Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
J Shoulder Elbow Surg. 2022 Mar;31(3):668-679. doi: 10.1016/j.jse.2021.10.016. Epub 2021 Nov 10.
Although revision to new components is favored after shoulder periprosthetic joint infections (PJIs), implant exchange is not always feasible. In certain cases, definitive treatment may be retainment of an antibiotic spacer or resection arthroplasty. The purpose of this investigation was to systematically review the literature for studies reporting on outcomes after resection arthroplasty or permanent antibiotic spacer for salvage treatment of shoulder PJIs.
A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, SCOPUS, and Cochrane Central Register of Controlled Trials were searched for Level I-IV studies that reported on the final treatment of periprosthetic shoulder infections using resection arthroplasty or a permanent antibiotic spacer. Data recorded included study demographics, causative infectious organism, shoulder-specific range of motion and outcome measures, and infection eradication rate. Study methodological quality was analyzed using the Methodological Index for Non-Randomized Studies score. Forest plots of proportions and meta-analyses of single means were generated for infection eradication rates and outcomes, respectively. Heterogeneity was quantified using the I statistic. A P value of .05 was set as significant.
The initial search yielded 635 articles (211 duplicates, 424 screened, 57 full-text review). Twenty-three articles (126 resection arthroplasty and 177 retained antibiotic spacer patients, 51% females, mean age range 37-78.5 years, mean Methodological Index for Non-Randomized Studies score 9.6 ± 0.7) were included and analyzed. The pooled infection eradication rate was 82% (72%-89%) after resection arthroplasty and 85% (79%-90%) after permanent antibiotic spacer. The pooled mean forward flexion (71.5° vs. 48.7°; P < .001) and mean American Shoulder and Elbow Surgeons score (53.5 vs. 31.0; P < .001) were significantly higher for patients treated with a permanent antibiotic spacer compared with resection arthroplasty. No significant differences were found for mean external rotation (13.5° vs. 20.5°; P = .07), abduction (58.2° vs. 50.3°; P = .27), or visual analog scale pain (3.7 vs. 3.4; P = .24) between groups. There was a statistically significant, but not clinically significant, difference in mean Constant score between permanent antibiotic spacer and resection arthroplasty patients (33.6 vs. 30.0; P < .001).
When implant exchange after shoulder PJI is not feasible, permanent antibiotic spacers and resection arthroplasty are both salvage procedures that provide similar rates of infection eradication. Although both can decrease pain levels, the permanent antibiotic spacer may result in better functional outcomes compared with resection arthroplasty.
尽管在肩假体周围关节感染（PJI）后更换新的组件是首选，但植入物的更换并非总是可行的。在某些情况下，最终的治疗可能是保留抗生素 spacer 或关节切除成形术。本研究的目的是系统地回顾文献，以报告使用关节切除成形术或永久性抗生素 spacer 治疗肩 PJI 的结果。
使用系统评价和荟萃分析的首选报告项目（PRISMA）指南进行系统评价。在 PubMed、SCOPUS 和 Cochrane 中央对照试验注册库中搜索了关于使用关节切除成形术或永久性抗生素 spacer 治疗肩 PJI 的最终治疗的 I 级-IV 级研究。记录的数据包括研究人口统计学、致病感染生物、肩部特定的运动范围和结果测量以及感染清除率。使用非随机研究方法学指数（Methodological Index for Non-Randomized Studies，MINORS）评分分析研究方法学质量。分别为感染清除率和结果生成了比例的森林图和单一均值的荟萃分析。使用 I 统计量来量化异质性。设定 P 值<.05 为有统计学意义。
最初的搜索产生了 635 篇文章（211 篇重复，424 篇筛选，57 篇全文审查）。23 篇文章（126 例关节切除成形术和 177 例保留抗生素 spacer 患者，51%为女性，平均年龄 37-78.5 岁，平均 MINORS 评分为 9.6±0.7）被纳入并进行了分析。关节切除成形术后感染清除率为 82%（72%-89%），永久性抗生素 spacer 后为 85%（79%-90%）。与关节切除成形术相比，接受永久性抗生素 spacer 治疗的患者的平均前屈（71.5° vs. 48.7°；P<.001）和平均美国肩肘外科医生评分（53.5 vs. 31.0；P<.001）明显更高。两组之间的平均外旋（13.5° vs. 20.5°；P=0.07）、外展（58.2° vs. 50.3°；P=0.27）或视觉模拟评分疼痛（3.7 vs. 3.4；P=0.24）无显著差异。永久性抗生素 spacer 和关节切除成形术患者的平均 Constant 评分之间存在统计学显著但无临床意义的差异（33.6 vs. 30.0；P<.001）。
当肩 PJI 后更换植入物不可行时，永久性抗生素 spacer 和关节切除成形术都是可提供相似感染清除率的挽救性手术。尽管两者都可以降低疼痛水平，但与关节切除成形术相比，永久性抗生素 spacer 可能会带来更好的功能结果。
