Stringfellow T D, Majed A, Higgs D
Shoulder and Elbow Unit, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, HA7 4LP, London, UK.
University College London, Institute of Orthopaedics and Musculoskeletal Science, Brockley Hill, Stanmore, Middlesex, HA7 4AP, London, UK.
J Clin Orthop Trauma. 2024 Aug 24;56:102520. doi: 10.1016/j.jcot.2024.102520. eCollection 2024 Sep.
Evidence for management of shoulder periprosthetic joint infection (PJI) has traditionally originated from the hip and knee literature. The differing microbiome, anatomy and implants used in the shoulder mean this evidence is not always directly transferrable. The 2018 Philadelphia International Consensus Meeting for the first-time produced evidence-based guidelines and diagnostic criteria relating specifically to PJI of the shoulder. These guidelines and criteria recognize the pathogenicity of lower virulence organisms in the shoulder which often means clinical presentation is less obvious than other joints. The role of Cutibacterium in shoulder PJI is the subject of increasing basic science and clinical research and advances in microbiological research may help to understand the pathology behind shoulder infections. There is new evidence that outcomes after revision shoulder arthroplasty are dependent on the virulence of the causative organism. An individualised approach to treatment considering host factors, organism, soft tissues and bone stock is recommended. Debate continues in the literature regarding the indications of one- or two-stage revision and the latest evidence is discussed and synthesized in this review article. We advocate careful multidisciplinary team decision making for cases of shoulder PJI and recognize a limited role for debridement and implant retention in acute shoulder PJI (<6 weeks). There appears to be a role for one-stage revision in lower risk cases with low virulence organisms but caution against its' universal adoption. In higher risk or complex cases, there remains a clear role for two-stage revision arthroplasty, and we detail the specifics of this protocol and procedure from our tertiary shoulder and elbow unit.
传统上，肩关节假体周围感染（PJI）的管理证据来源于髋关节和膝关节的文献。肩关节中不同的微生物群、解剖结构和使用的植入物意味着这些证据并非总是可以直接照搬。2018年费城国际共识会议首次制定了专门针对肩关节PJI的循证指南和诊断标准。这些指南和标准认识到肩关节中低毒力微生物的致病性，这通常意味着临床表现不如其他关节明显。痤疮丙酸杆菌在肩关节PJI中的作用是越来越多基础科学和临床研究的主题，微生物学研究的进展可能有助于理解肩部感染背后的病理。有新证据表明，翻修肩关节置换术后的结果取决于致病微生物的毒力。建议采用个体化的治疗方法，考虑宿主因素、微生物、软组织和骨量。文献中关于一期或二期翻修的适应症仍存在争议，本文对最新证据进行了讨论和综合。我们主张对肩关节PJI病例进行谨慎的多学科团队决策，并认识到清创和保留植入物在急性肩关节PJI（<6周）中的作用有限。对于低毒力微生物的低风险病例，一期翻修似乎有作用，但要谨慎对待其普遍采用。在高风险或复杂病例中，二期翻修关节成形术仍有明确作用，我们从三级肩关节和肘关节科室详细介绍了该方案和手术的具体细节。
