Surgical treatment of shoulder infections: a comparison between arthroscopy and arthrotomy

Böhler, C.; Pock, A.; Waldstein, W.; Staats, K.; Puchner, S.E.; Holinka, J.; Windhager, R.

Journal of Shoulder and Elbow Surgery 26(11): 1915-1921

2017

Management of bacterial shoulder infections includes antibiotic therapy and surgical joint decompression. Arthroscopy and open arthrotomy are recommended treatment options. Whether 1 of the 2 surgical options is superior remains unclear. The present study aimed (1) to compare the reinfection rates after arthroscopy and open arthrotomy and (2) to identify risk factors of reinfection after surgical intervention. The data of 59 consecutive patients were available for final analysis. All patients received arthroscopy or open arthrotomy at our institution between 2001 and 2015. The reinfection rates between the 2 distinct interventions were compared. We also evaluated the influence of potential confounders, such as age, sex, comorbidities, microbiological findings, duration of symptoms, osteoarthritis, Gächter score, and preoperative inflammatory parameters, on the recurrence of infections and compared the functional outcome between the 2 surgery groups. From 59 included patients, 38 (64.4%) underwent open arthrotomy, and 21 (35.6%) were treated arthroscopically. Reinfection was documented in 18 patients (30.5%). The reinfection rate was significantly higher in arthroscopically treated patients (11 [52.4%]) than in patients who underwent open arthrotomy (7 [18.4%]; P = .007). An infection with Staphylococcus aureus negatively influenced the treatment success (P = .034). According to our data, open arthrotomy is the more effective treatment method in septic arthritis of the shoulder, with lower reinfection rates and a comparable functional outcome. Furthermore, we could identify Staphylococcus aureus as an independent risk factor for the recurrence of infections.

J
Shoulder
Elbow
Surg
(2017)
ELSEVIER
ORIGINAL
ARTICLE
Surgical
treatment
of
shoulder
infections:
a
comparison
between
arthroscopy
and
arthrotomy
Christoph
Hiller,
MD
,
Alexander
Pock,
MD,
Wenzel
Waldstein,
MD,
Kevin
Staats,
MD,
Stephan
E.
Puchner,
MD,
Johannes
Holinka,
MD,
Reinhard
Windhager,
MD
Department
of
Orthopaedic
Surgery,
Medical
University
of
Vienna,
Vienna,
Austria
Background:
Management
of
bacterial
shoulder
infections
includes
antibiotic
therapy
and
surgical
joint
decompression.
Arthroscopy
and
open
arthrotomy
are
recommended
treatment
options.
Whether
1
of
the
2
surgical
options
is
superior
remains
unclear.
The
present
study
aimed
(1)
to
compare
the
reinfection
rates
after
arthroscopy
and
open
arthrotomy
and
(2)
to
identify
risk
factors
of
reinfection
after
surgical
intervention.
Materials
and
methods:
The
data
of
59
consecutive
patients
were
available
for
final
analysis.
All
pa-
tients
received
arthroscopy
or
open
arthrotomy
at
our
institution
between
2001
and
2015.
The
reinfection
rates
between
the
2
distinct
interventions
were
compared.
We
also
evaluated
the
influence
of
potential
con-
founders,
such
as
age,
sex,
comorbidities,
microbiological
findings,
duration
of
symptoms,
osteoarthritis,
Gachter
score,
and
preoperative
inflammatory
parameters,
on
the
recurrence
of
infections
and
compared
the
functional
outcome
between
the
2
surgery
groups.
Results:
From
59
included
patients,
38
(64.4%)
underwent
open
arthrotomy,
and
21
(35.6%)
were
treated
arthroscopically.
Reinfection
was
documented
in
18
patients
(30.5%).
The
reinfection
rate
was
signifi-
cantly
higher
in
arthroscopically
treated
patients
(11
[52.4%])
than
in
patients
who
underwent
open
arthrotomy
(7
[18.4%0];
P
=
.007).
An
infection
with
Staphylococcus
aureus
negatively
influenced
the
treatment
success
(P
=
.034).
Conclusion:
According
to
our
data,
open
arthrotomy
is
the
more
effective
treatment
method
in
septic
ar-
thritis
of
the
shoulder,
with
lower
reinfection
rates
and
a
comparable
functional
outcome.
Furthermore,
we
could
identify
Staphylococcus
aureus
as
an
independent
risk
factor
for
the
recurrence
of
infections.
Level
of
evidence:
Level
Ill;
Retrospective
Cohort
Design;
Treatment
Study
©
2017
Journal
of
Shoulder
and
Elbow
Surgery
Board
of
Trustees.
All
rights
reserved.
Keywords:
Septic
arthritis;
shoulder;
treatment;
arthroscopy;
arthrotomy;
reinfection;
risk
factors
JOURNAL
OF
SHOULDER
AND
ELBOW
SURGERY
www.elsevier.com/locate/ymse
Septic
arthritis
is
an
orthopedic
emergency
that
requires
prompt
treatment
to
avoid
permanent
joint
damage
and
po-
tentially
life-threatening
complications."
The
incidence
of
The
Medical
University
of
Vienna
Ethics
Committee
approved
this
study
(Study
No.
1177/2016).
*Reprint
requests:
Christoph
Bohler,
MD,
Wahringer
Giirtel
18-20,
A-1090
Vienna,
Austria.
E-mail
address:
christoph.boehler@meduniwien.ac.at
(C.
Bohler).
bacterial
joint
infection
is
between
4
and
10
per
100,000
pa-
tients
per
year
and
increases
with
age
9,13,17,19,28
The
diagnosis
of
septic
arthritis
is
generally
based
on
a
clinical
examina-
tion,
laboratory
investigations,
imaging,
and
joint
aspiration.'
Apart
from
the
knee,
the
shoulder
is
the
most
frequently
affected
joint.'
Infections
of
joints
can
occur
after
hematog-
enous
seeding
or
directly
after
local
trauma
or
iatrogenic
injury.
Several
studies
have
identified
risk
factors
for
the
development
of
septic
arthritis,
including
osteoarthritis,
1058-2746/$
-
see
front
matter
©
2017
Journal
of
Shoulder
and
Elbow
Surgery
Board
of
Trustees.
All
rights
reserved.
http://dx.doi.org/10.1016/j.jse.2017.04.001
2
C.
Bailer
et
al.
immunosuppression,
aging,
diabetes
mellitus,
rheumatoid
ar-
thritis,
intravenous
drug
use,
and
previous
intra-articular
corticosteroid
injection.
10,13,14,16,18
Staphylococcus
(S)
aureus
is
responsible
for
most
of
the
bacterial
joint
infections,
followed
by
streptococci
and
other
gram-positive
bacteria.
7
'
11
Residual
functional
impairment
is
reported
in
up
to
50%
of
the
patients
2,27
Management
of
the
septic
arthritis
includes
antibiotic
therapy
and
immediate
joint
decompression.
Serial
closed-needle
aspiration
and
surgical
interventions,
such
as
an
open
arthrotomy
with
debridement
or
arthroscopic
lavage
with
or
without
debridement,
are
ac-
cepted
treatment
options.
2,6,16,29
Although
needle
aspiration
appears
to
be
only
effective
in
the
early
stages
of
infection,
3
further
clear
recommenda-
tions
of
the
preferable
surgical
intervention
are
lacking.
A
recent
retrospective
study
and
a
small-scale
prospective
study
were
able
to
show
that
arthroscopic
irrigation
is
more
effec-
tive
regarding
infection
eradication
in
septic
arthritis
of
the
knee.
4
'
2°
However,
information
about
the
treatment
of
shoul-
der
infections
is
scarce.
s
'
12
Owing
to
anatomic
differences
between
the
knee
and
the
shoulder
(ie,
the
communication
between
the
glenohumeral
joint
and
the
subacromial
space),
treatment
concepts
could
vary.
Therefore,
the
current
study
focuses
on
the
following
aims:
Firstly,
to
compare
the
efficacy
of
arthroscopy
and
open
ar-
throtomy
in
patients
with
bacterial
arthritis
of
the
shoulder.
The
primary
end
point
was
the
recurrence
of
infection
that
made
a
second
surgical
intervention
necessary.
Secondly,
we
aimed
to
identify
potential
risk
factors
for
a
failure
of
a
single
surgical
debridement.
hi
addition,
we
analyzed
the
postop-
erative
range
of
motion.
Materials
and
methods
Patients
In
this
case-control
study,
we
retrospectively
reviewed
data
from
con-
secutive
patients
who
were
treated
at
our
department
because
of
a
septic
monoarthritis
of
the
shoulder
between
2001
and
2015.
All
in-
cluded
patients
were
treated
by
arthroscopy
or
by
open
arthrotomy.
The
diagnosis
of
a
septic
arthritis
had
to
be
confirmed
by
a
posi-
tive
culture
of
the
joint
fluid
or
by
histopathologic
examination.
The
analysis
excluded
patients
with
osteomyelitis
or
any
implant
in
a
contiguous
bone
or
soft
tissue
of
the
affected
joint.
The
medical
and
radiologic
records
of
59
patients
were
available
for
final
analysis.
A
pretreatment
joint
aspiration
for
microbiological
diagnostic
was
conducted
in
all
study
participants.
Laboratory
studies
included
in-
flammatory
parameters,
such
as
C-reactive
protein
(CRP,
in
mg/
dL)
and
white
blood
cell
(WBC,
in
G/L)
count,
as
well
as
blood
culture
at
the
initial blood
examination.
Data
obtained
from
each
patient
comprised
demographic
data
(sex,
age
at
surgery,
duration
of
symptoms
before
presentation,
body
mass
index
[BMI]),
medical
history,
and
comorbidities.
The
Charlson
Comorbidity
Index
(CCI)
was
also
applied
to
summarize
comorbidities.
5
Range
of
motion
(ROM)
in
abduction
was
determined
before
and
after
surgery.
The
postoperative
ROM
data
were
chosen
from
the
latest
available
examination.
Radiographs
of
the
affected
shoulder
were
performed
in
all
patients,
and
the
Kellgren
and
Lawrence
classification
was
used
to
determine
osteoarthritis
severity.°
The
intra-articular
inflammato-
ry
process
was
graded
by
Gachter's
classificafion
24
:
stage
I
indicates
turbid
effusion,
mild
synovitis,
possible
petechial
bleeding,
and
no
radiologic
alterations;
stage
II,
purulent
effusion,
fibrinous
deposi-
tion,
pronounced
synovitis,
and
no
radiologic
alterations;
stage
III,
synovial
adhesions,
hypertrophic
synovitis,
necrotic
areas
of
synovia
and
cartilage,
and
no
radiologic
alterations;
and
stage
W,
aggressive
pannus,
cartilage
necrosis,
bone
erosions,
and
osteoly-
sis.
Days
of
hospitalization
and
length
of
surgery
were
also
registered.
Treatment
Intravenous
antibiotic
therapy
commenced
after
initial
joint
aspi-
ration.
Cefazolin
was
generally
given
except
in
patients
allergic
to
penicillin
or
cephalosporins.
In
such
a
case,
treatment
was
switched
to
clindamycin.
Dependent
on
culture
results,
the
antibiotic
therapy
was
adapted
in
consultation
with
the
department
of
infectious
dis-
eases.
Antibiotics
were
routinely
administered
for
6
weeks
after
surgery
and
replaced
with
an
oral
medication
after
discharge.
The
choice
of
intervention
method,
arthroscopy
or
open
ar-
throtomy,
was
subject
to
the
personal
preference
of
the
executing
consultant
orthopedic
surgeon.
Operations
were
conducted
with
pa-
tients
under
general
anesthesia
and
in
the
beach-chair
position.
Arthroscopy
was
performed
in
21
patients,
and
38
were
treated
with
open
arthrotomy.
An
anterior
deltopectoral
approach
with
subscapu-
laris
tenotomy
was
generally
used
in
case
of
arthrotomy.
For
arthroscopy
3
or
4
standard
portals
were
used:
a
posterior,
an
anterosuperior,
and
a
lateral
portal,
or
alternatively,
a
posterior,
an
anterosuperior,
an
anterolateral,
and
a
posterolateral
portal.
Both
surgical
procedures
included
synovectomy,
debridement,
and
joint
irrigation
with
sterile
physiological
sodium
saline
solu-
tion
as
well
as
sampling
for
microbiological
and
histopathologic
examination.
Debridement,
synovectomy,
and
irrigation
were
per-
formed
in
the
joint
and
in
the
subacromial
space.
Saline
irrigation
was
performed
with
3
to
5
liters
in
the
arthrotomy
group
and
with
5
to
20
liters
in
the
arthroscopy
group.
A
complete
bursectomy
was
routinely
performed.
No
local
antibiotics
were
applied.
At
least
1
suction
drain
was
used
and
usually
left
for
5
days.
Patients
were
encouraged
to
put
the
arm
in
a
sling
for
at
least
4
to
5
days
postoperatively.
In
case
of
complete
subscapularis
te-
notomy,
a
sling
was
necessary
for
3
weeks,
and
outward
rotation
was
not
allowed
for
6
weeks.
Patients
were
usually
seen
at
2
weeks,
6
weeks,
and
at
3,
6,
and
12
months
after
discharge
in
the
outpatient
clinic
for
treat-
ment
response
evaluation.
These
visits
included
physical
examination
and
blood
testing.
Recurrence
of
infection
was
suspected
when
inflammatory
parameters
increased
anew
or
were
persistently
elevated,
pain
in
the
affected
joint
increased,
or
purulent
joint
swelling
recurred.
In
the
event
of
a
recurring
infection,
the
patient
was
readmitted
to
our
institution,
and
an
additional
debridement
was performed.
The
median
(25th,
75th
percentile)
follow-up
was
28
(17,
34)
months.
Statistical
analysis
First,
a
descriptive
statistic
assessment
was
performed.
Continu-
ous
variables
are
described
by
median
(25th
and
75th
percentile)
when
Surgical
treatment
options
of
shoulder
infections
3
appropriate.
The
x
2
test
was
used
to
compare
the
reinfection
rate
in
the
arthroscopy
and
the
open
arthrotomy
groups.
Differences
in
the
presence
of
potential
confounders
between
the
2
surgery
groups
and
between
patients
with
primary
infection
eradication
and
those
with
reinfection
were
analyzed.
The
following
parameters
were
evalu-
ated:
age,
diabetes
mellitus
(DM),
rheumatoid
arthritis
(RA),
positive
culture
of
S
aureus,
CCI,
Kellgren
and
Lawrence
grade,
Gachter
score,
preoperative
CRP
and
WBC
levels,
duration
of
symptom
before
pre-
sentation,
BMI,
height,
weight,
and
sex.
These
evaluations
were
done
using
the
Mann-Whitney
U
test
and
the
x
2
test.
Odds
ratios
and
95%
confidence
intervals
were
used
to
describe
the
influence
of
poten-
tial
risk
factors
for
reinfection,
applying
logistic
regression
as
the
calculation
method.
A
comparison
of
the
postoperative
ROM
was
drawn
between
the
2
surgical
techniques
and
between
the
reinfec-
tion
group
and
the
primary
eradication
group.
Again,
these
comparisons
were
made
using
the
Mann-Whitney
U
test.
Values
of
P
.05
were
considered
as
statistically
significant.
The
statistical
analysis
was
performed
with
IBM
SPSS
20
software
(IBM,
Armonk,
NY,
USA).
Demographics
The
presented
study
included
59
patients
with
a
median
(25th,
75th
percentile)
age
of
72
(57,
82)
years.
Table
I
summarizes
the
patient
characteristics.
Open
arthrotomy
was
performed
in
38
patients
(64.4%),
and
21
(35.6%)
underwent
arthroscopic
treatment.
Iden-
tification
of
the
causative
organism
from
joint
fluid
was
possible
in
31
patients
(52.5%).
A
diagnosis
of
septic
arthritis
was
confirmed
in
the
remaining
patients
by
histopathologic
examination.
S
aureus
was
the
most
commonly
found
(18
[30.5%0]
patients)
isolate.
In
4
of
these,
a
methicillin-resistant
S
aureus
(MRSA)
grew
in
the
culture.
The
following
other
bacteria
were
registered:
Streptococcus
spp
in
4
patients
(6.8%),
other
Staphylococcus
spp
than
S
aureus,
includ-
ing
S
epidermidis,
in
5
patients
(8.5%),
Pseudomonas
aeruginosa
in
2
patients
(3.4%),
and
extended-spectrum
p-lactamase-producin
g
Enterobacteriaceae
in
1
patient.
Regarding
the
etiology
of
the
infection,
23
patients
(39%)
re-
ported
previous
intra-articular
corticosteroid
injections,
hematogenous
spread
with
confirmed
primary
focus
was
found
in
18
patients
Table
I
Patient
characteristics
and
differences
between
the
arthroscopy
and
arthrotomy
groups
Variable
Total
Arthrotomy
Arthroscopy
P
value
Patients
59
38
(64.4)
21
(35.6)
Reinfection
18
(30.5)
7
(18.4)
11
(52.4)
.007
Female
34
(57.6)
25
(65.8)
9
(42.9)
.088
Age,
y
72
(57,
82)
74
(58,
83)
71
(57,
77)
.501
Weight,
kg
68
(58,
83)
67
(55,
85)
70
(60,
81)
.926
Height,
cm
167
(158,
175)
165
(156,
176)
168
(163,
174)
.378
Body
mass
index,
kg/m
2
24.6
(21.8,
27.1)
25.1
(21.8,
28.1)
24.5
(22,
27)
.511
Hospitalization,
d
12
(7,
19)
12
(5,
21)
11
(7,
18)
.804
Duration
of
symptoms,
d
4
(3,
7)
5
(3,
7)
4
(2,
6)
.494
CCI
5
(4,
8)
5
(4,
8)
6
(3,
8)
.439
Rheumatoid
arthritis
6
(10.2)
5
(13.2)
1
(4.8)
.307
Diabetes
mellitus
13
(22)
9
(23.7)
4
(19)
.681
Staphylococcus
aureus
18
(30.5)
11
(28.9)
7
(33.3)
.726
CRP
presurgery,
mg/dl
14.3
(6.6,
20.9)
17
(8.1,
23.2)
8
(3,
19.3)
.066
WBC
count
presurgery,
G/L
11.3
(8.5,
14.1)
10.9
(8.6,
14.2)
11.8
(7.5,
13.6)
.546
Length
of
surgery,
min
45
(30,
55)
45
(35,
50)
45
(25,
60)
.950
Gachter
.010
I
16
(28.1)
5
(13.5)
11
(55)
II
21
(36.8)
16
(43.2)
5
(25)
III
17
(29.8)
14
(37.8)
3
(15)
IV
3
(5.3)
2
(5.4)
1
(5)
Kellgren
and
Lawrence
.346
0
9
(15.3)
6
(15.8)
3
(14.3)
I
6
(10.2)
2
(5.3)
4
(19)
II
22
(37.3)
17
(44.7)
5
(23.8)
III
14
(23.7)
8
(21.1)
6
(28.6)
IV
8
(13.6)
5
(13.2)
3
(14.3)
Etiology
of
infection
.869
Intra-articular
injections
23
(39)
14
(36.8)
9
(42.9)
Hematogenous
spread
18
(30.5)
12
(31.6)
6
(28.6)
Causative
trauma
1
(1.7)
1
(2.6)
Unknown
17
(28.8)
11
(28.9)
6
(28.6)
CCI,
Charleston
Comorbidity
Index;
CRP,
C-reactive
protein;
WBC,
white
blood
cell.
*
Values
for
continuous
data
are
presented
as
the
median
(25th
percentile,
75th
percentile)
and
for
continuous
data
as
number
(%).
t
Bold
values
are
statistically
significant
(P
<
.05).
4
C.
Bailer
et
al.
(30.5%),
and
a
causative
trauma
could
be
identified
in
1
patient.
The
origin
remained
unknown
in
17
patients
(28.8%).
Results
A
reinfection
necessitating
a
second
surgery
occurred
in
18
patients
(30.5%).
The
reinfection
rate
was
significantly
higher
in
patients
who
were
treated
arthroscopically
(
11
[52.4%])
than
in
those
who
underwent
open
arthrotomy
(7
[18.4%];
P
=
.007).
Of
the
18
patients
with
recurrent
infection,
15
(83%)
were
treated
with
open
arthrotomy
and
3
(17%)
arthroscopically.
We
compared
the
2
surgery
groups
regarding
the
pres-
ence
of
potential
risk
factors.
No
differences
between
the
2
surgery
groups
were
found
concerning
age,
sex,
BMI,
number
of
patients
with
RA, number
of
patients
with
DM,
number
of
patients
with
S
aureus
infection,
CCI,
etiology
of
infec-
tion,
Kellgren
and
Lawrence
score,
preoperative
CRP
levels,
preoperative
WBC
levels,
durations
of
symptoms
before
therapy,
duration
of
hospitalization,
and
duration
of
surgery.
The
Gachter
score
differed
significantly
between
the
2
groups.
The
open
arthrotomy
group
(P
=
.010)
showed
higher
grades.
Table
I
provides
a
detailed
report
of
the
2
surgery
groups
and
the
corresponding
P
values.
Of
all
analyzed
potential
risk
factors,
S
aureus
was
sig-
nificantly
more
often
discovered
in
patients
with
reinfection
(P
=
.034).
The
number
of
MRSA
infections
(4
patients)
in
this
study
was
too
low
to
be
considered
for
separate
analy-
sis.
All
patients
with
MRSA
infection
were
initially
treated
with
open
arthrotomy,
of
which
2
had
a
recurrent
infection.
Other
parameters,
such
as
age,
sex,
BMI,
number
of
pa-
tients
with
RA,
number
of
patients
with
DM,
CCI,
osteoarthritis,
Gachter
score,
preoperative
CRP
levels,
pre-
operative
WBC
levels,
etiology
of
infection,
durations
of
symptoms
before
therapy,
and
duration
of
surgery,
did
not
differ
between
the
reinfection
group
and
the
primary
eradi-
cation
group.
Table
II
summarizes
these
results.
Table
II
Differences
between
primary
eradication
group
and
reinfection
group
Variable
Primary
eradication
Reinfection
P
values
Patients
41
(69.5)
18
(30.5)
Female
24
(58.5)
10
(55.6)
.831
Age,
y
73
(54,
83)
72
(65,
78)
.954
Weight,
kg
68
(59,
84)
63
(55,
80)
.440
Height,
cm
167
(160,
170)
170
(158,
175)
.552
Body
mass
index,
kg/m
2
24.6
(22,
27.5)
24.6
(21.6,
26.3)
.475
Hospitalization,
d
10
(6,
18)
13
(8,
21)
.150
Duration
of
symptoms,
d
4
(2,
7)
6
(3,
26)
.086
CCI
5
(3,
8)
7
(5,
8)
.263
Rheumatoid
arthritis
3
(7.3)
3
(16.7)
.274
Diabetes
mellitus
9
(22)
4
(22.2)
.982
Staphylococcus
aureus
9
(22)
9
(50)
.034
CRP
presurgery,
mg/dL
15
(7.4,
20.3)
9.1
(3.5,
24.5)
.649
WBC
count
presurgery,
G/L
11.3
(8.6,
14.2)
10.8
(8,
12.6)
.371
Length
of
surgery,
min
45
(30,
55)
45
(40,
50)
1.000
Gachter
.463
I
10
(25.6)
6
(33.3)
II
13
(33.3)
8
(44.4)
III
13
(33.3)
4
(22.2)
IV
3
(7.7)
0
Kellgren
and
Lawrence
.938
0
6
(14.6)
3
(16.7)
I
5
(12.2)
1
(5.6)
II
15
(36.6)
7
(38.9)
III
10
(24.4)
4
(22.2)
IV
5
(12.2)
3
(16.7)
Etiology
of
infection
.876
Intra-articular
injections
16
(39)
7
(38.9)
Hematogenous
spread
13
(31.7)
5
(27.8)
Causative
trauma
1
(2.4)
Unknown
11
(26.8)
6
(33.3)
CCI,
Charleston
Comorbidity
Index;
CRP,
C-reactive
protein;
WBC,
white
blood
cell.
*
Values
for
continuous
data
are
presented
as
the
median
(25th
percentile,
75th
percentile)
and
for
continuous
data
as
number
(%).
t
Bold
values
are
statistically
significant
(P
<
.05).
Surgical
treatment
options
of
shoulder
infections
5
Table
III
Logistic
regression
of
independent
risk
factors
for
reinfection
Variable
Odds
ratio
95%
CI
P
values*
Surgery
type
7.6
1.6-35.1
.01
Staphylococcus
aureus
8.7
1.6-46.6
.011
CCI
1.5
1.1-2
.021
Gachter
score
0.5
0.23-1.3
.163
CCI,
Charleston
Comorbidity
Index;
Cr,
confidence
interval.
*
Bold
values
are
statistically
significant
(P
<
.05).
Consequently,
logistic
regression
was
performed
to
eval-
uate
independent
risk
factors
for
failure
of
a
single
surgery.
hi
the
model,
the
type
of
surgery,
infection
with
S.
aureus,
and
the
CCI
could
be
identified
as
influencing
risk
factors
for
reinfection.
Gachter's
score
was
included
in
the
analysis
of
this
model
but
did
not
show
significant
influences.
Table
III
assembles
the
results
and
shows
the
odds
ratios
and
95%
con-
fidence
intervals.
Evaluating
the
postoperative
functional
outcome,
no
dif-
ferences
between
patients
with
reinfection
and
with
successful
primary
surgery
or
between
the
2
surgery
groups
could
be
found.
Median
(25th,
75th
percentile)
ROM
reached
80°
(45°,
90°)
in
the
reinfection
group,
100°
(45°,
145°)
in
the
suc-
cessful
primary
surgery
group
(P
=
.785),
100°
(30°,
170°)
in
the
arthroscopy
group,
and
90°
(50°,
100°)
in
the
open
ar-
throtomy
group
(P
=
.732).
Discussion
Septic
arthritis
is
a
rare
but
severe
and
potentially
lethal
disease"
that
requires
immediate
antibiotic
therapy
and
sur-
gical
joint
decompression.'
Up
to
now,
only
few
studies
have
compared
the
surgical
treatment
options:
arthroscopy
and
open
arthrotomy.
Most
of
these
studies
focused
on
infections
of
the
knee
or
did
not
distinguish
between
single
joints.
2-4,11,29
Information
about
the
treatment
of
infections
of
the
gleno-
humeral
joint
is
scarce,
and
surgical
treatment
concepts
may
differ
from
those
of
the
knee.
To
the
best
of
our
knowledge,
this
is
the
largest
series
to
compare
treatment
outcome
of
bac-
terial
shoulder
infections.
hi
the
current
study,
we
could
demonstrate
that
the
reinfection
rate
was
significantly
lower
in
patients
who
were
treated
with
open
arthrotomy
than
in
patients
who
underwent
arthroscopy.
The
study
further
iden-
tified
S
aureus
infection
and
increasing
CCI
scores
as
independent
risk
factors
for
failure
of
a
single
operation.
In
the
present
study,
overall
70%
of
the
patients
with
shoul-
der
infection
were
successfully
treated
with
a
single
operation.
These
results
are
comparable
with
other
reports,
which
de-
scribed
primary
success
rates
between
68%
and
74%2'
12
Generally,
the
reinfection
rate
appears
to
be
slightly
higher
in
the
shoulder
than
in
the
knee,
where
primary
salvage
rates
between
82%
and
90%
were
reported.
4,20,26
hi
the
open
ar-
throtomy
group,
a
single
operation
led
to
infection
eradication
in
82%
of
our
cohort.
Results
were
significantly
poorer
in
the
arthroscopy
group,
where
a
single
debridement
was
only
suc-
cessful
in
48%.
Logistic
regression
also
identified
arthroscopy
as
a
risk
factor
for
reinfection.
So
far,
to
our
knowledge,
no
studies
are
available
com-
paring
arthroscopy
and
open
arthrotomy
exclusively
in
infections
of
the
shoulder.
By
comparison,
in
infections
of
the
knee,
patients
treated
arthroscopically
showed
a
more
fa-
vorable
outcome
with
lower
reinfection
rates.
3
A
2°
Therefore,
the
significantly
better
results
of
the
open
arthrotomy
group
are
very
intriguing.
In
our
opinion,
the
communication
between
the
glenohumeral
joint
and
the
subacromial
space,
especial-
ly
the
subacromial
bursa,
might
be
responsible.
Likewise,
tears
in
the
rotator
cuff
and
in
the
capsule,
especially
in
elderly
patients,
are
common.
22
'
25
Hence,
arthroscopic
high-pressure
irrigation
could
lead
to
dissemination
of
microorganisms
in
the
surrounding
soft
tissue
and
might
be
responsible
for
an
infection
recurrence.
Moreover,
an
involvement
of
the
sub-
acromial
bursa
is
prevalent
in
shoulder
infections.
Again,
arthroscopic
bursectomy
and
high-pressure
irrigation
could
cause
a
spread
of
bacteria.
We
found
no
differences
between
the
2
groups
regarding
the
presence
of
potential
confounders
that
could
have
influ-
enced
the
reinfection
rate.
Only
the
Gachter
score
was
higher
in
the
open
arthrotomy
group.
The
homogeneity
of
the
2
groups
confirms
the
independent
influence
of
the
surgery
type
on
the
reinfection
group.
Furthermore,
al-
though
the
open
arthrotomy
is
the
more
invasive
procedure,
we
found
no
differences
regarding
the
duration
of
surgery
and
the
duration
of
hospitalization.
Also
the
ROM
in
abduction
did
not
differ
between
the
open
arthrotomy
and
the
arthroscopy
group.
Different
results
are
described
for
the
knee,
with
a
significantly
better
functional
outcome
after
arthroscopy.
4,20,29
hi
the
current
study
we
analyzed
several
confounders
and
their
influence
on
the
recurrence
of
infection.
As
in
other
studies,
S
aureus
was
the
most
common
bacterial
isolate.
11,12'21
It
was
detected
in
31%,
and
after
patients
with
no
growth
on
culture
were
excluded,
S
aureus
accounted
for
58%
of
in-
fections.
S
aureus
was
significantly
more
often
found
in
patients
with
reinfection
and
could
be
identified
as
an
inde-
pendent
risk
factor
for
reinfection
in
multivariate
analysis.
These
results
are
in
line
with
a
previous
report.'
The
number
of
patients
with
S
aureus
infection
did
not
differ
between
the
2
surgery
groups.
Also
analyzed
was
the
influence
of
comorbidities
on
re-
infection,
including
DM,
RA,
immunosuppressing
diseases,
the
CCI,
and
age.
With
the
numbers
available,
no
single
comorbidity
significantly
influenced
the
reinfection
rate.
The
influence
of
risk
factors
such
as
DM
and
RA
might
be
un-
derestimated
because
of
the
limited
sample
size.
However,
the
multivariate
analysis
showed
that
patients
with
a
de-
creased
general
condition
(ie,
higher
CCI
scores)
are
at
increased
risk
for
failure
of
primary
surgery.
Other
risk
factors
that
have
been
discussed
in
the
literature,
such
as
duration
of
symptoms
before
treatment
and
Gachter
score,
showed
no
negative
influence
on
the
reinfection
rate
in
our
cohort.
3
'
29
To
6
C.
BMler
et
al.
further
investigate
the
influence
of
comorbidities,
larger
pro-
spective
studies
are
needed.
Our
study
has
several
limitations.
Firstly,
data
were
ac-
quired
retrospectively,
and
therefore,
no
randomization
to
one
of
the
surgical
treatments
was
conducted.
A
consultant
or-
thopedic
surgeon
decided,
based
on
personal
preferences,
which
operation
should
be
performed.
Furthermore,
owing
to
the
retrospective
design,
the
only
available
functional
outcome
parameter
was
the
ROM
in
abduction.
In
many
cases
no
standardized
scores
or
pain
assessments
were
available
and,
therefore,
could
not
be
included
in
the
study.
Secondly,
different
surgeons
performed
the
surgical
pro-
cedures;
however,
all
procedures
were
performed
by
experienced
orthopedic
surgeons.
Thirdly,
magnetic
resonance
imaging
was
not
available
for
a
sufficient
number
of
patients
to
correlate
imaging
findings
and
surgical
success
rates.
Fourthly,
the
sample
size
was
limited
to
59
patients
with
a
substantial
recruiting
period
of
14
years.
Given
the
sample
size
of
59
patients,
the
influence
of
potential
risk
factors
might
have
been
underestimated.
However,
this
is
still
one
of
the
largest
studies
on
treatment
of
septic
shoulder
infections
cur-
rently
available
in
the
literature.
Based
on
the
numbers
available,
our
findings
might
be
helpful
for
surgical
deci-
sion
making
in
clinical
practice.
Future
studies
with
larger
sample
sizes
including
prospective
randomized-controlled
trials
are
needed
to
confirm
the
current
findings.
Conclusion
This
study
demonstrated
that
open
arthrotomy
was
a
more
effective
treatment
method
in
septic
arthritis
of
the
shoul-
der,
with
lower
reinfection
rates
and
a
comparable
functional
outcome.
Furthermore,
we
could
identify
S
aureus
and
the
CCI
as
an
independent
risk
factor
for
re-
currence
of
infection.
Disclaimer
The
authors,
their
immediate
families,
and
any
research
foundation
with
which
they
are
affiliated
have
not
re-
ceived
any
financial
payments
or
other
benefits
from
any
commercial
entity
related
to
the
subject
of
this
article.
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