The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Patient and Surgeon Variables Associated With a Diagnosis of Shoulder Periprosthetic Joint Infection

Document Type : RESEARCH PAPER

Authors
Richard Feng 1
Kacie Mitchell 1
Shyam S. Ramachandran 1
Melle Broekman 2
Anthony Johnson 3
David Ring 2
Sina Ramtin 2
1 Texas A&M Health Science Center, School of Medicine, Dallas, TX, USA
2 Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, TX, USA
3 Orthopaedic Surgery Residency Program, Dell Medical School at the University of Texas, Austin, TX, USA
10.22038/abjs.2024.80401.3675
Abstract
Objectives: There is no consensus reference standard for diagnosing prosthetic shoulder joint infection (PJI). There may be inadequate distinction between colonization and infection. It is not clear that culture of a common shoulder commensal organism can account for unexpected pain or stiffness after shoulder arthroplasty. In this survey-based experiment, we asked: 1) What patient and surgeon variables are associated with diagnosis of shoulder PJI? And 2) What is the surgeon interobserver agreement for diagnosis of shoulder PJI?
Methods: One hundred seven members of the Science of Variation Group reviewed ten hypothetical patient scenarios with five randomized variables: examination findings, serum markers, synovial fluid markers, histological assessment, and organism cultured from deep tissue specimens. Participants diagnosed the presence or absence of shoulder PJI. Mixed multilevel logistic regression sought variables associated with PJI diagnosis. Interobserver agreement was measured with Fleiss kappa.
Results: Surgeon diagnosis of shoulder PJI was independently associated with deep tissue culture growth of C. acnes (OR=235 [95% CI 19 to 2933]; P < 0.01), S. epidermidis (OR=147 [95% CI 8.4 to 2564]; P < 0.01), and S. aureus (OR=110 [95% CI 6.9 to 1755]; P < 0.01) much more so than presence of a sinus tract on examination (OR=43 [95% CI 3.7 to 505]; P < 0.01), inflammatory histology (OR=15 [95% CI 4.0 to 58]; P < 0.01), inflammatory synovial fluid markers (OR=13 [95% CI 3.9 to 45]; P < 0.01), and serum inflammatory markers (OR=5.8  [95% CI 2.0 to 17]; P < 0.01). The reliability of surgeon diagnosis for shoulder PJI was poor (Fleiss kappa = 0.013 [95% CI -0.0039 to 0.031]).
Conclusion: The observation that surgeons may not adequately distinguish colonization and infection – considering any positive culture as an infection – combined with the low reliability of diagnosis observed, suggests possible overdiagnosis and overtreatment of shoulder PJI.  
        Level of evidence: IV
Keywords
Arthroplasty
C. Acnes
Colonization
Infection
Prosthetic joint infection
Shoulder
Subjects
  1. Malone M. The microbiome of diabetic foot ulcers and the role of biofilms. In: The Microbiology of Skin, Soft Tissue, Bone and Joint Infections. 2th ed. Kon K, Rai M, eds. Academic Press: UK; 2017.
  2. Robinson J. Colonization and infection of the respiratory tract: What do we know? Paediatr Child Health. 2004; 9(1):21-24. doi:10.1093/pch/9.1.21.
  3. Bowler PG, Duerden BI, Armstrong DG. Wound Microbiology and Associated Approaches to Wound Management. Clin Microbiol Rev. 2001; 14(2):244-269. doi:10.1128/CMR.14.2.244-269.2001.
  4. Falconer TM, Baba M, Kruse LM, et al. Contamination of the Surgical Field with Propionibacterium acnes in Primary Shoulder Arthroplasty. JBJS. 2016; 98(20):1722. doi:10.2106/JBJS.15.01133.
  5. Hudek R, Brobeil A, Brüggemann H, Sommer F, Gattenlöhner S, Gohlke F. Cutibacterium acnes is an intracellular and intra-articular commensal of the human shoulder joint. J Shoulder Elbow Surg. 2021; 30(1):16-26. doi:10.1016/j.jse.2020.04.020.
  6. Qiu B, Al K, Pena-Diaz AM, et al. Cutibacterium acnes and the shoulder microbiome. J Shoulder Elbow Surg. 2018; 27(10):1734-1739. doi:10.1016/j.jse.2018.04.019.
  7. Singh AM, Sethi PM, Romeo AA, Anakwenze OA, Abboud JA, Namdari S. Strategies to decolonize the shoulder of Cutibacterium acnes: a review of the literature. J Shoulder Elbow Surg. 2020; 29(4):660-666. doi:10.1016/j.jse.2019.11.037.
  8. Ahsan ZS, Somerson JS, Matsen FAI. Characterizing the Propionibacterium Load in Revision Shoulder Arthroplasty: A Study of 137 Culture-Positive Cases. J Bone Joint Surg Am. 2017; 99(2):150. doi:10.2106/JBJS.16.00422.
  9. Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and Management of Prosthetic Joint Infection: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013; 56(1):e1-e25. doi:10.1093/cid/cis803.
  10. 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(11):2992-2994. doi:10.1007/s11999-011-2102-9.
  11. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J. 2013; 95-B(11):1450-1452. doi:10.1302/0301-620X.95B11.33135.
  12. Tubb CC, Polkowksi GG, Krause B. Diagnosis and Prevention of Periprosthetic Joint Infections. J Am Acad Orthop Surg. 2020; 28(8):e340-e348. doi:10.5435/JAAOS-D-19-00405.
  13. Fink B, Sevelda F. Periprosthetic Joint Infection of Shoulder Arthroplasties: Diagnostic and Treatment Options. Biomed Res Int. 2017; 2017:4582756. doi:10.1155/2017/4582756.
  14. McGoldrick E, McElvany MD, Butler-Wu S, Pottinger PS, Matsen FA. Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty. J Shoulder Elbow Surg. 2015; 24(1):31-35. doi:10.1016/j.jse.2014.05.008.
  15. Zeller V, Ghorbani A, Strady C, Leonard P, Mamoudy P, Desplaces N. Propionibacterium acnes: An agent of prosthetic joint infection and colonization. J Infect. 2007; 55(2):119-124. doi:10.1016/j.jinf.2007.02.006.
  16. Do DH, Mounasamy V, Sambandam S. Predictors of Higher Costs Following Reverse Total Shoulder Arthroplasty. Arch Bone Jt Surg. 2024; 12(7):469-476. doi:10.22038/ABJS.2024.77124.3564.
  17. Falstie-Jensen T, Lange J, Daugaard H, et al. unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome? J Shoulder Elbow Surg. 2021; 30(6):1299-1308. doi:10.1016/j.jse.2020.12.014.
  18. Hodakowski AJ, Cohn MR, Mehta N, Menendez ME, McCormick JR, Garrigues GE. An evidence-based approach to managing unexpected positive cultures in shoulder arthroplasty. J Shoulder Elbow Surg. 2022; 31(10):2176-2186. doi:10.1016/j.jse.2022.03.019.
  19. Austin DC, Townsley SH, Rogers TH, et al. Shoulder Periprosthetic Joint Infection and All-Cause Mortality: A Worrisome Association. JB JS Open Access. 2022; 7(1):e21.00118. doi:10.2106/JBJS.OA.21.00118.
  20. Sarwar F, Teunis T, Ring D, et al. Surgeon Ratings of the Severity of Idiopathic Median Neuropathy at the Carpal Tunnel Are Not Influenced by Magnitude of Incapability. Clin Orthop Relat Res. 2022; 480(6):1143-1149. doi:10.1097/CORR.0000000000002062.
  21. Lin E, Crijns TJ, Ring D, Jayakumar P, The Science of Variation Group. Imposter Syndrome Among Surgeons Is Associated With Intolerance of Uncertainty and Lower Confidence in Problem Solving. Clin Orthop Relat Res. 2023; 481(4):664-671. doi:10.1097/CORR.0000000000002390.
  22. Ramachandran SS, Ring D, Crijns TJ, Science of Variation Group. Upper Extremity Surgeon Recommendations for Imaging Do Not Correspond with Imaging Appropriateness Guidelines. J Hand Microsurg. 2024; 16(1):100012. doi:10.1055/s-0042-1758670.
  23. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977; 33(1):159-174.
  24. Patel MS, Singh AM, Gregori P, Horneff JG, Namdari S, Lazarus MD. Cutibacterium acnes: a threat to shoulder surgery or an orthopedic red herring? J Shoulder Elbow Surg. 2020; 29(9):1920-1927. doi:10.1016/j.jse.2020.02.020
  25. Ahmadi S, Lawrence TM, Sahota S, et al. Significance of Perioperative Tests to Diagnose the Infection in Revision Total Shoulder Arthroplasty. Arch Bone Jt Surg. 2018; 6(5):359-364.
  26. Chen RE, Vaughan AK, Cox RM, Alfonsi S, Belden KA, Namdari S. Shoulder periprosthetic joint infection is associated with increased mortality. J Shoulder Elbow Surg. 2023; 32(6S):S1-S7. doi:10.1016/j.jse.2023.02.004.
  27. Millett PJ, Yen YM, Price CS, Horan MP, van der Meijden OA, Elser F. Propionobacter acnes Infection as an Occult Cause of Postoperative Shoulder Pain: A Case Series. Clin Orthop Relat Res. 2011; 469(10):2824-2830. doi:10.1007/s11999-011-1767-4.
  28. Shields MV, Abdullah L, Namdari S. The challenge of Propionibacterium acnes and revision shoulder arthroplasty: a review of current diagnostic options. J Shoulder Elbow Surg. 2016; 25(6):1034-1040. doi:10.1016/j.jse.2016.01.009.
  29. Patel VV, Ernst SMC, Rangarajan R, Blout CK, Lee BK, Itamura JM. Validation of new shoulder periprosthetic joint infection criteria. J Shoulder Elbow Surg. 2021; 30(7, Supplement):S71-S76. doi:10.1016/j.jse.2021.04.009.
  30. Kopp B, Furlough K, Goldberg T, Ring D, Koenig K. Factors associated with pain intensity and magnitude of limitations among people with hip and knee arthritis. J Orthop. 2021; 25:295-300. doi:10.1016/j.jor.2021.05.026.
  31. Elston MJ, Dupaix JP, Opanova MI, Atkinson RE. Cutibacterium acnes (formerly Proprionibacterium acnes) and Shoulder Surgery. Hawaii J Health Soc Welf. 2019; 78(11 Suppl 2):3-5.
  32. Kadler BK, Mehta SS, Funk L. Propionibacterium acnes infection after shoulder surgery. Int J Shoulder Surg. 2015; 9(4):139-144. doi:10.4103/0973-6042.167957.
  33. Foruria AM, Fox TJ, Sperling JW, Cofield RH. Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty. J Shoulder Elbow Surg. 2013; 22(5):620-627. doi:10.1016/j.jse.2012.07.017.
  34. Rahmi H, Jawa A. Management of complications after revision shoulder arthroplasty. Curr Rev Musculoskelet Med. 2015; 8(1):98-106. doi:10.1007/s12178-014-9249-4.

 

 

 

 

The Archives of Bone and Joint Surgery
Volume 13, Issue 5
May 2025
Pages 258-265

  • Receive Date 11 June 2024
  • Revise Date 09 September 2024
  • Accept Date 09 September 2024