Outcomes after shoulder replacement: comparison between reverse and anatomic total shoulder arthroplasty.

BACKGROUND: Anatomic total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA) are increasingly common procedures employed to treat arthritic conditions. Although TSA is a widely accepted procedure for glenohumeral arthritis with intact rotator cuff, concerns about RTSA persist because of variable complication rates and outcomes. METHODS: This is a prospective, case-control study comparing outcomes and complications after TSA and RTSA. The study included 47 patients undergoing TSA for glenohumeral arthritis and 53 patients undergoing RTSA for rotator cuff tear arthropathy. Average clinical follow-up was more than 2 years in both groups. Major complications included infection, periprosthetic fracture, instability, glenoid loosening, and need for revision surgery. Patient outcome measures included the American Shoulder and Elbow Surgeons score, pain visual analog scale score, and goniometer-measured range of motion. Plain radiographs were reviewed to assess for degree of glenoid lucency in TSA and scapular notching in RTSA. RESULTS: At 2 years, there were no differences in rate of major complications (TSA, 15%; RTSA, 13%; P = .808) or revision surgeries (TSA, 11%; RTSA, 9%). Outcomes assessed by the American Shoulder and Elbow Surgeons score and visual analog scale were also similar between the 2 groups. TSA patients had greater external rotation than RTSA patients did (53° vs 38°; P = .001). Otherwise, forward flexion, abduction, and internal rotation were comparable in range of motion. CONCLUSIONS: TSA and RTSA have similar complication rates, need for revision, patient-reported outcomes, and range of motion at 2 years of follow-up. The use of side-by-side cohorts in this study allows standardized comparison between these 2 shoulder arthroplasty procedures.

Management of deep postoperative shoulder infections: is there a role for open biopsy during staged treatment?

BACKGROUND: Despite the gold standard treatment of 2-stage exchange arthroplasty, reinfection after periprosthetic shoulder infections and periarticular osteomyelitis can be as high as 37%. This study describes a protocol to detect persistent deep shoulder infection before revision arthroplasty. METHODS: Patients who presented with periprosthetic shoulder infections and osteomyelitis after previous surgery were treated with a standardized protocol of irrigation and debridement (I&D), removal of implants, antibiotic cement spacer placement, and pathogen-directed antibiotic therapy for 6 weeks. After completion of antibiotics and resolution of clinical symptoms, specimens were obtained from an open biopsy performed in the operating room, followed by revision arthroplasty at a later date if final cultures were without evidence of infection. If evidence of infection persisted, then another course of I&D and antibiotic treatment was performed. American Shoulder and Elbow Surgeon scores were used to evaluate clinical outcomes. RESULTS: Eighteen patients were included between 2005 and 2012. The most common pathogens isolated were Propionibacterium acnes (44%), Staphylococcus epidermidis (39%), and S aureus (22%). Four patients (22%) had evidence of persistent infection on specimens from open biopsy and required subsequent rounds of I&D before replantation. The infecting pathogen in 75% of patients with persistent infection was P acnes, and 38% of patients with P acnes infection had recurrence. Mean follow-up of 24 months showed no signs of recurrent infection in any patient and an average American Shoulder and Elbow Surgeon score of 71. CONCLUSION: Despite prior staged treatment for deep postoperative shoulder infections, specimens obtained from open biopsy before replantation detected a persistent infection rate of 22% in all patients and 38% in patients with P acnes infection, which may indicate a role for this procedure in the prevention of recurrent infections.