Shoulder Arthroplasty: Doxy + Cefazolin No Better than Cefazolin Alone Against P. Acnes
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD, in response to a recent study in JBJS.
Propionibacterium acnes (now called Cutibacterium acnes, according to an updated classification) is a ubiquitous microbe in the setting of shoulder surgery and is a well-established cause of indolent infection and prosthetic loosening1,2. In 2016, JBJS published a study by Hsu et al. investigating single-stage revision shoulder replacement in patients with subclinical infection, and the authors reported that almost half of the patients had >2 positive cultures for P. acnes3. However, the exact consequence of positive cultures at the time of primary surgery is unknown, and the efficacy of specific antibiotic prophylaxis against this microbe remains unclear.
In the June 6, 2018 issue of JBJS, Rao et al. randomised 56 patients scheduled to undergo a primary anatomic or reverse total shoulder replacement to receive either preoperative cefazolin alone (n=27) or a combination of cefazolin and doxycycline (n=29) 4. All patients had standard skin preparation at the time of surgery with both alcohol and chlorhexidine.
The primary outcome measure was ≥1positive culture after 14 days of incubation from either superficial and/or deep-tissue samples taken intraoperatively. The authors deemed that a decrease of 50% in the positive culture rate would be clinically significant. However, they found no significant difference between the groups in terms of the primary outcome measure (p=0.99). The authors carried out a secondary analysis to determine which other factors might be associated with ≥1 positive P. acnes culture and found that younger age, male sex, and a lower Charlson Comorbidity Index were predictive. Although this study was potentially underpowered, it demonstrated that in patients undergoing primary shoulder arthroplasty, preoperative doxycycline does not significantly reduce the prevalence of positive culture rates for P. acnes.
These findings are similar to those found in previous research and should lead us to question whether preoperative antibiotics aimed specifically at preventing P. acnes infection associated with shoulder arthroplasty are truly useful. P. acnes infections are difficult to detect both clinically and via culture—which makes any intervention difficult to measure, especially in a potentially underpowered study. Consequently, larger studies in this area would help to more definitively determine whether preoperative antibiotics aimed specifically at P. acnes decrease infection rates or, instead, may be adding to the growing problem of bacterial resistance. In particular, such trials seem most useful when they focus on patients who are at higher risk of these specific infections—in this case, younger, healthy males.
Finally, as Rao et al. wisely observed, doxycycline is a bacteriostatic agent, which slows the growth and production of bacteria, rather than a bactericidal agent, which kills bacteria. Given that antimicrobial limitation, doxycycline might not be the most appropriate prophylactic drug to be investigating for these cases.
Andrew D. Duckworth, MSc, FRCSEd(Tr&Orth), PhD is a consultant orthopaedic trauma surgeon at Edinburgh Orthopaedic Trauma, Royal Infirmary of Edinburgh, and he is a member of the JBJS Social Media Advisory Board.
References
- Gausden EB, Villa J, Warner SJ, Redko M, Pearle A, Miller A, Henry M, Lorich DG, Helfet DL, Wellman DS. Nonunion After Clavicle Osteosynthesis: High Incidence of Propionibacterium acnes. J Orthop Trauma. 2017 Apr;31(4):229-235.
- Chuang MJ, Jancosko JJ, Mendoza V, Nottage WM. The Incidence of Propionibacterium acnes in Shoulder Arthroscopy. 2015 Sep;31(9):1702-7.
- Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA III. Single-Stage Revision Is Effective for Failed Shoulder Arthroplasty with Positive Cultures for Propionibacterium. J Bone Joint Surg 2016;98:2047-2051.
- Rao AJ, Chalmers PN, Cvetanovich GL, O’Brien MC, Newgren JM, Cole BJ, Verma NN, Nicholson GP, Romeo AA. Preoperative Doxycycline Does Not Reduce Propionibacterium acnes in Shoulder Arthroplasty. J Bone Joint Surg Am. 2018 Jun 6;100(11):958-964.
JBJS 100: Massive Rotator Cuff Tears, Continuous Passive Motion
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears
L M Galatz, C M Ball, S A Teefey, W D Middleton, K Yamaguchi: JBJS, 2004 February; 86 (2): 219
In one of the earliest studies to investigate the relationship between the anatomic integrity of arthroscopic rotator cuff repair and clinical outcome, these authors found that the rate of recurrent defects was high but that at 12 months after surgery, patients experienced excellent pain relief and functional improvement. However, at the 2-year follow-up, the clinical results had deteriorated substantially. Investigations into the relationship between cuff-repair integrity and clinical outcomes are ongoing.
The Biological Effect of Continuous Passive Motion on the Healing of Full-thickness Defects in Articular Cartilage: An Experimental Investigation in the Rabbit
R B Salter, D F Simmonds, B W Malcolm, E J Rumble, D Macmichael, N D Clements: JBJS, 1980 January; 62 (8): 1232
In this paper, Salter and colleagues hypothesized that “continuous passive motion [CPM] of a synovial joint in vivo would have a beneficial biological effect on the healing of full-thickness defects in articular cartilage.” They found that CPM stimulated more rapid and complete cartilage restoration than either immobilization or intermittent active motion, and since then CPM has been commonly used in humans after cartilage repair. However, CPM’s actual efficacy in people—after cartilage repair or total knee arthroplasty—remains controversial.
JBJS 100: Shoulder Impingement and Distraction Osteogenesis
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Anterior Acromioplasty for Chronic Impingement Syndrome in the Shoulder
C S Neer: JBJS, 1972 January; 54 (1): 41
For many years after its publication, this 1972 JBJS article changed the treatment approach for patients with shoulder disability. But more recently, arthroscopy and magnetic resonance imaging arthrography have identified other painful non-impingement shoulder conditions. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete rotator cuff tear, and performing aggressive rehabilitation prior to corrective surgery.
Use of the Ilizarov Technique for Treatment of Non-union of the Tibia Associated with Infection
G K Dendrinos, S Kontos, E Lyritsis: JBJS, 1995 June; 77 (6): 835
This case series described a technique of bone transport with bridging achieved by distraction osteogenesis. The defects averaged 6 cm, the mean duration of treatment was 10 months, and the mean time to union was 6 months. More recent research has focused on augmenting the osteogenic potential of tissues in the distraction gap with substances such as bone morphogenetic protein, platelet-rich plasma, and mesenchymal stem cells.
May 24 Webinar – Proximal Humerus Fractures: Improving Outcomes Amid Uncertainty
The incidence of proximal humerus fractures is increasing with the aging of the population worldwide and the associated rise in prevalence of osteopenia and osteoporosis. Anecdotally, the incidence of high-energy proximal humerus fractures in the nonelderly also seems to be on the rise. In cases of complex, comminuted fractures, interest in surgical management has increased due to favorable reported outcomes with locking-plate fixation and reverse shoulder arthroplasty.
Still, many questions remain about how best to manage these fractures in individual patients and by surgeons with varying levels of experience. Beyond the dilemma of operative versus nonoperative management lie many decisions about technical details if surgical treatment is selected.
On Thursday, May 24, 2018 at 8:00 pm EDT, the Journal of Shoulder and Elbow Surgery (JSES) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar—co-moderated by JSES Editor-in-Chief Bill Mallon, MD and JBJS Deputy Editor Andy Green, MD—that will address some of these questions.
JSES co-author Mark Frankle, MD will discuss findings from a recently published decision analysis that found experienced shoulder surgeons agreeing on optimal treatment for these fractures only 64% of the time. Patients may have poorer range-of-motion outcomes in scenarios where uncertainty exists.
Brent Ponce, MD, co-author of a cadaveric study published in JBJS, explains how his research team concluded that medial comminution is a predictor of poor stability in proximal humerus fractures treated with locking plates, but that stability may be improved in such cases (and in non-comminuted fractures) when fixation includes the calcar.
After each author’s presentation, an additional shoulder-fracture expert will add clinical perspective to these important findings. Xavier Duralde, MD will shed additional light on Dr. Frankle’s paper, and Joaquin Sanchez-Sotelo, MD will comment on Dr. Ponce’s paper. During the last 15 minutes of the webinar, a live Q&A session will provide the audience with the opportunity to question the panelists about the concepts and data presented.
Seats are limited, so Register Now.
What’s New in Sports Medicine 2018
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Albert Gee, MD, a co-author of the April 18, 2018 Specialty Update on Sports Medicine, to select the five most clinically compelling findings from among the 30 studies cited in the article.
Anterior Cruciate Ligament (ACL) Reconstruction
–The conversations about graft selection for ACL reconstruction go on. A meta-analysis of 19 Level-I studies comparing 4-strand hamstring autograft with patellar tendon grafts1 revealed no differences in terms of rupture rate, clinical outcome scores, or arthrometer side-to-side testing at >58 months of follow-up. The prevalence of anterior knee pain and kneeling pain was significantly less in the hamstring group, and that group also exhibited a lower rate of extension deficit.
Cartilage Repair
–Fourteen-year outcomes from a randomized controlled trial (n = 80 patients) comparing autologous chondrocyte implantation (ACI) with microfracture for treating large focal cartilage defects included the following:
- No significant between-group difference in functional outcome scores
- Fairly high treatment failure rates in both groups (42.5% in the ACI group; 32.5% in the microfracture group)
- Radiographic evidence of grade 2 or higher osteoarthritis in about half of all patients
These findings raise doubts about the long-term efficacy of these two treatments.
Rehab after Rotator Cuff Repair
–A randomized trial comparing early and delayed initiation of range of motion after arthroscopic single-tendon rotator cuff repair in 73 patients2 found no major differences in clinical outcome, pain, range of motion, use of narcotics, or radiographic evidence of retear. The early motion group showed a small but significant decrease in disability. The findings indicate that early motion after this surgical procedure may do no harm.
Platelet-Rich Plasma (PRP)
–A systematic review of 105 human clinical trials that examined the use of PRP in musculoskeletal conditions revealed the following:
- Only 10% of the studies clearly explained the PRP-preparation protocol.
- Only 16% of the studies provided quantitative information about the compositi0on of the final PRP product.
- Twenty-four different PRP processing systems were used across the studies.
- Platelet composition in the PRP preparations ranged from 38 to 1,540 X 103/µL.
Consequently, care should be taken when drawing conclusions from such studies.
Meniscal Tear Treatment
–A follow-up to the MeTeOR trial (350 patients initially randomized to receive either a partial arthroscopic meniscectomy or physical therapy [PT]) found that crossover from the PT group to the partial meniscectomy group was significantly associated with higher baseline pain scores or more acute symptoms within 5 months of enrollment. Investigators also found identical 6-month WOMAC and KOOS scores between those who crossed over and those who had surgery initially. These findings suggest that an initial course of PT prior to meniscectomy does not compromise outcomes.
References
- Chee MY, Chen Y, Pearce CJ, Murphy DP, Krishna L, Hui JH, Wang WE, Tai BC,Salunke AA, Chen X, Chua ZK, Satkunanantham K. Outcome of patellar tendon versus 4-strand hamstring tendon autografts for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of prospective randomized trials. Arthroscopy. 2017 Feb;33(2):450-63. Epub 2016 Dec 28.
- Mazzocca AD, Arciero RA, Shea KP, Apostolakos JM, Solovyova O, Gomlinski G, Wojcik KE, Tafuto V, Stock H, Cote MP. The effect of early range of motion on quality of life, clinical outcome, and repair integrity after arthroscopic rotator cuff repair. Athroscopy. 2017 Jun;33(6):1138-48. Epub 2017 Jan 19.
JBJS 100: Metal-on-Metal Hips and Shoulder Function
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Metal-on-Metal Bearings and Hypersensitivity in Patients with Artificial Hip Joints
H-G Willert, G H Buchhorn, A Fayyazi, R Flury, M Windler, G Köster, C H Lohmann: JBJS, 2005 January; 87 (1): 28
At the turn of the 21st century, many efforts were underway to discover why some patients who had received second-generation metal-on-metal hip replacements were having postoperative problems. This clinical and histomorphological study, illustrated with detailed tissue sections, showed that a lymphocyte-dominated immunological response could be involved.
Observations on the Function of the Shoulder Joint
V T Inman, J B deC M Saunders, L C Abbott: JBJS, 1944 January; 26 (1): 1
Back in the days when 30-page JBJS articles were not uncommon, these authors set out to examine the whole shoulder mechanism, with detailed anatomical drawings, radiographic analysis, and action potentials derived from living shoulder muscles. This comprehensive, “eclectic approach” was published at a time when polio was endemic, but it is still relevant today.
Long-Term Outcomes of Glenohumeral Arthrodesis
Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. https://bit.ly/2HuHYBb #JBJS
Outcomes from Shoulder Fusion Are Durable, Not Spectacular
Glenohumeral arthrodesis is a salvage operation, so most patients and surgeons considering this option don’t have expectations of spectacular functional outcomes. Improving stability and relieving pain are usually the main goals. In the April 4, 2018 edition of The Journal of Bone & Joint Surgery, a retrospective study by Wagner et al. sheds light on long-term results of this procedure (mean follow-up of 12 years) and the patient and surgical factors that might improve or worsen outcomes.
The authors reviewed electronic and paper medical records of 29 cases of glenohumeral arthrodesis performed between 1992 and 2009. They also analyzed patient questionnaires, which included DASH, SSV, and SF-36 scoring instruments.
All patients reported improvement in pain at the time of their latest postoperative follow-up. However, 12 patients (41%) had postoperative complications, including nonunions, fractures, and deep infections. Eleven patients (38%) required additional post-arthrodesis surgical procedures. The mean postoperative shoulder position was 60° in flexion and 13° in external rotation.
The authors identified the following correlations between patient/surgical factors and outcomes:
- Patients with a history of brachial plexus injuries had worse clinical and functional outcomes.
- Patients with shoulders fused in abduction and flexion of >25° had better shoulder function but a slightly higher risk of peri-fixation fracture.
- There were no significant outcome differences between procedures that used plate-and-screw and screw-only fixation. However, incorporation of the acromion in fixation was strongly associated with a lower risk of nonunion.
The authors conclude that despite the limitations of this complex salvage procedure, “its ability to relieve pain and to maintain reasonable upper-extremity function in select patients should not be overlooked.”
Clinical Outcomes Following the Latarjet Procedure in Contact and Collision Athletes
Few studies have evaluated the success of the Latarjet procedure for recurrent anterior glenohumeral instability in the contact or collision athlete. The purpose of this study was to evaluate the return-to-sport and functional results of the Latarjet procedure in this select group. https://bit.ly/2I2hB50 #JBJS
For Biceps Tenodesis, Bone-Tunnel and Cortical-Surface Fixation Are Equally Good
Many orthopaedic procedures involve reattaching a tendon to bone, but the decision as to whether that fixation is made through a bone tunnel or by cortical-surface attachment is usually left up to the surgeon’s preference. In the March 21, 2018 issue of The Journal of Bone & Joint Surgery, Tan et al. attempted to determine which fixation technique, in a rabbit model, provides better tendon-to-bone healing.
The rabbits in the bone-tunnel group and the cortical surface attachment group were killed 8 weeks after biceps tenodesis surgery, and the authors performed detailed biomechanical testing, microcomputed tomography analysis, and histological analysis to evaluate the tendon healing. Here’s what they found:
- There were no significant between-group differences in mean failure loads or stiffness.
- There were no significant between-group differences in mean volume of newly formed bone or in the mineral density of newly formed bone.
- In both groups, histological analysis revealed tendon-bone interdigitation and early fibrocartilaginous zone formation on the outer cortical surface. (This article includes interactive digital whole-slide images of cortical surface attachment and bone-tunnel fixation.)
These findings led the authors to conclude that “tendon fixation in a bone tunnel and on the cortical surface resulted in similar healing profiles.” Because both techniques facilitate good tendon-to-bone healing, surgeon preference will probably continue to dictate the decision to use one method over another.
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