Role of pre-revision tissue biopsy in evaluation of painful shoulder arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Pre-revision tissue biopsy (PTB) for culture has been used as a diagnostic tool in the evaluation for periprosthetic joint infection among patients with a painful shoulder arthroplasty. The purpose of this study was to (1) determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of PTB culture results compared with results of "gold-standard" tissue biopsy for culture taken at the time of subsequent revision surgery (TBR), and (2) report the current indications and protocols described for use of PTB. The hypothesis was that PTB culture results would correlate highly with results of TBR and that protocols for PTB would vary by institution. METHODS: By use of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis of English-language literature were performed using the Embase, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases from inception through March 2020. Methodological Index for Non-randomized Studies (MINORS) validated grading criteria were used to summarize the quality and bias of included studies. Studies were included if an arthroscopic or open tissue biopsy was performed in patients who had previously undergone anatomic total shoulder arthroplasty, shoulder hemiarthroplasty, or reverse total shoulder arthroplasty as a separate procedure prior to revision of components, if applicable. Meta-analysis to identify the sensitivity, specificity, NPV, and PPV of PTB was performed. Analysis was performed by first defining 1 positive PTB culture result as infection and then defining 2 positive culture results as infection. RESULTS: A total of 1751 titles were screened, and 66 full-text articles were reviewed for inclusion. Four total studies encompassing 72 cases met the inclusion criteria. All studies were small (N = 13 to N = 23), retrospective series, with all but 12 biopsies performed arthroscopically. Sixty-five patients (90.2%) underwent subsequent revision surgery and TBR. Of these patients, 23 (35.4%) had ≥1 positive culture result with PTB and TBR. By this definition, the sensitivity of PTB was 92.0% (95% confidence interval [CI], 72.5%-98.6%); specificity, 70.0% (95% CI, 53.3%-82.9%); PPV, 65.7% (95% CI, 47.7%-80.3%); and NPV, 93.3% (95% CI, 76.5%-98.8%). For 2 positive PTB results, the sensitivity of PTB was 100% (95% CI, 51.7%-100%); specificity, 50.0% (95% CI, 31.4%-68.6%); PPV, 33.3% (95% CI, 14.4%-58.8%); and NPV, 100% (95% CI, 69.9%-100%). No complications of PTB were reported. The mean Methodological Index for Non-randomized Studies (MINORS) grade was 11.4 (range, 8.5-14). CONCLUSION: PTB is a sensitive diagnostic modality with a high NPV that may aid in the diagnosis of shoulder periprosthetic joint infection in patients with a painful shoulder arthroplasty. Given the disparate biopsy protocols, greater standardization of clinical best practices and broader prospective studies are necessary to define the future role of PTB in dictating treatment.

Patient compliance and satisfaction with topical benzoyl peroxide gel prior to shoulder surgery.

Background: Cutibacterium acnes is a common pathogen leading to postoperative shoulder infections. Many centers are utilizing 5% topical benzoyl peroxide (BPO) gel to decrease cutibacterium acnes bioburden prior to surgery. The purpose of this study was to evaluate patient compliance, tolerance, and side effects of applying BPO to the shoulder prior to surgery. Our hypothesis was that BPO would be well tolerated with few, minor side effects, and patients would comply with a regimen of 5 treatments spanning 48 hours prior to surgery. Methods: All patients undergoing operative intervention, either open or arthroscopic, about the shoulder from August 7, 2020, through July 15, 2021, by a single surgeon were instructed to apply BPO to the shoulder after showering, on dry skin, in the morning and evening, starting 48 hours before their surgical date. Patients were instructed to apply a half-dollar-sized quantity for each treatment. There were a total of 5 topical applications. On the day of surgery, patients were given a 6-question survey regarding side effects experienced, BPO treatments missed, ease of treatment, and a scenario question. Demographic information was collected, and a satisfaction survey was administered upon study completion. Results: A total of 183 patients out of a possible 284 eligible patients (64.4%) completed the survey. The median (interquartile range) age at surgery was 59.9 years. Sixty-four participants (35%) in the study cohort were female. One-hundred thirteen (61.7%) had an arthroscopic surgical approach, whereas 70 (38.3%) underwent open shoulder surgery. Most patients (N = 152, 83.5%) experienced no side effects from the topical 5% BPO gel treatments. Twenty-two (12.0%) patients missed 1 treatment, 10 (5.5%) missed 2 treatments, 1 (0.5%) missed 3 treatments, 3 (1.6%) missed 4 treatments, and 4 (2.2%) missed all 5 treatments. The majority of patients, 143 (78.1%), completed all 5 treatments. When prompted to choose between serial skin preparation treatments at home leading up to surgery or a single light-based decolonization procedure in the preoperative holding area on the day of surgery, 111 (60.7%) preferred to undergo antimicrobial treatment at home and arrive for surgery as otherwise scheduled. Conclusion: Serial preoperative applications of topical 5% BPO gel are well tolerated by the majority of patients. Over 20% of patients missed at least one application of BPO. Most patients prefer home-based antimicrobial treatments compared with arriving earlier on the day of surgery for a single light-based antimicrobial treatment.