The utility and cost of atypical cultures in revision shoulder arthroplasty.

BACKGROUND: At the time of revision shoulder arthroplasty, it is common practice to take cultures to evaluate for prosthetic joint infection even when an alternative cause of failure has been identified. Although isolation of fungal or acid-fast organisms is rare, it remains common practice to send all specimens for aerobic, anaerobic, and atypical (fungal and acid-fast) cultures. We hypothesize that the rate of positive atypical cultures at the time of revision shoulder arthroplasty is very low and routine use imposes a considerable financial burden on the health care system. METHODS: A retrospective review of all revision shoulder arthroplasties performed between January 1, 2010, and December 31, 2019, at our institution was performed. Patients with a hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, or pre-existing antibiotic spacer who underwent revision to hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty, antibiotic spacer, or resection arthroplasty were included. Electronic patient charts were reviewed to gather patient, surgical, and culture data. An analysis of the hospital billing charges associated with each culture was performed using our hospital billing database and the current procedural terminology (CPT) codes for aerobic, anaerobic, fungal, and acid-fast cultures. A secondary outcome analysis was performed to identify factors associated with positive cultures. RESULTS: A total of 237 revision shoulder arthroplasties performed on 189 patients were analyzed. Cultures were sent on 158 of 237 (66.7%) surgeries with an average of 2.2 specimens per surgery. A total of 341 aerobic, 331 anaerobic, 187 fungal, and 174 acid-fast cultures were collected. Positive cultures were found in 52 of 341 (15.2%) aerobic cultures and 36 of 331 (10.9%) anaerobic cultures. The most commonly isolated organism was Cutibacterium acnes (42.2%), followed by methicillin-resistant Staphylococcus aureus (15.6%), coagulase-negative Staphylococcus species (13.3%), and methicillin-sensitive S. aureus (12.2%). There were zero positive fungal or acid-fast cultures in our series. The total billing charges for aerobic, anaerobic, fungal, and acid-fast cultures over the study period were $77,748, $23,832, $8,789, and $106,662, respectively, with atypical cultures accounting for 53.2% of the total charges for all cultures. For a single sample sent for all 4 culture types, atypical cultures account for 69% of the total amount charged. CONCLUSION: Isolation of fungal or acid-fast organisms at the time of revision shoulder arthroplasty is rare and imposes a considerable financial burden when these atypical cultures are sent on a routine basis. The collection of fungal and acid-fast cultures should be reserved for patients in whom risk factors for these atypical organisms have been identified.

Treatment of Glenoid Wear with the Use of Augmented Glenoid Components in Total Shoulder Arthroplasty: A Scoping Review.

¼ Treatment of glenoid bone loss continues to be a challenge in total shoulder arthroplasty (TSA). Although correcting glenoid wear to patient's native anatomy is desirable in TSA, there is lack of consensus regarding how much glenoid wear correction is acceptable and necessary in both anatomic and reverse TSA.¼ Use of augmented glenoid components is a relatively new treatment strategy for addressing moderate-to-severe glenoid wear in TSA. Augmented glenoid components allow for predictable and easy correction of glenoid wear in the coronal and/or axial planes while at the same time maximizing implant seating, improving rotator cuff biomechanics, and preserving glenoid bone stock because of off-axis glenoid reaming.¼ Augmented glenoid components have distinct advantages over glenoid bone grafting. Glenoid bone grafting is technically demanding, adds to the surgical time, and carries a risk of nonunion and graft resorption with subsequent failure of the glenoid component.¼ The use of augmented glenoid components in TSA is steadily increasing with easy availability of computed tomography-based preoperative planning software and guidance technology (patient-specific instrumentation and computer navigation).¼ Although different augment designs (full wedge, half wedge, and step cut) are available and a particular design may provide advantages in specific glenoid wear patterns to minimize bone removal (i.e. a half wedge in B2 glenoids), there is no evidence to demonstrate the superiority of 1 design over others.

Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults.

BACKGROUND: We sought to determine whether any relevant patient, fracture, surgical, or postoperative characteristics are associated with loss of reduction after plate fixation of isolated olecranon fractures in adults. METHODS: Patients who underwent open reduction and internal fixation of an olecranon fracture at our institution over an 11-year period were analyzed. Electronic patient charts and radiographic images were reviewed to gather patient, fracture, surgical, and postoperative data. Statistical analysis to explore the differences between groups was performed. RESULTS: Seven of 96 patients experienced a loss of fracture reduction diagnosed at a median of 19 days after their initial surgery (range: 4-116 days). The radiographic mode of failure of all patients who lost reduction was proximal migration of the proximal fracture fragment with or without implant failure. The group that lost reduction had a significantly smaller proximal fragment (14.2 vs 18.6 mm), a higher incidence of malreduction with a persistent articular step-off greater than 2 mm (6/7 vs 14/89), a greater distance between the most proximal screw and the olecranon tip (19.8 vs 13.5 mm), a higher proportion of constructs with screws placed outside of the primary plate (4/7 vs 14/89), and a higher proportion of patients that were not immobilized postoperatively (3/7 vs 8/89). CONCLUSIONS: Our results suggest anatomical reduction at the articular surface and adequate fixation of the proximal fragment are key factors in maintenance of reduction, with smaller proximal fragments being at higher risk for failure. A period of postoperative immobilization may decrease the risk of loss of reduction.

Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review.

Neurologic injury during shoulder replacement is one of the less common complications of the procedure, however the clinical implications can be significant. The purpose of this paper is to review the current literature on neurologic complications in various types of shoulder replacement and provide recommendations regarding avoidance, evaluation, and management of these complications.

Outpatient Total Shoulder Arthroplasty: A Systematic Review Evaluating Outcomes and Cost-Effectiveness.

BACKGROUND: Orthopaedic surgical procedures are increasingly being performed in outpatient settings. The drive for cost reduction without compromising patient safety and outcomes has increased interest in outpatient total shoulder arthroplasty (TSA). The primary aim of this study was to perform a review of the evidence regarding the outcomes and cost-effectiveness of outpatient TSA. METHODS: A search of the PubMed, Embase, and Cochrane Library databases was performed using several keywords: "outpatient," "shoulder replacement," "ambulatory," "day case," "day-case," "shoulder arthroplasty," "same day," and "shoulder surgery." Studies that were published from May 2010 to May 2020 in the English language were considered. Research design, questions, and outcomes were recorded for each study. Qualitative and quantitative pooled analysis was performed on the data where appropriate. RESULTS: Twenty studies met the inclusion criteria. Six retrospective studies compared complication rates between inpatient and outpatient cohorts and found no significant differences. Four studies found that the complication rate was lower in the outpatient cohort compared with the inpatient cohort. In a pooled analysis, the readmission rate after outpatient TSA was significantly lower than the readmission rate after inpatient TSA at 30 days (0.65% vs. 0.95%) and 90 days (2.03% vs. 2.87%) postoperatively (p < 0.05 for both). Four studies evaluated the cost of outpatient TSA in comparison with inpatient TSA. All of these studies found that TSA at an ambulatory surgery center was significantly less costly than TSA at an inpatient facility, both for the health-care system and for the patient. Patient selection for outpatient TSA may depend on several important factors, including the presence or absence of diabetes, chronic obstructive pulmonary disease, chronic kidney disease, congestive heart failure, poor functional status, higher American Society of Anesthesiologists class, chronic narcotic use, higher body mass index, and older age. CONCLUSIONS: Our results show that patient selection is the most critical factor that predicts the success of outpatient TSA. While outpatient TSA is significantly less costly than inpatient TSA, patients undergoing outpatient TSA are more likely to be healthier than patients undergoing inpatient TSA. More high-quality long-term studies are needed to add to this body of evidence. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review.

PURPOSE OF REVIEW: Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years. RECENT FINDINGS: The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.