Preventing infection in reverse shoulder arthroplasty

Reverse shoulder arthroplasty (RSA) is a highly effective and generally safe procedure. However, periprosthetic joint infections (PJI) occur more frequently than in anatomical shoulder arthroplasty [1]. Although rare, they have the potential to significantly increase the short- and long-term health risks. Revision surgery is often required and commonly has a substantially poorer outcome than the primary procedure [2]. It is imperative that a surgical team works to prevent, recognize, treat, and monitor infection if it does arise—prevention is key. In this article Simon Lambert, an experienced consultant orthopedic and trauma surgeon at the University College London Hospital, UK, gives an overview of steps to follow to prevent infection before, during, and after RSA surgery.

Periprosthetic joint infection: What should we be prepared for?

The most common pathogens causing periprosthetic joint infection (PJI) are the gram-positive coccus Staphylococcus (S ) aureus, the family of coagulase-negative staphylococci, specifically S epidermidis, and Cutibacterium acnes (C acnes) [3–5], which has the ability to evade rigorous skin preparation and administered prophylactic antibiotics [6, 7]. Cutibacterium acnes is becoming more problematic in postoperative shoulder infections and is elusive, requiring particular laboratory culture strategies to diagnose its presence [8]. Understanding the types of bacteria that are most frequent in this type of surgery can help the surgical team to prepare for and eliminate them in the operating room setting.

Being vigilant throughout the whole procedure: pre-, peri- and postoperative steps to follow

The incidence of infection with RSA varies between 0.3% and 6% [4, 9]. This increases further after revision RSA [7, 10] and also following RSA performed after previous surgical interventions. As the aging population increases in number, so will the number of RSAs. Reducing the risk of infection associated with RSA relies on detailed preoperative preparation, refining surgical exposure techniques to reduce surgical operating time and intraoperative bleeding, and limiting the incidence of postoperative adverse events (AEs), particularly bleeding and primary wound healing problems. The medical team can take several measures to reduce the risk of opportunistic bacteria causing nosocomial infection.

Preparation of the patient

The treating surgeon should fully understand the general health of their patient and, if needed, optimize their health before the procedure so as to lower the risk of infections and complications. Comorbidities including the related conditions of bleeding disorders (eg, intrinsic coagulopathies, liver disease, anemia of all causes), microvascular diseases (diabetes, lupus erythematosus), immunosuppressive conditions and treatments (eg, the inflammatory arthritides, ongoing corticosteroid therapy, immunosuppressive therapies), and disorders characterized by poor metabolite handling (eg, renal failure, malnutrition) have been reported as risk factors for infection [3, 7]. Other modifiable factors, such as high body mass index, smoking, and excessive alcohol use, increase the risk of PJI [11]. Surgeons should evaluate these comorbidities preoperatively, obtain optimal advice from colleagues regarding the cessation of medications, and/or bridging of disease treatments during the perioperative period, and ensure that the patient is as fit as reasonably possible before undergoing surgery.
To give an example of the available literature, Cancienne et al [9], for instance, analyzed infection and risk factors in a large study Medicare population in the US and reported a rate of 0.26% for infections within 90 days after RSA [9]. Revision surgery (after any other intervention) was the most significant risk factor for infection, while intraoperative steroid injection was an independent risk factor for postoperative infection. The study highlighted that obesity, male gender, chronic anemia, malnutrition, depression, and alcohol use were all patient-related risk factors for postoperative infection [9]. Previous intraarticular corticosteroid injections administered for the management of rotator cuff disease, previous surgical interventions (whether arthroscopic or open) including prior rotator cuff surgery and arthroplasty are all associated with an increased risk of PJI, particularly in RSA [11].