The Choice of Antibiotic Prophylaxis Influences the Infection Reoperation Rate in Primary Shoulder Arthroplasty: Analysis From the Swedish Shoulder Arthroplasty Register.

BACKGROUND: Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacteriumacnes , benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection. QUESTIONS/PURPOSES: After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin? METHODS: Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been estimated that more than 90% of all primary shoulder arthroplasties and shoulder reoperations are reported to the register. The age of the study population ranged between 16 and 98 years; the mean age at the primary surgery was 70 ± 10 years for the entire cohort, with a mean age of 67 ± 10 years and 72 ± 9 years for men and women, respectively. The mean observation period was 989 ± 669 days. From 2013 to 2019, there was a clear change in prophylaxis; in particular, the use of the combination of benzylpenicillin and cloxacillin increased dramatically and the use of cloxacillin alone decreased. Clindamycin prophylaxis increased moderately. The primary study endpoint was reported reoperation for infection. In the register, this is defined as repeat procedures of any kind, including biopsy, lavage of the joint, or revision, defined as secondary surgery in which a component was exchanged, removed, or added. To compare the reoperation rate in relation to the different antibiotics used, which changed over time, we controlled for age, gender, previous surgery, cement fixation, and arthroplasty type using a Cox proportional hazards model. RESULTS: When adjusting for age, gender, previous surgery, cement fixation, and arthroplasty type, cloxacillin prophylaxis was associated with an increased relative risk of reoperation for infection compared with the combination of cloxacillin and benzylpenicillin (hazard ratio [HR] 2.40 [95% confidence interval (CI) 1.35 to 4.25]; p = 0.003) and compared with clindamycin alone (HR 1.78 [95% CI 1.11 to 2.85]; p = 0.02). No difference was found between the cloxacillin and benzylpenicillin combination and clindamycin (HR 0.74 [95% CI 0.42 to 1.32]; p = 0.31). CONCLUSION: Our results indicate that prophylaxis against C. acnes may be warranted in shoulder arthroplasty. Because the absolute number of infections was low and infections could have been underreported to the register, our results should be interpreted with caution. There is no available information about the causative microorganisms. The study lays the groundwork for further investigations of antibiotic prophylaxis regimens in shoulder arthroplasty. Because large randomized controlled trials would be impractical to perform, prospective register-based randomized controlled studies might be a viable method. LEVEL OF EVIDENCE: Level Ⅲ, therapeutic study.

Neither critical shoulder angle nor acromion index were related with specific pathology 20 years later!

PURPOSE: The critical shoulder angle (CSA) and the acromion index (AI) are measurements of acromial shape reported as predictors of degenerative rotator cuff tears (RCT) and glenohumeral osteoarthritis (GH OA). Whether they are the cause or effect of shoulder pathologies is uncertain since pre-morbid radiographs most often are lacking. The main aim of this study was to investigate if CSA or AI were related to the development of RCT or GH OA after 20 years. A secondary aim was to investigate if the CSA and AI had changed over time. METHODS: In the hospital archive, 273 preoperative plain shoulder radiographs were found of patients scheduled for elective surgery other than cuff repair and arthroplasty. Forty-five images fulfilled the strict criteria published by Suter and Henninger (2015) and were used to measure CSA and AI with two independent assessors. No patient had any sign of OA in the index radiographs or any information in the medical records indicating RCT. After a median of 20 (16-22) years, 30 of these patients were radiologically re-examined with bilateral true frontal views and ultrasound of the rotator cuff. There were 19 men (20 study shoulders) and 11 females (12 study shoulders). RESULTS: Mean age at follow-up was 56 (32-78) years. There was no correlation between CSA (r = 0.02) (n.s) or AI (r = - 0.13) (n.s) in the primary radiographs and OA at follow-up. Nor was any correlation found between index CSA (r = 0.12) (n.s) or AI (r = - 0.13) (n.s) and RCT at follow-up. Mean difference in CSA was - 1.7 (- 10-3) degrees and mean AI difference was - 0.04 (- 0.13-0.09) between the first and the second radiographs, 20 years later. Bilaterally, mean CSA was 32 and AI 0.61 at follow-up. CONCLUSION: In this study, no correlation between the CSA, AI and development of OA or RCT could be found. The mean CSA and AI decreased over a 20-year period but the difference was very small. No difference was found between the study shoulders and the contralaterals. These findings question previously reported etiological associations between scapular anatomy and the development of OA or RCT and thereby the use of these calculations as the basis of treatment. LEVEL OF EVIDENCE: III.

Solely sutures is a reliable fixation for valgus-impacted proximal humeral fractures.

PURPOSE: Valgus impacted proximal humeral fractures with substantial displacement may severely compromise shoulder function and open reduction can therefore be considered. Internal fixation hardware may eventually however constitute problems. In a small subset of these fractures, in which there is no medial comminution and intact blood supply it is possible to use a least possible fixation method with solely sutures through the tendons of the rotator cuff and the shaft as described by Bigliani 1990. The aim of the present study was to investigate the outcome of this fixation method in a retrospective series of patients. METHODS: Twenty-seven patients, 23 women and 4 men, with a mean age of 66 years (53-83) and minimum follow-up time of 2 years (2-11 years) accepted follow-up with standard shoulder radiographs and 22 were examined with Oxford Shoulder Score (OSS), Constant-Murley (CM) shoulder score and Numeric Rating Scale for pain (NRS). Reoperations or adverse events were recorded. RESULTS: The median OSS was 45 (range 5-48) and CM 63 (range 21-98). The relative CM score was 81% of the uninjured side and median NRS 0 (range 0-5). No reoperations were undertaken. One patient had a complete avascular necrosis (AVN), 3 patients had a partial AVN of the humeral head and two a partial resorption of the greater tuberosity. CONCLUSION: The use of sutures only for fixation of displaced valgus-impacted proximal humeral fractures provided a relatively reliable outcome with good functional scores and no reoperations. There appears to be no need for the use of hardware for fixation of this rare subset of fractures.

Good outcome after repair of trauma-related anterosuperior rotator cuff tears-a prospective cohort study.

BACKGROUND: Anterosuperior rotator cuff tears with a displaced long head of the biceps tendon are most often trauma-related, and patients with these conditions often present with severe pain and shoulder dysfunction. Repair of the subscapularis and supraspinatus and a biceps tenodesis or a tenotomy are the recommended treatments based on retrospective studies. The aim of this study was to prospectively evaluate clinical and structural treatment outcome in a cohort of trauma-related anterosuperior injuries in patients with previously healthy shoulders. MATERIALS AND METHODS: Patients seeking care for a suspected rotator cuff injury after shoulder trauma were screened according to a protocol including clinical examination, baseline scoring with Western Ontario Rotator Cuff Index (WORC) and numeric rating scale of pain, ultrasound, and magnetic resonance imaging (MRI). Those with anterosuperior injuries were offered surgical treatment, structured postoperative physiotherapy, and inclusion in the present study with 1-year follow-up, including MRI, baseline scores, Constant-Murley score, and Patient Global Impression of Change. Thirty-three patients (78% men) with a mean age of 59 (40-76) years were included. RESULTS: All patients had a biceps pulley lesion, a displaced biceps tendon, and incomplete full-thickness subscapularis and supraspinatus tears. Six patients declined surgery. At follow-up, the operated patients reached a median WORC score of 86% and a median change from baseline to follow-up of 50% (P = .0001). Pain decreased (P = .0001) at rest, at night, and during activity. The median Constant-Murley score was 86% of the contralateral nonoperated shoulder, 58% of the contralateral abduction strength recovered after surgery, and 86% reported that they were recovered or much improved. All repairs and tenodeses healed except for 2 supraspinatus tendons. The 6 nonoperated patients reached a median WORC score of 90, a change in the median value from baseline to follow-up of 31, but reported more pain, and a smaller proportion considered themselves as recovered or much improved. In all patients, the 1-year MRIs had signal changes in the upper muscular portion of subscapularis, consistent with fatty infiltration, regardless of operative or nonoperative treatment. CONCLUSION: Anterosuperior rotator cuff injury with an associated pulley lesion and displaced long head of the biceps tendon may be treated successfully with surgery as the majority of patients in our cohort clinically recovered or were much improved without pain after a year. With a 1-year perspective, nonoperatively treated patients may also reach a reasonable clinical outcome. Independently of treatment or tendon healing, residual subscapularis muscle injury was seen, which may have long-term implications.

Surgery and physiotherapy were both successful in the treatment of small, acute, traumatic rotator cuff tears: a prospective randomized trial.

BACKGROUND: Previous randomized trials on cuff repair have included mainly degenerative tears, but studies on acute traumatic tears are lacking. We aimed to compare early surgical repair with nonoperative treatment for traumatic supraspinatus tears. METHODS: We did a 2-center randomized controlled trial of patients with small rotator cuff tears mainly involving supraspinatus, comparing surgical repair (n = 32) and physiotherapy (n = 26). The primary outcome was a group difference in the Constant-Murley score at 12-month follow-up. Secondary outcomes were differences in the Western Ontario Rotator Cuff index, pain (Numerical Rating Scale 0-10), and Euro quality-of-life-visual analog scale. We used magnetic resonance imaging to assess retear rate, tear progression, fatty infiltration, and atrophy. RESULTS: The mean age was 59.7 years (range, 44-77 years), median sagittal tear size was 9.7 mm (range, 4-21 mm), and baseline characteristics were well balanced between the 2 groups. The repair group had a median Constant-Murley of 83 (25 quartile range [QR]) and the physiotherapy group 78 (QR, 22) at 12 months, with the between-group difference in medians of 4.5 (-5 to 9, 95% confidence interval; P = .68). The corresponding values for the Western Ontario Rotator Cuff index were 91% (QR, 24) vs. 86% (QR, 24), with the between-group difference of 5.0 (-4 to 9, 95% confidence interval; P = .62). There was no difference in Numerical Rating Scale or in Euro quality-of-life-visual analog scale. Retear was found in 6.5% of repaired patients and tear progression >5 mm in 29.2% of unrepaired patients. CONCLUSIONS: We found no significant differences in clinical outcomes between cuff repair and nonoperative treatment at 12-month follow-up. Approximately one third of unrepaired patients had a tear enlargement of more than 5 mm.

Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up.

BACKGROUND: Treatment options for irreparable cuff tears include synthetic interposition grafts, but whether such grafts can maintain acceptable shoulder function and prevent cuff tear arthropathy in the long-term is unknown. METHOD: This was a retrospective case series of 13 consecutive patients treated with a synthetic interposition graft made of Dacron (DuPont, Wilmington, DE, USA). Patients were examined with bilateral ultrasonography, bilateral x-ray imaging, Constant-Murley score, and Western Ontario Rotator Cuff score. RESULTS: After a mean of 18 years (range, 17-20 years), 1 patient had died, and 12 were available for x-ray imaging and 10 also for ultrasonography and clinical scores. Cuff tear arthropathy (Hamada grade ≥2) had developed in 9 of 12 (75%; 95% confidence interval, 43%-95%), including 3 patients operated on with arthroplasty in the follow-up period. The mean absolute Constant-Murley score was 46 (standard deviation, 26), and the mean Western Ontario Rotator Cuff score was 59 (standard deviation, 20). In 7 of 10 patients (70%) with available ultrasonography, the graft was interpreted as not intact. All patients had a contralateral full-thickness tear, and 7 of 12 patients (58 %; 95% confidence interval, 28%-85%) had contralateral cuff tear arthropathy. The number of patients with cuff tear arthropathy was not significantly different between the shoulder repaired with a Dacron graft and the contralateral shoulder (P = .667). CONCLUSION: These results indicate that a synthetic interposition graft with screw fixation could not prevent cuff tear arthropathy and preserve cuff integrity in a long-term perspective.

Patients with a long-standing cuff tear in one shoulder have high rates of contralateral cuff tears: a study of patients with arthroscopically verified cuff tears 22 years ago.

BACKGROUND: The prevalence of contralateral full-thickness cuff tears (FTTs) and cuff tear arthropathy (CTA) is presumed to be higher in patients with long-standing cuff tears than in those with newly diagnosed tears, but data are currently lacking. METHODS: Sixty-one patients with 38 partial and 23 full-thickness tears of 1 shoulder at arthroscopy were examined with bilateral radiographs, ultrasound, and the Constant-Murley score at a mean of 22 years (range, 21-25 years) after arthroscopy. RESULTS: The overall rate of full-thickness tears in the contralateral shoulder was 50.8%. In patients with a full-thickness tear and CTA (Hamada grade ≥2) in the index shoulder at follow-up, 18 of 20 (90%) had a contralateral full-thickness tear and 4 of 20 (20%) had CTA. In patients with a partial tear in the index shoulder at follow-up, 3 of 22 (13.6%) had a contralateral full-thickness tear and none had CTA. CTA changes were more common in patients with FTT and a previous acromioplasty (P < .001). The correlation between shoulders was 0.72 for the number of tendons with FTT (P <.001), 0.31 for the Hamada grade (P = .016), and 0.65 for the absolute Constant-Murley score (P <.001). The number of tendons with a full-thickness tear at follow-up was a risk factor (odds ratio, 3.28; 95% confidence interval, 1.67-6.44; P <.001) for a contralateral full-thickness tear. Patients with a partial or full-thickness tear in the contralateral shoulder had pain in 39.2% of cases. CONCLUSION: Patients with long-standing cuff tears have high rates of contralateral cuff tears. The severity of the condition is strongly correlated between the shoulders. Patients with full-thickness tears and a previous acromioplasty have a significantly higher frequency of CTA than patients with cuff tears who had not undergone a previous acromioplasty.

Specific exercises for subacromial pain.

Background and purpose - We have previously shown that specific exercises reduced the need for surgery in subacromial pain patients at 1-year follow-up. We have now investigated whether this result was maintained after 5 years and compared the outcomes of surgery and non-surgical treatment. Patients and methods - 97 patients were included in the previously reported randomized study of patients on a waiting list for surgery. These patients were randomized to specific or unspecific exercises. After 3 months of exercises the patients were asked if they still wanted surgery and this was also assessed at the present 5-year follow-up. The 1-year assessment included Constant-Murley score, DASH, VAS at night, rest and activity, EQ-5D, and EQ-VAS. All these outcome assessments were repeated after 5 years in 91 of the patients. Results - At the 5-year follow-up more patients in the specific exercise group had declined surgery, 33 of 47 as compared with 16 of 44 (p = 0.001) in the unspecific exercise group. The mean Constant-Murley score continued to improve between the 1- and 5-year follow-ups in both surgically and non-surgically treated groups. On a group level there was no clinically relevant change between 1 and 5 years in any of the other outcome measures regardless of treatment. Interpretation - This 5-year follow-up of a previously published randomized controlled trial found that specific exercises reduced the need for surgery in patients with subacromial pain. Patients not responding to specific exercises may achieve similar good results with surgery. These findings emphasize that a specific exercise program may serve as a selection tool for surgery.

Clinical and structural outcome 22 years after acromioplasty without tendon repair in patients with subacromial pain and cuff tears.

BACKGROUND: Long-term results regarding tear progression, arthropathy, and clinical scores of unrepaired rotator cuff tears are largely unknown. This study investigated whether the condition of the glenohumeral joint and rotator cuff had deteriorated at a minimum of 20 years after an acromioplasty without cuff repair and assessed the clinical results. METHODS: A retrospective analysis was conducted of a consecutive series of patients treated between 1989 and 1993 with acromioplasty without cuff repair due to subacromial pain and cuff tear. At follow-up results of x-ray, ultrasonography, and clinical scores were recorded. RESULTS: At a mean of 22 years (range, 21-25 years), 69 patients were available for follow-up with Western Ontario Rotator Cuff Index, Constant-Murley (CM) score, x-ray, and ultrasonography. Mean age at operation was 49 years (range, 19-69 years). There were 45 partial-thickness tears (PTT) and 24 full-thickness tears (FTT). Of 23 patients with FTT, 17 (74% with x-ray) had developed cuff tear arthropathy (Hamada ≥2) and 20 (87% with ultrasonography) had progressed in tear size. Mean relative CM in patients with FTT and cuff tear arthropathy was 62 (standard deviation [SD], 27), and the mean WORC was 58% (SD, 26%). In the 43 PTT patients, 3 (7% with x-ray) had developed cuff tear arthropathy and 16 (42% with ultrasonography) had tear progression. With PTT at follow-up, the mean relative CM was 101 (SD, 22), and the mean WORC was 81% (SD, 20%). CONCLUSIONS: After an acromioplasty, most unrepaired full-thickness tears will, in long-term, increase in size and be accompanied by cuff tear arthropathy changes. Most partial thickness tears remain unchanged; cuff tear arthropathy is rare, and clinical scores generally good.