A complex revision of an infected reverse total shoulder


Monday, July 7, 2014

A complex revision of an infected reverse total shoulder

A 45 year old right handed active man had a Simple Shoulder Test score of 4/12. His x-rays revealed severe capsulorrhaphy arthropathy with posterior dislocation of right shoulder after a Putti Platt procedure for shoulder instability performed many years earlier.

At surgery he was found to have massive humeral and glenoid deformity with severe posterior glenoid erosion and malformation of the humeral head with posterior capsular laxity and anterior capsular contracture. His surgery was a humeral hemiarthroplasty with subscapularis lengthening. His post operative film is shown here.


However, the humeral head again became posteriorly unstable. A year later he had an open reduction of the posteriorly dislocated shoulder with anterior release, prosthetic head removal, posterior cortical iliac autograft of the glenoid with screw fixation, posterior soft tissue reconstruction, and reinsertion of hemiarthroplasty head. However, on testing the range of motion of the shoulder at surgery, the securely fixed bone graft fragmented requiring removal of the graft and screws and insertion of a reverse total shoulder. His postoperative film is shown here.


Three years later he represented with pain in his shoulder that started with golfing. He had no clinical evidence of infection. His x-rays showed humeral osteolysis and subsidence


He then had a primary exchange revision of reverse total shoulder arthroplasty to a long stemmed humeral component and a new glenoid component at which time six cultures were obtained before antibiotics were administered. At this procedure there was a substantial amount of membrane and granulomatous tissue from the glenoid and from the humeral medullary canal. There was no cloudy fluid and no purulence.

His histology showed gram-positive rods and up to 40 white blood cells per high power field on frozen section. The patient’s final pathology eventually returned “synovial tissue with multiple foci of dense neutrophilic infiltrates (greater than five neutrophils per high power microscopic field using a 40 X objective in at least five separate microscopic fields) in a background of prominent plasmacytic inflammation and hemosiderin-laden macrophages.” He was placed on a six-week course of IV vancomycin and rifampin, which was changed to ceftriaxone to better cover Propionibacterium after the culture results were final at 3 weeks.

His culture results were as follows:
Glenoid Membrane No. 1: 2+ Propionibacterium
Glenoid Membrane No. 2: 1+ Propionibacterium
Fluid Right Glenoid: 1+ Propionibacterium
Humeral Membrane No.1: 1 colony Propionibacterium
Humeral Membrane No. 2: 1+ Propionibacterium
Humeral Membrane  No. 3 One colony Propionibacterium

He remained on oral Augmentin for a year.

Today six years after his most recent revision he plays tennis (tossing the ball with his right hand serving with his left), skis gentle slopes, and runs for fitness. His Simple Shoulder Test responses are 8/12:
1: Is your shoulder comfortable with your arm at rest by your side?: Yes
2: Does your shoulder allow you to sleep comfortably?: Yes
3: Can you reach the small of your back to tuck in your shirt with your hand?: Yes
4: Can you place your hand behind your head with the elbow straight out to the side?: Yes
5: Can you place a coin on a shelf at the level of your shoulder without bending your elbow?: Yes Yes
6: Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow?: Yes
7: Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow?: No
8: Can you carry twenty pounds at your side with this extremity?: Yes
9: Do you think you can toss a softball under-hand twenty yards with this extremity?: No
10: Do you think you can toss a softball over-hand twenty yards with this extremity?: No
11: Can you wash the back of your opposite shoulder with this extremity?: No
12: Would your shoulder allow you to work full-time at your regular job?: Yes

His x-rays today continue to show stable component fixation.


Comment: This case reveals the challenges of severe capsulorrhaphy arthropathy with posterior instability as well as the substantially delayed insidious presentation of osteolysis associated with Propionibacterium.