Shoulder:Sepsis of the Shoulder

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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.
  • 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.

Key Words

Infection; Arthroplasty; Shoulder; Cutibacterium acnes; Propionibacterium; Revision.

==Introduction==[1]

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.[2][3][4] 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.[5][6] Patients undergoing primary RSA are found to have a six times greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty.6 Arthroplasties for trauma are more at risk of infection than those from other causes.6 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.[7] PSI is the major cause for revision within the first two post-operative years after an arthroplasty.[8]

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 PSI.[9] Saltzman et al.[10] 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.

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.[11]

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.[12][13] Cutibacterium acnes mostly colonises the pilosebaceous follicles in the skin of the upper-body, especially the head, neck, shoulders and axilla.[14][15] 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.[12] Cutibacterium acnes also secretes cytotoxic chemicals and enzymes designed to degrade body tissues, which can be harmful within the shoulder capsule.[12] 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.[12] 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’.[13]

Drug resistance

Patient knowledge about Cutibacterium acnes is mostly limited to acne vulgaris, the skin infection present in the vast majority of young adults and teenagers.[12] Hormonal changes and genetics cause sebaceous gland inflammation, dysfunction and proliferation providing an environment for the opportunistic P. acnes.[12] The treatment of this skin condition with experimental courses of broad-spectrum antibiotics, often combined with poor compliance, is thought to be a contributor to antibiotic resistance.[14] Gold standard antibiotics such as penicillins, vancomycin, tetracyclines and erythromycin often eradicate the bacterium, however, over half of P. acnes cultures now carry resistance to more than one of the above antibiotics.[14]

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.[16] 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.[17] 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.[18] 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.[19] 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[19] Cutibacterium acnes appears to be a prominent aggressor and is becoming more prevalent.


Risk Factors

Recorded risk factors for Cutibacterium acnes infection are male gender, surgery of the upper body (especially the shoulder), increased duration of surgery and, interestingly, being the first surgery of the day. (3, [20] The predominance of Cutibacterium acnes in shoulder infections has been linked with the presence of the axillary lymph nodes.[21] A study that involved culturing the epidermis of wounds during revision surgery, found that 16 of the 18 males involved had Cutibacterium acnes infection whereas only 7 of the 12 female subjects tested positive.[22] Further studies have also found that male gender and prior prosthetic implants are significant risk factors for Cutibacterium acnes infection.[18][20] The male predisposition has been linked with the habitat of Cutibacterium acnes being in the hair follicles and therefore the upper body of males would harbour more of the bacterium.[20] Furthermore, males were found to have over 2.5 times higher risk than females after shoulder arthroplasty.[23] Interestingly, if shoulder arthroplasty was performed following trauma rather than elective surgery, the risk of infection was nearly 3 times higher. Reverse shoulder arthroplasty again was shown to increase the risk of infection with Cutibacterium acnes. Younger age was also identified as a risk factor, with each year of increasing age causing a risk reduction of 5%. Body Mass Index and diabetes mellitus, which are usually associated with increased risk of infection, were not found to be risk factors.[23] 

From the literature it is evident that patients most at risk of Cutibacterium acnes infection are young people, males, those who have undergone upper limb surgeries (especially reverse shoulder replacements) and those who have surgery following trauma.



Diagnosis

Despite laboratory and investigative advances, the diagnosis of shoulder infections due to relatively low-virulence organisms, like Cutibacterium acnes, remains difficult. The non-specific clinical presentation, inadequate culture performance and the inability to accurately interpret positive cultures mean that diagnosis can be delayed.[18] Research has found that inflammatory markers usually indicative of infection may not be raised in Cutibacterium acnes infection.[24] In 2014, in a clinic in the US, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were both raised in only 10% of patients who were identified as having Cutibacterium acnes infections of the shoulder.[24] In a further study, the sensitivities of CRP and ESR in the shoulder were found to be 42% and 16% respectively, whereas in the lower limbs the sensitivities for CRP and ESR were 88% and 75% respectively.[25] Thus, although the sensitivity and specificity of these inflammatory markers are strong in the lower limbs, they are poor indicators of post-operative shoulder infections.[24] These data fit well with the distribution of Cutibacterium acnes and its indolent nature. It has been further suggested that, due to its slow growth, Cutibacterium acnes needs longer culture times (up to two weeks), making it harder to spot.[25] Furthermore, lowering the threshold for diagnosis (concentration of neutrophils in the tissues) would increase sensitivity because of the low inflammatory behavior of Cutibacterium acnes.[25]

Clinical Presentation

A common assumption is that the origin of Cutibacterium acnes infection is in the dermis of the patient’s skin and that it travels from the surface to contaminate the surgical site.[22] Surface sterilisation before surgery does not, however, eradicate the bacterium as the organism actually resides deep in the sebaceous glands. Scalpel incisions slice through these follicles, allowing for seeding and leakage of the bacteria.[22] Innovative methods of sterilization may therefore be required to penetrate the dermis and reduce Cutibacterium acnes spread. Further, the need for intraoperative screening of wounds and prolonged cultures to assess the risk of developing a postoperative shoulder infection has been emphasised.[22] For low-grade Cutibacterium acnes shoulder infections, pain may be the only symptom, followed by stiffness with all other signs of infection being absent.[26] Periprosthetic joint infections can be extremely serious and may result in loss of normal function of the joint or even progress to sepsis.[17]

A study which focussed on postoperative pain, found that patients felt pain for an average of 3 months before diagnosis of Cutibacterium acnes infection and that the mean time from surgery to diagnosis was almost 2 years.[14] It was also suggested that the variance in the clinical presentation of shoulder infections may not only be due to the non-specific clinical manifestation of Cutibacterium acnes, but also due to co-infection with other bacteria within the surgical site.[14]

Treatment

Debridement

Debridement, irrigation and multiple deep samples may be proposed in cases of acute infection in order to save the prosthesis.[27] treated eight cases of acute infection with debridement and succeeded when it was performed within eight days after the diagnosis. They concluded that the earlier the debridement is done, the more effective it is in eradicating the infection. This procedure can be repeated, based on the patient’s response.[28] Moreover, mobile parts of the prosthesis may be exchanged during the procedure especially in case of reverse shoulder arthroplasty (glenosphere, polyethylene liner) providing better access for debridement. Then, an appropriate antibiotics regime is required for a minimum of four weeks.[29] 21 ,

28

[30] However, the rate of success reported in the literature is only in the range of 50% to 95%.[31]

28-29

Cement spacer

An antibiotic-loaded cement spacer can be used either permanently or as the first step of a two-stage revision procedure. In this case, it maintains the space and soft-tissue tension for re-implantation and theoretically releases antibiotics to decrease the growth of microorganisms. Antibiotic mean concentration peak is reached at day 1 and dramatically decreases during the following seven days.30 Levy et al31 described a ‘functional cement spacer’ model, which is made of a hemi-arthroplasty coated with cement. In their series of 14 patients initially chosen for a two-stage procedure, nine did not undergo a prosthesis re-implantation because of satisfactory clinical outcomes. On the other hand, Verhelst et al32 did not prove any difference between patients with a cement spacer and resection arthroplasty regarding infection control and clinical outcomes. Complications of the cement-spacer such as breakage, glenoid erosion or dislocation have been reported.32

One-stage revision arthroplasty

Based on the experience of knee and hip infection management, a single-stage exchange is proposed as a reasonable option when the infecting micro-organism is satisfactorily identified. The advantages are a reduced hospital stay, costs, period of antibiotic administration and the best clinical outcomes (Table 2).9,22,27,29,33-37 Klatte et al33 reported the outcomes of the largest single-centre series of 35 patients with a mean follow-up of 4.7 years. The authors excised infected tissues, thoroughly irrigated the wound using pulsatile lavage with polyhexanide before re-implantation and delivered specific intravenous antibiotherapy for an average of two weeks post-operatively. The success rate was more than 90%. No recurrence was observed in the series of Coste et al.,27 Ince et al34 and Cuff et al.35 The presence of a productive fistula seems not to be a contra-indication for many authors.33,36 Beekman et al36 performed a one-stage revision in 11 cases of RSAs, among which eight had a fistula, and achieved a success rate of 90%.

Two-stage revision arthroplasty

In a medically stable patient with a high demand, a two stage revision procedure is generally accepted (Table).22,27,29,33,38-40 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 CRP or IL-6 have been shown to be valuable to predict the eradication of infection and, so, the time of re-implantation.41,42 However, IL-6 seems to be normalised faster than CRP and allows earlier revision for better outcomes.41 An iterative irrigation and debridement could be proposed in case of persistent infection. For re-implantation, RSA 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 al43 reported that there is still uncertainty whether two-stage revision is superior to one-stage (

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. It has been shown that functional results are poor, but pain relief is achieved in more than 50% of cases.9,44 Rispoli et al.44 reported a mean active elevation of 70° at long-term follow-up after ‘anatomical’ shoulder arthroplasty removal. Verhelst et al32 demonstrated that preservation of the tuberosities is a predictive factor for better results, because it can avoid antero-superior subluxation of the humerus. In cases of RSA, Jacquot et al.21 did not improve functional outcomes after removal of the implant and identified a high rate of post-operative complications. Bone loss and soft-tissue impairment after such constrained prostheses could partly explain these findings. Despite Jacquot21 and Coste’s27 studies, the literature reports a high rate of infection eradication, reaching more than 90% of cases.9,27,29,32,44,45

References

1. 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. 2. Padegimas EM, Maltenfort M, Ramsey ML, et al. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg 2015;24:741-746. 3. D ay JS, Lau E, Ong KL, et al. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-1120. 4. 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;20:146-157. 5. M orris BJ, O’Connor DP, Torres D, et al. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:161-166. 6. R ichards J, Inacio MC, Beckett M, et al. Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty. Clin Orthop Relat Res 2014;472:2809-2815. 7. Smucny M, Menendez ME, Ring D, Feeley BT, Zhang AL. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:747-753. 8. Portillo ME, Salvadó M, Alier A, et al. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471:3672-3678. 9. S altzman MD, Marecek GS, Edwards SL, Kalainov DM. Infection after shoulder surgery. J Am Acad Orthop Surg 2011;19:208-218. 10. Patel A, Calfee RP, Plante M, Fischer SA, Green A. Propionibacterium acnes colonization of the human shoulder. J Shoulder Elbow Surg 2009;18:897-902. 11. L evy O, Iyer S, Atoun E, et al. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg 2013;22:505-511. 12. L ee MJ, Pottinger PS, Butler-Wu S, et al. Propionibacterium persists in the skin despite standard surgical preparation. J Bone Joint Surg [Am] 2014;96:1447-1450. 13. M accioni CB, Woodbridge AB, Balestro JC, et al. Low rate of Propionibacterium acnes in arthritic shoulders undergoing primary total shoulder replacement surgery using a strict specimen collection technique. J Shoulder Elbow Surg 2015;24:1206-1211. 14. H udek R, Sommer F, Kerwat M, et al. Propionibacterium acnes in shoulder surgery: true infection, contamination, or commensal of the deep tissue? J Shoulder Elbow Surg 2014;23:1763-1771. 15. Lovallo J, Helming J, Jafari SM, et al. Intraoperative intra-articular injection of gentamicin: will it decrease the risk of infection in total shoulder arthroplasty? J Shoulder Elbow Surg 2014;23:1272-1276. 16. 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-A:1949-1953. 17. Marecek GS, Weatherford BM, Fuller EB, Saltzman MD. The effect of axillary hair on surgical antisepsis around the shoulder. J Shoulder Elbow Surg 2015;24:804-808. 18. F ranceschini V, Chillemi C. Periprosthetic shoulder infection. Open Orthop J 2013;7:243-249. 19. H ärle A. Infection management in total hip replacement. Arch Orthop Trauma Surg 1989;108:63-71. 20. F rangiamore SJ, Saleh A, Grosso MJ, et al. Early versus late culture growth of Propionibacterium acnes in revision shoulder arthroplasty. J Bone Joint Surg [Am] 2015;97:1149-1158. 21. Jacquot A, Sirveaux F, Roche O, et al. Surgical management of the infected reversed shoulder arthroplasty: a French multicenter study of reoperation in 32 patients. J Shoulder Elbow Surg 2015;24:1713-1722. 22. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res 2001;382:206-216. 23. D ilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg [Am] 2014;96:1952-1958. 24. Zhang AL, Feeley BT, Schwartz BS, Chung TT, Ma CB. Management of deep postoperative shoulder infections: is there a role for open biopsy during staged treatment? J Shoulder Elbow Surg 2015;24:e15-e20. 25. N iskanen RO, Korkala O, Pammo H. Serum C-reactive protein levels after total hip and knee arthroplasty. J Bone Joint Surg [Br] 1996;78-B:431-433. 26. Parvizi J, Zmistowski B, Berbari EF, et al. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011;469:2992-2994. 27. Coste JS, Reig S, Trojani C, et al. The management of infection in arthroplasty of the shoulder. J Bone Joint Surg [Br] 2004;86-B:65-69. 28. Duncan SF, Sperling JW. Treatment of primary isolated shoulder sepsis in the adult patient. Clin Orthop Relat Res 2008;466:1392-1396. 29. Romanò CL, Borens O, Monti L, Meani E, Stuyck J. What treatment for periprosthetic shoulder infection? Results from a multicentre retrospective series. Int Orthop 2012;36:1011-1017. 30. Anagnostakos K, Wilmes P, Schmitt E, Kelm J. Elution of gentamicin and vancomycin from polymethylmethacrylate beads and hip spacers in vivo. Acta Orthop 2009;80:193-197. 31. L evy JC, Triplet J, Everding N. Use of a functional antibiotic spacer in treating infected shoulder arthroplasty. Orthopedics 2015;38:e512-e519. 32. Verhelst L, Stuyck J, Bellemans J, Debeer P. Resection arthroplasty of the shoulder as a salvage procedure for deep shoulder infection: does the use of a cement spacer improve outcome? J Shoulder Elbow Surg 2011;20:1224-1233. 33. Klatte TO, Junghans K, Al-Khateeb H, et al. Single-stage revision for periprosthetic shoulder infection: outcomes and results. Bone Joint J 2013;95-B:391-395. 34. Ince A, Seemann K, Frommelt L, Katzer A, Loehr JF. One-stage exchange shoulder arthroplasty for peri-prosthetic infection. J Bone Joint Surg [Br] 2005;87-B: 814-818. 35. Cuff DJ, Virani NA, Levy J, et al. The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics. J Bone Joint Surg [Br] 2008;90-B:336-342. 36. Beekman PD, Katusic D, Berghs BM, Karelse A, De Wilde L. One-stage revision for patients with a chronically infected reverse total shoulder replacement. J Bone Joint Surg [Br] 2010;92-B:817-822. 37. G rosso MJ, Sabesan VJ, Ho JC, Ricchetti ET, Iannotti JP. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elbow Surg 2012;21:754-758. 38. S trickland JP, Sperling JW, Cofield RH. The results of two-stage reimplantation for infected shoulder replacement. J Bone Joint Surg [Br] 2008;90-B: 460-465. 39. O rtmaier R, Resch H, Hitzl W, et al. Treatment strategies for infection after reverse shoulder arthroplasty. Eur J Orthop Surg Traumatol 2014;24:723-731. 40. S abesan VJ, Ho JC, Kovacevic D, Iannotti JP. Two-stage reimplantation for treating prosthetic shoulder infections. Clin Orthop Relat Res 2011;469:2538-2543. 41. Coffey MJ, Ely EE, Crosby LA. Treatment of glenohumeral sepsis with a commercially produced antibiotic-impregnated cement spacer. J Shoulder Elbow Surg 2010;19:868-873. 42. Villacis D, Merriman JA, Yalamanchili R, et al. Serum interleukin-6 as a marker of periprosthetic shoulder infection. J Bone Joint Surg [Am] 2014;96:41-45. 43. S hirwaiker RA, Springer BD, Spangehl MJ, et al. A clinical perspective on musculoskeletal infection treatment strategies and challenges. J Am Acad Orthop Surg 2015;23:S44-S54. 44. R ispoli 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- B:1184-1187. 45. Weber P, Utzschneider S, Sadoghi P, et al. Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature. Int Orthop 2011;35:365-373. 46. Atkins BL, Athanasou N, Deeks JJ, et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS

Collaborative Study Group J Clin Microbiol 1998;36:2932-2939.

  1. ↑ Bonnevialle N, Dauzères F, Toulemonde J, Elia F, Laffosse J-M, Mansat, P. Periprosthetic shoulder infection: an overview EFORT Open Rev. 2017;2(4):104–109
  2. ↑ 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
  3. ↑ Padegimas EM, Maltenfort M, Ramsey ML, et al. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elbow Surg 2015;24:741-746
  4. ↑ Day JS, Lau E, Ong KL, et al. Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015. J Shoulder Elbow Surg 2010;19:1115-1120
  5. ↑ 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;20:146-157
  6. ↑ Morris BJ, O’Connor DP, Torres D, et al. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:161-166
  7. ↑ Smucny M, Menendez ME, Ring D, Feeley BT, Zhang AL. Inpatient surgical site infection after shoulder arthroplasty. J Shoulder Elbow Surg 2015;24:747-753
  8. ↑ Portillo ME, Salvadó M, Alier A, et al. Prosthesis failure within 2 years of implantation is highly predictive of infection. Clin Orthop Relat Res 2013;471:3672-3678
  9. ↑ Lovallo J, Helming J, Jafari SM, et al. Intraoperative intra-articular injection of gentamicin: will it decrease the risk of infection in total shoulder arthroplasty? J Shoulder Elbow Surg 2014;23:1272-1276
  10. ↑ 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(8):1949-53
  11. ↑ Marecek GS, Weatherford BM, Fuller EB, Saltzman MD. The effect of axillary hair on surgical antisepsis around the shoulder. J Shoulder Elbow Surg 2015;24:804-808
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 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 Jun;44(6):241-50 2014;44(6):241-50
  13. ↑ 13.0 13.1 Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, et al. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elbow Surg. 2013;22(4):505-11
  14. ↑ 14.0 14.1 14.2 14.3 14.4 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 Oct;469(10):2824-30
  15. ↑ 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 Dec 4;2013:bcr2013201090
  16. ↑ Crane JK, Hohman DW, Nodzo SR, Duquin TR. Antimicrobial susceptibility of Propionibacterium acnes isolates from shoulder surgery. Antimicrob Agents Chemother 2013;57(7):3424-6
  17. ↑ 17.0 17.1 Klatte TO, Junghans K, Al-Khateeb H, Rueger JM, Gehrke T, Kendoff D, et al. Single-stage revision for peri-prosthetic shoulder infection: outcomes and results. Bone Joint J. 2013;95-B(3):391-5
  18. ↑ 18.0 18.1 18.2 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(2):195-9
  19. ↑ 19.0 19.1 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(11):1534-41
  20. ↑ 20.0 20.1 20.2 Patel A, Calfee RP, Plante M, Fischer SA, Green A. Propionibacterium acnes colonization of the human shoulder. J Shoulder Elbow Surg. 2009;18(6):897-902
  21. ↑ Achermann Y, Sahin F, Schwyzer HK, Kolling C, Wust J, Vogt M. Characteristics and outcome of 16 periprosthetic shoulder joint infections. Infection. 2013;41(3):613-20
  22. ↑ 22.0 22.1 22.2 22.3 Matsen FA, 3rd, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R. Origin of propionibacterium in surgical wounds and evidence-based approach for culturing propionibacterium from surgical sites. J Bone Joint Surg Am. 2013 Dec 4;95(23):e1811-7
  23. ↑ 23.0 23.1 Richards J, Inacio MC, Beckett M, Navarro RA, Singh A, Dillon MT, et al. Patient and Procedure-specific Risk Factors for Deep Infection After Primary Shoulder Arthroplasty. Clin Orthop Relat Res. 2014 Sep;472(9):2809-15
  24. ↑ 24.0 24.1 24.2 Mook WR, Garrigues GE. Diagnosis and Management of Periprosthetic Shoulder Infections. J Bone Joint Surg Am. 2014 4;96(11):956-965
  25. ↑ 25.0 25.1 25.2 Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg Am. 2014 19;96(6):442-7
  26. ↑ Schneeberger AG, Yian E, Steens W. Injection-induced low-grade infection of the shoulder joint: preliminary results. Arch Orthop Trauma Surg. 2012;132(10):1387-92
  27. ↑ Coste et al.Coste JS, Reig S, Trojani C, et al. The management of infection in arthroplasty of the shoulder. J Bone Joint Surg Br. 2004;86(1):65-9
  28. ↑ Duncan SF, Sperling JW. Treatment of primary isolated shoulder sepsis in the adult patient. Clin Orthop Relat Res 2008;466:1392-1396
  29. ↑ Jacquot A, Sirveaux F, Roche O, et al. Surgical management of the infected reversed shoulder arthroplasty: a French multicenter study of reoperation in 32 patients. J Shoulder Elbow Surg 2015;24:1713-1722
  30. ↑ Romanò CL, Borens O, Monti L, Meani E, Stuyck J. What treatment for periprosthetic shoulder infection? Results from a multicentre retrospective series. Int Orthop 2012;36:1011-1017
  31. ↑ Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res 2001;382:206-216
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