Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LI Yu ¹ , ZHANG Hao ² , WANG Lizhi ¹ , ZHENG Qiu ¹ , XIAO Shizhuo ¹ ,  YANG Hongbin ¹

1. Department of Bone and Joint Surgery, Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China;
2. Department of Orthopacdics, the People’s Hospital of Linshui, Linshui Sichuan, 638500, P.R.China;

Corresponding?author：

YANG Hongbin, Email: yanghongbin1234@163.com

Keywords：

Shoulder joint; reverse total shoulder arthroplasty; proximal humeral fracture; internal fixation; infection

DOI：

10.7507/1002-1892.201907079

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Objective To summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture.Methods Between June 2014 and January 2018, 17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated. There were 8 males and 9 females, aged from 52 to 78 years (mean, 63.8 years). The infection occurred at 19-66 months after the initial internal fixation (mean, 34.8 months). Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases. The preoperative Constant score, American shoulder and elbow surgeons (ASES) score, and visual analogue scale (VAS) score were 36.41±8.65, 31.06±7.43, and 7.29±0.99, respectively. The preoperative ranges of forward flexion, abduction, external rotation were (45.88±12.46), (42.18±12.31), and (16.76±4.92)°, respectively. The preoperative range of internal rotation was buttock in 9 cases, lumbosacral joint in 3 cases, L₃ in 5 cases. At the first-stage surgery, the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation. After the infections disappeared, the two-stage reverse total shoulder arthroplasty was performed. The mean interval between the two procedures was 4.2 months (range, 3.0-6.5 months).Results All the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred. All patients were followed up 15-32 months (mean, 22.0 months). At last follow-up, the ranges of forward flexion, abduction, and external rotation were (109.00±23.66), (98.53±16.92), (41.41±6.82)°, respectively; and the range of internal rotation was lumbosacral joint in 5 cases, L₃ in 8 cases, T₁₂ in 4 cases. The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion (P<0.05). The Constant score (64.88±8.70), ASES score (65.18±8.10), and VAS score (2.94±1.25) were significantly superior to the preoperative scores (P<0.05). X-ray films showed that no prosthesis loosening occurred.Conclusion Two-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture, which has advantages of low risk of infection recurrence, good shoulder function, and satisfactory short-term effectiveness.

Citation： LI Yu, ZHANG Hao, WANG Lizhi, ZHENG Qiu, XIAO Shizhuo, YANG Hongbin. Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(2): 184-189. doi: 10.7507/1002-1892.201907079 Copy

1.	García-Fernández C, Lopiz Y, Rizo B, et al. Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures. Injury, 2018, 49(Suppl 2): S22-S26.
2.	Kunutsor SK, Wylde V, Beswick AD, et al. One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis. Sci Rep, 2019, 9(1): 232.
3.	Pellegrini A, Legnani C, Macchi V, et al. Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections. Orthop Traumatol Surg Res, 2018, 105(2): 237-240.
4.	Braman JP, Sprague M, Bishop J, et al. The outcome of resection shoulder arthroplasty for recalcitrant shoulder infections. J Shoulder Elbow Surg, 2006, 15(5): 549-553.
5.	張健, 黃強. 反球型人工肩關節置換術治療合并肩袖損傷的老年粉碎性肱骨近端骨折. 中國骨傷, 2019, 32(1): 17-21.
6.	吳昊, Goutallier Danial. 逆向型人工全肩關節置換研究進展. 中國修復重建外科雜志, 2015, 29(7): 905-911.
7.	羅登科, 陳墾, 秦平, 等. 反式肩關節置換與切開復位鋼板內固定治療老年肱骨近端骨折骨不連的效果比較. 中國組織工程研究, 2018, 22(15): 2327-2332.
8.	Hussey MM, Hussey SE, Mighell MA. Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus: outcomes and complications. Bone Joint J, 2015, 97-B(7): 967-972.
9.	Garrigues GE, Zmistowski B, Cooper AM, et al. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elbow Surg, 2019, 28(6S): S8-S12.
10.	Grosso MJ, Frangiamore SJ, Saleh A, et al. Poor utility of serum interleukin-6 levels to predict indolent periprosthetic shoulder infections. J Shoulder Elbow Surg, 2014, 23(9): 1277-1281.
11.	Nelson GN, Paxton ES, Narzikul A, et al. Leukocyte esterase in the diagnosis of shoulder periprosthetic joint infection. J Shoulder Elbow Surg, 2015, 24(9): 1421-1426.
12.	Tseng WJ, Lansdown DA, Grace T, et al. Outcomes of revision arthroplasty for shoulder periprosthetic joint infection: a three-stage revision protocol. J shoulder Elbow Surg, 2019, 28(2): 268-275.
13.	Hsu JE, Gorbaty JD, Whitney IJ, et al. Single-stage revision is effective for failed shoulder arthroplasty with positive cultures for propionibacterium. J Bone Joint Surg (Am), 2016, 98(24): 2047-2051.
14.	Frangiamore SJ, Saleh A, Grosso MJ, et al. Neer Award 2015: Analysis of cytokine profiles in the diagnosis of periprosthetic joint infections of the shoulder. J Shoulder Elbow Surg, 2017, 26(2): 186-196.
15.	韓欣攸, 李曉林. 反置式肩關節置換治療肱骨近端骨折的研究進展. 實用骨科雜志, 2018, 24(9): 812-815.
16.	Lee SH, Kim SJ, Kook SH, et al. Two-stage revision of infected shoulder arthroplasty using prosthesis of antibiotic-loaded acrylic cement: minimum three-year follow-up. Int Orthop, 2018, 42(4): 867-874.
17.	宋興桂, 李昕, 宋俊雷, 等. 保留假體清創術治療人工關節置換術后假體周圍感染的臨床研究. 中國修復重建外科雜志, 2018, 32(6): 685-693.
18.	Cheung EV, Sperling JW, Cofield RH. Infection associated with hematoma formation after shoulder arthroplasty. Clin Orthop Relat Res, 2008, 466(6): 1363-1367.
19.	Ince A, Seemann K, Frommelt L, et al. One-stage exchange shoulder arthroplasty for peri-prosthetic infection. J Bone Joint Surg (Br), 2005, 87(6): 814-818.
20.	Sabesan VJ, Ho JC, Kovacevic D, et al. Two-stage reimplantation for treating prosthetic shoulder infections. Clin Orthop Relat Res, 2011, 469(9): 2538-2543.
21.	Nelson GN, Davis DE, Namdari S. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg, 2016, 25(8): 1337-1345.
22.	Buchalter DB, Mahure SA, Mollon B, et al. Two-stage revision for infected shoulder arthroplasty. J Shoulder Elbow Surg, 2017, 26(6): 939-947.
23.	Torrens C, Santana F, Puig L, et al. Results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection. J Orthop Surg Res, 2018, 13(1): 58-64.
24.	Kapadia BH, Berg RA, Daley JA, et al. Periprosthetic joint infection. Lancet, 2016, 387(10016): 386-394.
25.	Egglestone A, Ingoe H, Rees J, et al. Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty. Shoulder Elbow, 2019, 11(3): 167-181.
26.	Zhang AL, Feeley BT, Schwartz BS, et al. Management of deep postoperative shoulder infections: is there a role for open biopsy during staged treatment? J Shoulder Elbow Surg, 2015, 24(1): e15-e20.
27.	Jawa A, Shi L, O’Brien T, et al. Prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) use for the treatment of infection after shoulder arthroplasty. J Bone Joint Surg (Am), 2011, 93(21): 2001-2009.
28.	李奉龍, 姜春巖, 魯誼, 等. 采用分期反肩置換手術治療肱骨近端骨折術后感染的療效分析. 北京大學學報 (醫學版), 2016, 48(2): 263-267.
29.	姜春巖, 李奉龍, 魯誼, 等. 反球型人工肩關節假體置換術治療復雜肱骨近端骨折. 中華創傷骨科雜志, 2014, 16(10): 834-838.

1. García-Fernández C, Lopiz Y, Rizo B, et al. Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures. Injury, 2018, 49(Suppl 2): S22-S26.
2. Kunutsor SK, Wylde V, Beswick AD, et al. One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis. Sci Rep, 2019, 9(1): 232.
3. Pellegrini A, Legnani C, Macchi V, et al. Two-stage revision shoulder prosthesis vs. permanent articulating antibiotic spacer in the treatment of periprosthetic shoulder infections. Orthop Traumatol Surg Res, 2018, 105(2): 237-240.
4. Braman JP, Sprague M, Bishop J, et al. The outcome of resection shoulder arthroplasty for recalcitrant shoulder infections. J Shoulder Elbow Surg, 2006, 15(5): 549-553.
5. 張健, 黃強. 反球型人工肩關節置換術治療合并肩袖損傷的老年粉碎性肱骨近端骨折. 中國骨傷, 2019, 32(1): 17-21.
6. 吳昊, Goutallier Danial. 逆向型人工全肩關節置換研究進展. 中國修復重建外科雜志, 2015, 29(7): 905-911.
7. 羅登科, 陳墾, 秦平, 等. 反式肩關節置換與切開復位鋼板內固定治療老年肱骨近端骨折骨不連的效果比較. 中國組織工程研究, 2018, 22(15): 2327-2332.
8. Hussey MM, Hussey SE, Mighell MA. Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus: outcomes and complications. Bone Joint J, 2015, 97-B(7): 967-972.
9. Garrigues GE, Zmistowski B, Cooper AM, et al. Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elbow Surg, 2019, 28(6S): S8-S12.
10. Grosso MJ, Frangiamore SJ, Saleh A, et al. Poor utility of serum interleukin-6 levels to predict indolent periprosthetic shoulder infections. J Shoulder Elbow Surg, 2014, 23(9): 1277-1281.
11. Nelson GN, Paxton ES, Narzikul A, et al. Leukocyte esterase in the diagnosis of shoulder periprosthetic joint infection. J Shoulder Elbow Surg, 2015, 24(9): 1421-1426.
12. Tseng WJ, Lansdown DA, Grace T, et al. Outcomes of revision arthroplasty for shoulder periprosthetic joint infection: a three-stage revision protocol. J shoulder Elbow Surg, 2019, 28(2): 268-275.
13. Hsu JE, Gorbaty JD, Whitney IJ, et al. Single-stage revision is effective for failed shoulder arthroplasty with positive cultures for propionibacterium. J Bone Joint Surg (Am), 2016, 98(24): 2047-2051.
14. Frangiamore SJ, Saleh A, Grosso MJ, et al. Neer Award 2015: Analysis of cytokine profiles in the diagnosis of periprosthetic joint infections of the shoulder. J Shoulder Elbow Surg, 2017, 26(2): 186-196.
15. 韓欣攸, 李曉林. 反置式肩關節置換治療肱骨近端骨折的研究進展. 實用骨科雜志, 2018, 24(9): 812-815.
16. Lee SH, Kim SJ, Kook SH, et al. Two-stage revision of infected shoulder arthroplasty using prosthesis of antibiotic-loaded acrylic cement: minimum three-year follow-up. Int Orthop, 2018, 42(4): 867-874.
17. 宋興桂, 李昕, 宋俊雷, 等. 保留假體清創術治療人工關節置換術后假體周圍感染的臨床研究. 中國修復重建外科雜志, 2018, 32(6): 685-693.
18. Cheung EV, Sperling JW, Cofield RH. Infection associated with hematoma formation after shoulder arthroplasty. Clin Orthop Relat Res, 2008, 466(6): 1363-1367.
19. Ince A, Seemann K, Frommelt L, et al. One-stage exchange shoulder arthroplasty for peri-prosthetic infection. J Bone Joint Surg (Br), 2005, 87(6): 814-818.
20. Sabesan VJ, Ho JC, Kovacevic D, et al. Two-stage reimplantation for treating prosthetic shoulder infections. Clin Orthop Relat Res, 2011, 469(9): 2538-2543.
21. Nelson GN, Davis DE, Namdari S. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg, 2016, 25(8): 1337-1345.
22. Buchalter DB, Mahure SA, Mollon B, et al. Two-stage revision for infected shoulder arthroplasty. J Shoulder Elbow Surg, 2017, 26(6): 939-947.
23. Torrens C, Santana F, Puig L, et al. Results of cement spacer sonication in the second stage of two-stage treatment of shoulder arthroplasty infection. J Orthop Surg Res, 2018, 13(1): 58-64.
24. Kapadia BH, Berg RA, Daley JA, et al. Periprosthetic joint infection. Lancet, 2016, 387(10016): 386-394.
25. Egglestone A, Ingoe H, Rees J, et al. Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty. Shoulder Elbow, 2019, 11(3): 167-181.
26. Zhang AL, Feeley BT, Schwartz BS, et al. Management of deep postoperative shoulder infections: is there a role for open biopsy during staged treatment? J Shoulder Elbow Surg, 2015, 24(1): e15-e20.
27. Jawa A, Shi L, O’Brien T, et al. Prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) use for the treatment of infection after shoulder arthroplasty. J Bone Joint Surg (Am), 2011, 93(21): 2001-2009.
28. 李奉龍, 姜春巖, 魯誼, 等. 采用分期反肩置換手術治療肱骨近端骨折術后感染的療效分析. 北京大學學報 (醫學版), 2016, 48(2): 263-267.
29. 姜春巖, 李奉龍, 魯誼, 等. 反球型人工肩關節假體置換術治療復雜肱骨近端骨折. 中華創傷骨科雜志, 2014, 16(10): 834-838.

Chinese Journal of Reparative and Reconstructive Surgery

Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture

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