Infection (Anatomical Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty)

Infection (Anatomical Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty)

Stephen A. Parada, MD

Daniel B. Buchalter, MD

Lynn A Crosby, MD


The 2018 International Consensus Meeting (ICM) on Orthopaedic Infections provided important guidelines to define a periprosthetic joint infection (PJI) of the shoulder as characterized by either one definite criteria (TABLE 32.1)1 or by six or more points derived from minor criteria (TABLE 32.2).

While infection after anatomical total shoulder arthroplasty (ATSA) continues to be an uncommon, although potentially devastating, complication, early reports of reverse total shoulder arthroplasty (RTSA) demonstrated higher rates of overall complications, including infection.2,3 These series reported an infection rate of up to 6.7%. As implant designs and surgeon experience increased, these infection rates have decreased substantially and are now reported as less than 3% in systematic review articles.4,5 While the reasons are not completely clear, infection rate following ATSA is consistently lower than that following RTSA. Increased surface area of the implanted devices and larger dead space are thought to be the possible reasons which may explain this difference.6


Risk factors for PJI following shoulder arthroplasty include younger age, male sex, obesity, immunodeficiency, nutritional deficiency, diabetes mellitus, traumatic arthroplasty, and revision procedures for prior failed arthroplasty.7,8,9,10,11,12,13,14,15,16,17,18

Younger age and male gender are theorized to be risk factors for PJI because these populations are more likely to have had trauma, rheumatoid arthritis, or Cutibacterium acnes (C. acnes, formerly Propionibacterium acnes), an increasingly common organism in PJI.10,19 Class 3 obesity (BMI ≥40 kg/m2), poor glycemic control (hemoglobin A1c > 8.0 mg/dL), and malnutrition (preoperative albumin <3.5 g/dL) are all associated with an increased risk of PJI.7,8,13

Several types of immunodeficiency are suggested to increase the risk of PJI. Rheumatoid arthritis has previously been associated with an increased risk of PJI,9 though newer research suggests it poses no greater risk.14 Additionally, the use of intra-articular corticosteroid injections within 3 months of surgery has been implicated in recent literature.15 Lastly, systemic lupus erythematosus, systemic corticosteroid therapy, and chemotherapy have all been implicated, but data suggesting they lead to increased risk are over 20 years old.16,17

Revision arthroplasty has been found to have an infection rate twice that of primary shoulder arthroplasty in some reviews (5.8% compared with 2.9%).4 Alternatively, data are mixed on whether previous nonarthroplasty shoulder surgery increases PJI risk, though any prior shoulder surgery may increase the risk of subdermal C. acnes inoculation.14,18,20


Although Staphylococcus has historically been the most commonly isolated PJI bacteria, now the low-virulent C. acnes predominates.10 C. acnes is a gram-positive anaerobic bacillus that was once thought to be a contaminant, but is now known to be a pathologic organism.21 Other commonly reported bacteria responsible for PJI include coagulase-negative Staphylococcus, Klebsiella, and Escherichia coli.22 C. acnes is normal skin flora and is found frequently in the epidermal and subdermal layers of the shoulder at the regular incision site, especially in male patients.20,23 Presence of sebaceous follicle glands also contributes to a 2.5 times increase in relative risk of C. acnes PJI in male patients compared with women.24

Jun 23, 2022 | Posted by in ORTHOPEDIC | Comments Off on Infection (Anatomical Total Shoulder Arthroplasty and Reverse Total Shoulder Arthroplasty)
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