For most cases of shoulder periprosthetic infection, the single stage with complete implant exchange is the “go to” procedure.
However, in some patients with complex periprothetic infections in which complete implant exchange is difficult and risky, surgeons have competing priorities: 1. trying to cure the patient’s infection or 2. trying to preserve the comfort and function of the patient’s shoulder. The interesting thing about #1 is that no matter how hard we try, we can never be sure that we have removed every last bug from the shoulder and have eliminated the possibility of a recurrence down the line.
Vigorous attempts to stamp out infection may involve removal of all implants and cement, but these attempts may permanently compromise the comfort and function of the patient’s shoulder. Imagine an elderly person with fragile bone and a well cemented implant who has developed drainage from her shoulder, which otherwise is functional and painless. Is she better served by complete explantation or by a washout, culture-specific antibiotics and – should she continue to drain – offering her the option of retaining her implants and managing the drainage with dressings?
Specifically they compared the rates of repeat infection at two years after 2-stage revision for prosthetic joint infection in 37 patients who had retained cement or hardware compared to those who had complete removal.
Repeat infection was defined as either ≥2 positive cultures at the time of the second-stage with the same organism that was cultured during the first-stage or repeat surgery for infection after the two-stage revision.
Six patients had retained cement and 1 patient had 2 retained broken glenoid baseplate screws after first-stage revision. 30 patients had no retained hardware.
10 cases had recurrent infection:
Patient demographics were not significantly associated with recurrent infection.
Of the 10 cases of recurrent infection, 1 case had retained cement/hardware while 9 had no retained cement/hardware.
Thus 1 of 7 (14%) with retained cement/hardware had a recurrent infection while 9 of 30 (30%) with no retained cement/hardware had a recurrent infection. Retained cement or hardware was not significantly associated with a repeat risk of infection.
The authors suggested that surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications.
