprosthetic shoulder infection can be treated with simple debridement, while chronic periprosthetic shoulder infection requires a one- or two-stage revision procedure. Indication for one-time exchange is based on pre-operative identification of a causative agent. Resection arthroplasty remains an option for low-demand patients or recalcitrant infection.
+*Treatment success depends on microorganism identification, appropriate surgical procedures and antibiotic administration efficiency. Post-operative early periprosthetic shoulder infection can be treated with simple debridement, while chronic periprosthetic shoulder infection requires a one- or two-stage revision procedure. Indication for one-time exchange is based on pre-operative identification of a causative agent. Resection arthroplasty remains an option for low-demand patients or recalcitrant infection.
 ==Key Words==
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 <ref name=":24">Bonnevialle N, Dauzères F, Toulemonde J, Elia F, Laffosse J-M, Mansat, P. Periprosthetic shoulder infection: an overview EFORT Open Rev. 2017;2:104–9</ref>
-While more than 66 000 prosthetic shoulder procedures were performed in 2011 in the United States, the rate of post-operative infection seems to remain stable with 0.98% of cases.<ref name=":25">Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg 2015;24:91-7</ref><ref>Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg 2015;24:741-6</ref><ref name=":11">Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20</ref> However, when infection occurs, this complication is always devastating with significant clinical and socioeconomic consequences.2 The rate is higher after revision surgery than after a primary procedure and reaches close to 5% in cases of reverse shoulder arthroplasty.<ref>Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2011;20:146-57</ref><ref name=":12">Morris BJ, O’Connor DP, Torres D, et al. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:161-6</ref> Patients undergoing primary reverse shoulder arthroplasty are found to have a six times greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty.<ref name=":12" /> Arthroplasties for trauma are more at risk of infection than those from other causes.<ref name=":12" /> Comorbidities such as coagulopathy, renal failure, diabetes, lupus erythematosus, rheumatoid arthritis, intra-articular steroid injections and corticosteroid therapy increase the risk of periprosthetic shoulder infection.<ref>Smucny M, Menendez ME, Ring D, Feeley BT, Zhang AL. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:747-53</ref> Periprosthetic shoulder infection is the major cause for revision within the first two post-operative years after an arthroplasty.<ref>Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP, Puig L. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471:3672-8</ref>
+While more than 66 000 prosthetic shoulder procedures were performed in 2011 in the United States, the rate of post-operative infection seems to remain stable with 0.98% of cases.<ref name=":25">Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg 2015;24:91-7</ref><ref>Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg 2015;24:741-6</ref><ref name=":11">Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20</ref> However, when infection occurs, this complication is always devastating with significant clinical and socioeconomic consequences. <ref name=":25" />''2'' The rate is higher after revision surgery than after a primary procedure and reaches close to 5% in cases of reverse shoulder arthroplasty.<ref>Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2011;20:146-57</ref><ref name=":12">Morris BJ, O’Connor DP, Torres D, et al. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:161-6</ref> Patients undergoing primary reverse shoulder arthroplasty are found to have a six times greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty.<ref name=":12" /> Arthroplasties for trauma are more at risk of infection than those from other causes.<ref name=":12" /> Comorbidities such as coagulopathy, renal failure, diabetes, lupus erythematosus, rheumatoid arthritis, intra-articular steroid injections and corticosteroid therapy increase the risk of periprosthetic shoulder infection.<ref>Smucny M, Menendez ME, Ring D, Feeley BT, Zhang AL. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:747-53</ref> Periprosthetic shoulder infection is the major cause for revision within the first two post-operative years after an arthroplasty.<ref>Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP, Puig L. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471:3672-8</ref>
 ==Microbiology==
 ===Prevention===
-Antibiotic prophylaxis is not specific to shoulder arthroplasty compared with other arthroplasties. Intravenous cephalosporine (2 g) administration is mandatory, given 30 minutes before the skin incision in many countries. However, some authors recommend a single 160 mg of gentamicin by intra-articular injection at the end of the procedure to reduce the risk of periprosthetic shoulder infection.<ref>Lovallo J, Helming J, Jafari SM, Owusu-Forfie A, Donovan S, Minnock C, Adib F. Intraoperative intra-articular injection of gentamicin: will it decrease the risk of infection in total shoulder arthroplasty? J Shoulder Elbow Surg 2014;23:1272-6</ref> Saltzman et al. have shown that pre-operative preparation of the surgical site with chlorhexidine gluconate and 70% isopropyl alcohol was more effective than iodine povacrylex and 74% isopropyl alcohol and povidone-iodine at eliminating overall bacteria, and that the two first ones were more effective than povidone-iodine regarding coagulase-negative Staphylococcus<ref name=":15">Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, Koh JL. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am. 2009;91:1949-53</ref>.
+Antibiotic prophylaxis is not specific to shoulder arthroplasty compared with other arthroplasties. In many countries intravenous cephalosporine (2 g) administration is mandatory 30 minutes before the skin incision. However, some authors recommend a single 160 mg of gentamicin by intra-articular injection at the end of the procedure to reduce the risk of periprosthetic shoulder infection.<ref>Lovallo J, Helming J, Jafari SM, Owusu-Forfie A, Donovan S, Minnock C, Adib F. Intraoperative intra-articular injection of gentamicin: will it decrease the risk of infection in total shoulder arthroplasty? J Shoulder Elbow Surg 2014;23:1272-6</ref> Saltzman et al. have shown that pre-operative preparation of the surgical site with chlorhexidine gluconate and 70% isopropyl alcohol was more effective than iodine povacrylex and 74% isopropyl alcohol and povidone-iodine to eliminate overall bacteria, and that the two first ones were more effective than povidone-iodine regarding coagulase-negative Staphylococcus<ref name=":15">Saltzman MD, Nuber GW, Gryzlo SM, Marecek GS, Koh JL. Efficacy of surgical preparation solutions in shoulder surgery. J Bone Joint Surg Am. 2009;91:1949-53</ref>.
 Hair removal is commonly performed before orthopaedic procedures and the use of razors is classically discouraged because micro-abrasions are created by shaving. However, removal of axillary hairs for shoulder surgery did not prove to have any effect on the cell-count of Cutibacterium acnes before surgical preparation.<ref>Marecek GS, Weatherford BM, Fuller EB, Saltzman MD. The effect of axillary hair on surgical antisepsis around the shoulder. J Shoulder Elbow Surg 2015;24:804-8</ref>
 ===Cutibacterium (Propionibacterium) acnes===
-Cutibacterium acnes (formerly Propionibacterium acnes) is a non-spore-forming, anaerobic, gram-positive bacillus. It is of low virulence and therefore can be a commensal in the lipid-rich sebaceous follicles and deep layers of the skin, conjunctiva, external auditory canal, respiratory tract and intestinal tract.<ref name=":0">Aubin GG, Portillo ME, Trampuz A, Corvec S. Propionibacterium acnes, an emerging pathogen: From acne to implant-infections, from phylotype to resistance. Med Mal Infect. 2014;44:241-50</ref><ref name=":1">Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg. 2013;22:505-11</ref> Cutibacterium acnes mostly colonises the pilosebaceous follicles in the skin of the upper-body, especially the head, neck, shoulders and axilla.<ref name=":2">Millett PJ, Yen YM, Price CS, Horan MP, van der Meijden OA, Elser F. Propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res. 2011;469:2824-30</ref><ref>Lorillou M, Martha B, Chidiac C, Ferry T, Lyon B, Joint Infection Study Group. Chronic Propionibacteriom acnes prosthesis joint infection manifesting as a large abscess with gas, without prosthesis loosening. BMJ Case Rep 2013; 2013:bcr2013201090</ref> Pathogenic activity of the organism has, however, been shown in conditions such as meningitis, septic arthritis, osteomyelitis, chronic prostatitis and sarcoidosis. Cutibacterium acnes expresses proteins required for cell-adherence, which are also antigenic and therefore capable of initiating an inflammatory response of the host’s innate immune system within the joint.<ref name=":0" /> Cutibacterium acnes also secretes cytotoxic chemicals and enzymes designed to degrade body tissues, which can be harmful within the shoulder capsule.<ref name=":0" /> Furthermore, Cutibacterium acnes is also able to secrete and live within an extracellular polysaccharide biofilm aiding joint colonisation and micro-colony formation, as well as avoid phagocytosis and survive macrophage engulfment.<ref name=":0" /> The combination of the bacterium’s upper-limb distribution and role in prosthetic joint infection is now forcing shoulder surgeons to consider Cutibacterium acnes as an ‘orthopaedic pathogen’.<ref name=":1" />
+Cutibacterium acnes (formerly Propionibacterium acnes) is a non-spore-forming, anaerobic, gram-positive bacillus. It is of low virulence and, therefore, can be a commensal in the lipid-rich sebaceous follicles and deep layers of the skin, conjunctiva, external auditory canal, respiratory tract and intestinal tract.<ref name=":0">Aubin GG, Portillo ME, Trampuz A, Corvec S. Propionibacterium acnes, an emerging pathogen: From acne to implant-infections, from phylotype to resistance. Med Mal Infect. 2014;44:241-50</ref><ref name=":1">Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg. 2013;22:505-11</ref> Cutibacterium acnes mostly colonises the pilosebaceous follicles in the skin of the upper-body, especially the head, neck, shoulders and axilla.<ref name=":2">Millett PJ, Yen YM, Price CS, Horan MP, van der Meijden OA, Elser F. Propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res. 2011;469:2824-30</ref><ref>Lorillou M, Martha B, Chidiac C, Ferry T, Lyon B, Joint Infection Study Group. Chronic Propionibacteriom acnes prosthesis joint infection manifesting as a large abscess with gas, without prosthesis loosening. BMJ Case Rep 2013; 2013:bcr2013201090</ref> However, pathogenic activity of the organism has been shown in conditions such as meningitis, septic arthritis, osteomyelitis, chronic prostatitis and sarcoidosis. Cutibacterium acnes expresses proteins required for cell-adherence, which are also antigenic and therefore capable of initiating an inflammatory response of the host’s innate immune system within the joint.<ref name=":0" /> Cutibacterium acnes also secretes cytotoxic chemicals and enzymes designed to degrade body tissues, which can be harmful within the shoulder capsule.<ref name=":0" /> Furthermore, Cutibacterium acnes is also able to secrete and live within an extracellular polysaccharide biofilm aiding joint colonisation and micro-colony formation, as well as avoid phagocytosis and survive macrophage engulfment.<ref name=":0" /> The combination of the bacterium’s upper-limb distribution and role in prosthetic joint infection is now forcing shoulder surgeons to consider Cutibacterium acnes as an ‘orthopaedic pathogen’.<ref name=":1" />
 ===Drug resistance===
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 ==Incidence and Prevalence==
-Over the past decade, Cutibacterium acnes has become increasingly recognised as a cause of infection in orthopaedic surgery, especially when prosthesis is involved.<ref>Crane JK, Hohman DW, Nodzo SR, Duquin TR. Antimicrobial susceptibility of Propionibacterium acnes isolates from shoulder surgery. Antimicrob Agents Chemother 2013;57:3424-6</ref> With regards to shoulder replacement surgery, one study reported infection rates for primary shoulder replacement to be less than 4% but, following reverse replacement, to be as high as 18%. In this study the most common bacteria identified were Staphylococcus epidermis and Cutibacterium acnes.<ref name=":9">Klatte TO, Junghans K, Al-Khateeb H, Rueger JM, Gehrke T, Kendoff D, Neumann J. Single-stage revision for peri-prosthetic shoulder infection: outcomes and results. Bone Joint J. 2013;95-B:391-5</ref> However, in a retrospective review over 7 years carried out in Canada, 80 patients were identified who underwent joint cultures after primary shoulder arthoplasty and Cutibacterium acnes was found to be the only significant infectious agent in 25% of participants, making it the most common pathogenic organism.<ref name=":4">Wang B, Toye B, Desjardins M, Lapner P, Lee C. A 7-year retrospective review from 2005 to 2011 of Propionibacterium acnes shoulder infections in Ottawa, Ontario, Canada. Diagn Microbiol Infect Dis. 2013 Feb;75:195-9</ref>  A study of periprosthetic joint infections after total shoulder arthroplasty (in the last 33 years) found that Staphylococcus was the dominant organism in the vast majority of cases, whereas, from 2001 – 2008, the incidence of Cutibacterium acnes was found to be almost as high as Staphylococcus.<ref name=":3">Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective.J Shoulder Elbow Surg. 2012;21:1534-41</ref> This increasing incidence could be the result of changes in the microbiology of shoulder infections, heightened awareness of the organism, better surveillance or improved laboratory diagnostic techniques<ref name=":3" /> Cutibacterium acnes appears to be a prominent aggressor and is becoming more prevalent.
+Over the past decade, Cutibacterium acnes has become increasingly recognised as a cause of infection in orthopaedic surgery, especially when prosthesis is involved.<ref>Crane JK, Hohman DW, Nodzo SR, Duquin TR. Antimicrobial susceptibility of Propionibacterium acnes isolates from shoulder surgery. Antimicrob Agents Chemother 2013;57:3424-6</ref> With regards to shoulder replacement surgery, one study reported infection rates for primary shoulder replacement to be less than 4%, but following reverse replacement, to be as high as 18%. In this study the most common bacteria identified were Staphylococcus epidermis and Cutibacterium acnes.<ref name=":9">Klatte TO, Junghans K, Al-Khateeb H, Rueger JM, Gehrke T, Kendoff D, Neumann J. Single-stage revision for peri-prosthetic shoulder infection: outcomes and results. Bone Joint J. 2013;95-B:391-5</ref> However, in a retrospective review over 7 years carried out in Canada, 80 patients were identified who underwent joint cultures after primary shoulder arthoplasty, and Cutibacterium acnes was found to be the only significant infectious agent in 25% of participants, making it the most common pathogenic organism.<ref name=":4">Wang B, Toye B, Desjardins M, Lapner P, Lee C. A 7-year retrospective review from 2005 to 2011 of Propionibacterium acnes shoulder infections in Ottawa, Ontario, Canada. Diagn Microbiol Infect Dis. 2013 Feb;75:195-9</ref>  A study of periprosthetic joint infections after total shoulder arthroplasty in the last 33 years found that Staphylococcus was the dominant organism in the vast majority of cases, whereas from 2001 - 2008 the incidence of Cutibacterium acnes was found to be almost as high as Staphylococcus.<ref name=":3">Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective.J Shoulder Elbow Surg. 2012;21:1534-41</ref> This increasing incidence could be the result of changes in the microbiology of shoulder infections, heightened awareness of the organism, better surveillance or improved laboratory diagnostic techniques<ref name=":3" /> Cutibacterium acnes appears to be a prominent aggressor and is becoming more prevalent.
 ==Risk Factors==

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 <ref name=":24">Bonnevialle N, Dauzères F, Toulemonde J, Elia F, Laffosse J-M, Mansat, P. Periprosthetic shoulder infection: an overview EFORT Open Rev. 2017;2:104–9</ref>
-While more than 66 000 prosthetic shoulder procedures were performed in 2011 in the United States, the rate of post-operative infection seems to remain stable with 0.98% of cases.<ref name=":25">Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg 2015;24:91-97</ref><ref>Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg 2015;24:741-6</ref><ref name=":11">Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20</ref> However, when infection occurs, this complication is always devastating with significant clinical and socioeconomic consequences.2 The rate is higher after revision surgery than after a primary procedure and reaches close to 5% in cases of reverse shoulder arthroplasty.<ref>Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2011;20:146-57</ref><ref name=":12">Morris BJ, O’Connor DP, Torres D, et al. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:161-6</ref> Patients undergoing primary reverse shoulder arthroplasty are found to have a six times greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty.<ref name=":12" /> Arthroplasties for trauma are more at risk of infection than those from other causes.<ref name=":12" /> Comorbidities such as coagulopathy, renal failure, diabetes, lupus erythematosus, rheumatoid arthritis, intra-articular steroid injections and corticosteroid therapy increase the risk of periprosthetic shoulder infection.<ref>Smucny M, Menendez ME, Ring D, Feeley BT, Zhang AL. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:747-53</ref> Periprosthetic shoulder infection is the major cause for revision within the first two post-operative years after an arthroplasty.<ref>Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP, Puig L. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471:3672-8</ref>
+While more than 66 000 prosthetic shoulder procedures were performed in 2011 in the United States, the rate of post-operative infection seems to remain stable with 0.98% of cases.<ref name=":25">Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg 2015;24:91-7</ref><ref>Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg 2015;24:741-6</ref><ref name=":11">Day JS, Lau E, Ong KL, Williams GR, Ramsey ML, Kurtz SM. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-20</ref> However, when infection occurs, this complication is always devastating with significant clinical and socioeconomic consequences.2 The rate is higher after revision surgery than after a primary procedure and reaches close to 5% in cases of reverse shoulder arthroplasty.<ref>Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2011;20:146-57</ref><ref name=":12">Morris BJ, O’Connor DP, Torres D, et al. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:161-6</ref> Patients undergoing primary reverse shoulder arthroplasty are found to have a six times greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty.<ref name=":12" /> Arthroplasties for trauma are more at risk of infection than those from other causes.<ref name=":12" /> Comorbidities such as coagulopathy, renal failure, diabetes, lupus erythematosus, rheumatoid arthritis, intra-articular steroid injections and corticosteroid therapy increase the risk of periprosthetic shoulder infection.<ref>Smucny M, Menendez ME, Ring D, Feeley BT, Zhang AL. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:747-53</ref> Periprosthetic shoulder infection is the major cause for revision within the first two post-operative years after an arthroplasty.<ref>Portillo ME, Salvadó M, Alier A, Sorli L, Martínez S, Horcajada JP, Puig L. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471:3672-8</ref>
 ==Microbiology==
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 Go to:
-== References ==
+==References==
 .
 Higginbotham TO, Kuhn JE. Atraumatic disorders of the sternoclavicular joint. J Am Acad Orthop Surg. 2005 Mar-Apr;13(2):138-45. [PubMed]