The treatment of post-infectious conditions in the shoulder joint is generally based on the defect left behind by the infection. While the treatment of acute and chronic infections is the domain of surgical therapy, where the primary goal is to quickly reduce the bacterial load and remove all foreign bodies, the post-infectious situation involves damage analysis, ensuring freedom from infection, and reconstructive options. Shoulder infections differ from other joints due to their specific bacterial spectrum, primarily due to the extensive colonization with Cutibacterium acnes. The cause of the infection, time of onset, bacterial spectrum, and comorbidities must also be considered when assessing and deciding on treatment in a post-infectious situation. In conditions following chronic and low-grade infections, the presence of foreign bodies and necrosis is particularly important because biofilm-forming bacteria can persist on them permanently. The treatment spectrum ranges from arthroscopic arthrolysis and open debridement with component exchange to single- and multi-stage replacement of the prosthesis after the use of antibiotic-loaded interim prostheses and bone augmentation. The decisive factor is always the complete elimination of an infection and its appropriate treatment before extensive subsequent damage to the soft tissue and bone can be reconstructed. Due to the high demands placed on it, the gradual reconstruction of the joint after an infection is usually only reliably mastered by specialized departments.

Background: Diagnosing shoulder periprosthetic joint infections is challenging. Several diagnostic tests are available, but their predictive value varies and is often poor. The aims of this study were to assess internationally how shoulder surgeons diagnose periprosthetic joint infections, and to investigate if there are intercollegiate and intercontinental differences. Methods: An online survey was designed for shoulder surgeons, incorporating questions regarding their utilization of various diagnostic tests and their level of professional experience. The survey was sent digitally to all members of the European Society for Surgery of the Shoulder and the Elbow, all European National Delegates, and 10 other Shoulder and Elbow societies worldwide. Results: Two hundred thirty-nine surveys were included in this study. The majority of the respondents (≥65%) routinely use at least 9 of different diagnostic tests as a workup for a shoulder periprosthetic joint infections: blood testing (C-reactive protein, white blood cell count, and erythrocyte sedimentation rate), pre-revision synovial fluid aspiration (culture, white blood cell count and neutrophil percentage), intraoperative synovial fluid aspiration (culture), pre-revision tissue biopsy for culture, and tissue biopsy for culture during revision surgery. Significantly more cultures were taken by respondents who perform fewer revisions (P = .008). These surgeons are also less likely to rely solely on cultures to diagnose an infection of the periprosthetic joint of the shoulder. Respondents outside Europe use frozen section and sonication significantly less often (P < .001), and more often erythrocyte sedimentation rate (P = .001) and Metal Artifact Reduction Sequence magnetic resonance imaging (P = .01)), compared to respondents in Europe. Conclusion: The majority of those who responded to the survey use at least 9 different tests to diagnose shoulder periprosthetic joint infections. Respondents who perform fewer revisions take more cultures, and are less likely to rely solely on these results, compared to surgeons who perform more revisions. There are several intercontinental differences in the use of diagnostic tests (within Europe and beyond).

This report details our experience and technique for addressing massive uncontained defects of the glenoid during revision in reverse total shoulder arthroplasty. The glenoid reconstruction was performed in a two-stage approach, with the initial stage involving the removal of all implants and the grafting of allogenic femoral head bone into the glenoid defect. Following confirmation of bone block consolidation on a CT-scan, the second stage entailed the implantation of the glenoid base over the bony block. Our results show no cases of loosening, implant failures.

We can observe increasing numbers for the implantation of shoulder endoprostheses in developed industrial countries. This is accompanied by a certain number of revision surgeries. The conversion to reverse arthroplasty systems is by far the most common revision procedure. Depending on the primary implant and the individual situation, the surgical effort and consumption of resources can be substantial. Particularly favorable revision scenarios exist in the conversion of stemless primary implants that are part of a platform system and allow a partial exchange and easy conversion from anatomical to reverse implants.

Functional outcomes are relatively poor when a shoulder prosthesis is implanted in a joint that has had a previous infection. High revision rates of approximately 30% in small case series are reported in the literature. The aim of this paper is to analyze the DVSE ("D-A-CH Vereinigung fur Schulter- und Ellenbogenchirurgie") shoulder prosthesis registry (SEPR) in this regard and to compare the patient group with infectious arthropathy with that without any known previous infection. A total of 15,255 patients from the SEPR from 2006-2022 were analyzed. A history of infectious arthropathy was present in 140 patients (78 males, 62 females, 61.3 +/- 13 years). Males in this group were 3.7 years younger than females. Preoperative Constant score was not different: 24.7 vs. 22.8 (p = 0.38). Intraoperative complications in infectious arthropathy: 5.9% vs. 2.8% in the control group (p = 0.0323). Postoperative complications in infectious arthropathy: 13.7% vs. 4% (p < 0.0001); revision rates in infectious arthropathy 12.9% vs. 1.6%(p < 0.0001). Deep wound infections in infectious arthropathy 3.2% vs. 0.2% (p < 0.0001). Patients with infectious arthropathy are nearly 10 years younger at the time of shoulder arthroplasty and more likely to be male than patients without a history of infection. In addition, intraoperative and postoperative complications are higher by a factor of 2, and a factor of 3.4, respectively, and revision rates are higher by a factor of 8 than in patients without a history of infection. The development of postoperative deep wound infection is higher than in the control group by a factor of 16.

Die Implantation von Schulterendoprothesen zeigt weiter steigende Fallzahlen in den entwickelten Industrienationen. Damit einher geht eine gewisse Anzahl an Revisionseingriffen. Die Konversion auf inverse Endoprothesensysteme ist der mit Abstand häufigste Revisionseingriff. Abhängig vom vorliegenden Primärimplantat und der individuellen Situation kann der chirurgische Aufwand und Ressourcenverbrauch erheblich sein. Besonders günstige Revisionsszenarien liegen bei der Konversion von schaftfreien Primärimplantaten vor, die Teil eines Plattformsystems sind und eine Konversion von anatomischen auf inverse Teilkomponenten erlauben.

Treatment of an infected shoulder prosthesis differs significantly from other joint infections because of the unique microbiome, dominated by Cutibacterium acnes. The cause of an infection, its time of onset, the bacterial spectrum and comorbidities have to be considered for evaluation and treatment. The diagnostic workup is sometimes complex, and the recognition of a chronic and low-grade infection is often difficult because typical clinical and laboratory markers may be normal. Treatment is surgical; the therapeutic spectrum ranges from arthroscopic irrigation and open debridement with the exchange of components to one- and two-stage revisions using antibiotic-loaded spacers. Early detection and a targeted, appropriate therapy are crucial to avoid extensive soft tissue and bone damage.

Comparison of scapular morphology in patients with early onset osteoarthritis and healthy controls to understand the pathogenesis.

Die kontinuierlich steigenden Zahlen primär implantierter Schulter- und Ellenbogenprothesen werden von einer Vielzahl neuer Materialkombinationen und modifizierten Implantationstechniken begleitet, damit ist auch ein Anstieg der Revisionseingriffe verbunden. Die chirurgische Sanierung postoperativer Komplikationen, insbesondere bei periprothetischen Infektionen, stellt enorme technische Anforderungen an das gesamte chirurgische Team. Die Anwendung antibiotikabeladener Zementspacer hat sich bei der Sanierung dieser komplexen Fälle etabliert. Die Erfahrungen zweizeitiger Prothesenwechsel aus Hüft- und Knieendoprothetik konnten auch erfolgreich in der Chirurgie der oberen Extremität Anwendung finden. Die Vorteile des zweizeitigen Einsatzes antibiotikabeladener Interimsprothesen liegen im hohen lokalen Antibiotikaspiegel und der oft zuverlässigen Eradikation periprothetischer Low-Grade-Infektionen bei Biofilm-bildenden Keimen. Demgegenüber stehen häufig die höheren Komplikationsraten und längeren Behandlungszeiten. Der vorliegende Artikel soll einen Überblick zur Indikationsstellung, technischen Umsetzung, klinischen Ergebnissen, Komplikationen und Beispielanwendungen temporärer Interimsprothese geben.

Die Behandlung einer infizierten Schulterprothese ist eine Domäne der operativen Therapie. Sie unterscheidet sich von der anderer Gelenkinfektionen insbesondere wegen des besonderen Keimspektrums der Schulter, allen voran wegen der Besiedelung mit Cutibacterium acnes. Infektursache, Zeitpunkt des Auftretens, Keimspektrum und Komorbiditäten müssen zur Beurteilung und Therapieentscheidung herangezogen werden. Bei chronischen und „Low-grade-Infekten“ ist v. a. die Erkennung schwierig, weil typische Infektmerkmale und laborchemische Marker völlig normal sein können. Das Therapiespektrum reicht von der arthroskopischen Spülung über das offene Débridement mit Komponententausch bis hin zu ein- und zweizeitigen Prothesenwechseln unter Verwendung antibiotikabeladener Interimsprothesen. Entscheidend ist immer die frühzeitige Erkennung einer Infektion und deren sachgerechte Therapie, um ausgedehnte Folgeschäden an den Weichteilen und am Knochenlager zu vermeiden. Der Wechsel einer infizierten Schulterprothese wird aufgrund der hohen Anforderungen meist nur von spezialisierten Abteilungen sicher beherrscht.

Die funktionellen Ergebnisse nach Schulterprothesenimplantation sind verhältnismäßig schlecht, wenn zuvor im betroffenen Gelenk eine Infektion vorlag. In der Literatur werden diesbezüglich hohe Revisionsraten von bis zu 30

Background The last few years have been characterized by further increases in the number of cases involving the implantation of shoulder endoprostheses in Germany. Register research offers the opportunity to identify healthcare trends with regard to demographic data and used implants at an early stage. Materials and methods The data from the shoulder endoprosthesis register SPR of the DVSE from the years 2015-2020 for all primary implantations were retrospectively evaluated with regard to the following parameters: demographic factors, use of implants (anatomical vs. reverse; cemented vs. cementless; stemless, short stems, classic stems), Number of documenting clinics/departments during this period. Results There has been an increase in documented cases in the SPR over the years (especially an increase in reverse endoprostheses). The reason for the increase in the number of cases is not a relevant decrease in the average age at the time of the first implantation. When implanting anatomical endoprostheses, there is a clear trend towards the use of stemless implants; stemless inverse implants tend to remain the exception; Glenoids are predominantly cemented with a slight downward trend, humeral components continue to be predominantly cemented implants, somewhat less remarkable in reverse endoprostheses. Conclusion The data show that the increase in the number of implantations cannot be attributed to an expansion of the indication for younger patients. There is a clear trend towards the use of stemless implants, especially when using anatomical systems.

Posterior glenoid bone defects are a frequent clinical problem impacting the surgical technique and choice of implant in total shoulder arthroplasty (TSA). Bone grafting with autologous or allogenic bone is one option for filling the defect and correcting pathological glenoid version. The use of posteriorly augmented glenoid implants, which were mostly cemented polyethylene components, have been described in the past and have recently been expanded by the use of augmented uncemented metallic components or a combination of either implant with or without bone grafting. Bone grafting for small posterior bone defects is technically challenging and the use of augmented implants represents a promising alternative. Clinical results are generally promising but are less favorable compared to cases without glenoid bone defects. The choice of implant, surgical technique, and the way to perform bone grafting is according to the surgeon's preference based on the patient's individual anatomy, available implants, and personal experience.

Zusammenfassung Hintergrund Die letzten Jahre sind geprägt von weiteren Fallzahlsteigerungen der Implantation von Schulterendoprothesen in Deutschland. Die Registerforschung bietet die Möglichkeit, Trends in der Versorgung im Hinblick auf die demografischen Daten als auch der verwendeten Implantate frühzeitig zu erkennen und sichtbar zu machen. Material und Methode Die Daten des Schulterendoprothesenregister SPR der DVSE aus den Jahren 2015–2020 für alle Primärimplantationen wurden retrospektiv ausgewertet im Hinblick auf folgende Parameter: demografische Faktoren, Verwendung von Implantaten (anatomisch vs. invers; zementiert vs. zementfrei; schaftfrei, Kurzschäften, klassische Schäfte), Anzahl der dokumentierenden Kliniken/Abteilungen während dieses Zeitraums. Ergebnisse Es zeigt sich ein Anstieg der dokumentierten Fälle im SPR über die Jahre (vor allem Zunahme inverser Endoprothesen). Ursache für die Fallzahlsteigerungen ist keine relevante Abnahme des Durchschnittsalters zum Zeitpunkt der Erstimplantation. Bei Implantation von anatomischen Endoprothesen zeigt sich ein klarer Trend zugunsten der Verwendung von schaftfreien Implantaten; schaftfreie inverse Implantate bleiben eher die Ausnahme; Glenoide werden überwiegend zementiert mit leicht fallendem Trend, humerale Komponenten werden weiterhin überwiegend zementiert implantiert, etwas weniger ausgeprägt auch bei inversen Endoprothesen. Schlussfolgerung Die Daten belegen, dass die Fallzahlsteigerung der Implantationen nicht auf eine Ausweitung der Indikation für jüngere Patienten zurückgeführt werden kann. Es zeigt sich ein klarer Trend zur Verwendung von schaftfreien Implantaten, besonders bei Versorgung mit anatomischen Systemen.

We aimed to assess the effectiveness and the risks when using articulating spacers in two-stage elbow revision arthroplasty in two European centers for elbow surgery.

Abstract Background Cutibacterium acnes is part of the anaerobic skin microbiome and resides in deeper skin layers. The organism is an agent of surgical site infections (SSI) in shoulder surgery. We hypothesized that prolonged skin preparation with an agent that penetrates deeply into the skin would be beneficial. Thus, we compared two classes of antiseptics, each combined with alcohol, each applied with two different contact times. Methods Using a cross-over arrangement, shoulders of 16 healthy volunteers were treated for 2.5 min (standard) or 30 min (prolonged) with alcohol-based chlorhexidine (CHG-ALC) or alcohol-based povidone-iodine (PVP-I-ALC). Skin sites were sampled before, immediately after, and 3 h after treatment, using a standardized cup-scrub technique. Results Aerobic skin flora was reduced more effectively by PVP-I-ALC than by CHG-ALC after 2.5 min application and immediate sampling (reduction factor [RF] 2.55 ± 0.75 vs. 1.94 ± 0.91, p = 0.04), but not after prolonged contact times and 3-h sampling. Coagulase-negative staphylococci were completely eliminated after PVP-I-ALC application, but still recovered from 4 of 32 samples after CHG-ALC application. Anaerobic flora was reduced more effectively by PVP-I-ALC than CHG-ALC after standard (RF 3.96 ± 1.46 vs. 1.74 ± 1.24, p < 0.01) and prolonged (RF 3.14 ± 1.20 vs. 1.38 ± 1.16, p < 0.01) contact times and immediate sampling, but not after 3-h sampling. No adverse events were reported. Conclusions PVP-I-ALC showed marginal benefits concerning the aerobic flora, but more substantial benefits over CHG-ALC concerning the anaerobic flora of the shoulder. Standard and prolonged contact times showed superiority for PVP-I-ALC for anaerobic flora at all immediate sampling points, but missed significance at 3-h sampling. The results underscore the need for protection against C. acnes and coagulase-negative staphylococci in orthopaedic surgery. The clinical relevance of these findings, however, should be studied with SSI as an endpoint.