Shoulder & Elbow

Revision for Propionibacterium

There is a renewed interest in subclinical infection across the whole of the arthroplasty world – with understanding of biofilms, improvements in diagnoses and the understanding that often apparently culture negative patients may have subclinical loosening leading to osteolysis has sparked renewed interest in indolent infections such as Propionibacterium. The usual suspect in revision shoulder surgery is Propionibacterium. Often implicated in subclinical infection associated with osteolysis, this low virulence organism is also only identified on delayed cultures. With the increasing recognition that Propionibacterium is often responsible for revision arthroplasty, the question then turns to how this indolent infection is best treated. Shoulder surgeons in Seattle, Washington (USA)¹ have set out to establish whether single-stage revision is successful in revision surgery. They report the clinical outcomes for single-stage revision arthroplasty in patients without obvious clinical infection at the time of surgery. The surgical team sent multiple samples at the time of revision surgery for extended cultures and bacteriotyping. Patients with more than two cultures positive for Propionibacterium (n = 27/55) were compared with the remainder of the cohort. Clinical outcomes were assessed using the Simple Shoulder Test (SST) and there were no significant differences between the groups in terms of raw improvement or percentage improvements achievable, with both groups achieving around 7.5 points on average on the SST. Similarly, there were no differences in the numbers of post-operative complications, with three patients in each group requiring intervention for ongoing pain or stiffness.

The authors conclude, and it certainly seems to us here at 360, that in this series the use of a single-stage revision approach is appropriate, with outcomes similar to a control group of aseptic revisions. Care should, however, be taken to ensure that appropriate antibiotic cover is used post operatively.