Bartels, Douglas W

Background: Although prophylactic antibiotics are considered the standard of care, data with regard to the comparative efficacy of specific antibiotics in the prevention of periprosthetic joint infection (PJI) have remained limited. This study evaluated whether perioperative antibiotic choice affects rates of PJI development in shoulder arthroplasty. Methods: From 2000 to 2019, all primary shoulder arthroplasty types (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse shoulder arthroplasty) performed for elective and trauma indications with perioperative antibiotic data and a minimum follow-up of 2 years were identified from a single institution. Demographic characteristics, PJI risk factors, and PJI-free survivorship data were retrieved. Multivariable analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Results: Of 7,713 shoulder arthroplasties, cefazolin was administered in 6,879 procedures (89.2%) and non-cefazolin antibiotics consisting of vancomycin (465 procedures [6.0%]), clindamycin (345 procedures [4.5%]), and alternative regimens (24 procedures [0.31%]) were administered in 834 procedures (10.8%). PJIs occurred in 101 shoulder arthroplasties (1.3%), with Cutibacterium acnes as the most common pathogen (44 procedures [43.6%]). PJI-free survivorship was greater in shoulder arthroplasties in which cefazolin was administered compared with those in which non-cefazolin antibiotics were administered, with 0.91% greater survival free of PJI at 1 month, 1.4% at 1 year, and 2.7% at 15 years (p < 0.001). Cefazolin administration, compared with non-cefazolin administration, was associated with a 69% reduction in all-cause PJI risk and a 78% reduction in C. acnes PJI risk (p < 0.001). A higher risk of PJI for both groups was observed with vancomycin; the hazard ratio [HR] was 2.32 (95% confidence interval [CI], 1.22 to 4.40; p = 0.010) for all-cause PJI and 2.94 (95% CI, 1.12 to 7.49; p = 0.028) for C. acnes PJI. A higher risk of PJI was also observed for both groups for clindamycin; the HR was 5.07 (95% CI, 2.83 to 9.05; p < 0.001) for all-cause PJI and 8.01 (95% CI, 3.63 to 17.42; p < 0.001) for C. acnes PJI. Conclusions: In primary shoulder arthroplasty, cefazolin administration was associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin. These risk discrepancies were observed across all infectious pathogens and may be considered even greater when C. acnes was the infecting bacterium. Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Glenoid component loosening is a primary cause of failure of anatomical total shoulder arthroplasty (TSA) and is commonly associated with glenoid bone loss. The purpose of the present study was to evaluate the outcome and survival following revision to a reverse total shoulder arthroplasty (RSA) for the treatment of loosening of a polyethylene cemented glenoid component in the setting of failed TSA. Methods: Between 2010 and 2017, 151 shoulders underwent revision to RSA for the treatment of loosening of an anatomical polyethylene glenoid component. Shoulders with staged reconstruction for the treatment of infection were excluded. One hundred and twenty-seven patients (67 women and 60 men) had a single-stage reconstruction and were available for follow-up. The mean age at the time of surgery was 70 years (range, 41 to 93 years). In all cases, the humeral component was revised and a standard glenoid baseplate was utilized. Bone graft was used at the discretion of the treating surgeon. Medical records and radiographs were reviewed to collect demographic, intraoperative, and postoperative data; to quantify glenoid bone loss; and to determine the radiographic outcome. The mean duration of follow-up was 35 months (range, 24 to 84 months). Results: Revision to RSA resulted in significant improvements in terms of pain and motion. Sixteen shoulders (13%) underwent revision surgery for the treatment of baseplate loosening. Radiographic baseplate loosening was present in 6 additional shoulders (overall rate of baseplate loosening, 17%). Intraoperative fracture or fragmentation of the greater tuberosity occurred in 30 shoulders (24%). Other reoperations included resection for deep infection (3 shoulders), arthroscopic biopsies for unexplained persistent pain (2 shoulders), humeral tray exchange for dislocation (2 shoulders), revision for humeral loosening (1 shoulder), irrigation and debridement for hematoma (1 shoulder), and internal fixation of periprosthetic fracture (1 shoulder) (overall reoperation rate, 20%). Among shoulders with surviving implants at the time of the most recent follow-up, pain was rated as none or mild in 83 shoulders (65.4%) and the average active elevation and external rotation were 132° and 38°, respectively. With the numbers available, no risk factors for failure could be identified. Conclusions: Revision RSA for the treatment of loosening of an anatomical polyethylene component was associated with a 17% glenoid mechanical failure rate. Although this procedure resulted in improvements in terms of pain and function, it was not universally successful and thus needs further refinement in order to improve outcomes. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Case: A 51-year-old man presented with pain and paresthesias in the median nerve distribution and a subjective loss of grip strength. Imaging revealed a thrombosed persistent median artery in the carpal tunnel abutting the median nerve. The thrombosed portion of the artery was surgically excised, and the patient experienced resolution of symptoms. Conclusion: Persistent median artery thrombosis is rare and can cause carpal tunnel syndrome. Ultrasound is a useful tool for diagnosis and appropriate surgical planning. Although treatment with systemic anticoagulation is an option, surgical excision resulted in resolution of symptoms and an excellent short-term outcome.