Background: An intraoperative culture sample obtained during revision elbow arthroplasty that is unexpectedly positive poses a dilemma for the surgeon. The purpose of our study was to determine the prevalence of positive cultures during revision elbow arthroplasty when infection is not suspected preoperatively, and the long-term implications of these positive cultures. Methods: Two hundred and thirteen consecutive revision elbow arthroplasties were performed at our institution between 2000 and 2007. Of these, sixteen patients had unexpected positive intraoperative cultures. Results: The majority of cultures grew either Staphylococcus epidermidis or Propionibacterium acnes. Twelve patients had more than two years of follow-up. One of the twelve patients was treated as for an infection because of unexplained early implant loosening and the isolation of Staphylococcus epidermidis. Ten of the twelve elbows were treated as “contaminants” and did not receive long-term antibiotic treatment. Nine of these ten remained infection-free at the time of the final follow-up, while the remaining one developed an infection with a different organism. Conclusions: In our series, there was a 7.5% chance of encountering an unexpected positive result on intraoperative culture at the time of revision elbow arthroplasty. The majority of patients were successfully treated without antibiotics with a low rate of failure. A minority were considered as infections, typically presenting with unexplained early loosening and isolation of an organism on solid culture medium.

Background: The perioperative diagnosis of infection in the setting of revision elbow arthroplasty may be difficult to establish. Intraoperative pathology with histology for identification of acute inflammatory changes has been reported to be of value in revision surgery after failed hip or knee arthroplasty. The purpose of this study was to study the role of intraoperative histology in the diagnosis of infection in patients undergoing revision elbow arthroplasty. Methods: From 2000 to 2007, 296 consecutive revision elbow procedures were performed at our institution. Both intraoperative histology and operative samples for culture were obtained at the time of 227 of these procedures, which form the basis of this study. Results: Histology was read as consistent with acute inflammation in patients undergoing thirty-three procedures (14.5%). Intraoperative cultures were positive in thirty-nine procedures (17.2%). Intraoperative histology was considered true positive (both histology and cultures positive) in twenty arthroplasties (8.8%), true negative (both histology and cultures were negative) in 175 arthroplasties (77.1%), false positive (the histology was positive but the culture was negative) in thirteen arthroplasties (5.7%), and false negative (the histology was negative but the culture was positive) in nineteen arthroplasties (8.4%). With regard to intraoperative histology, the sensitivity was 51.3%, the specificity was 93.1%, and the accuracy was 85.9%. The positive predictive value was 60.6% and the negative predictive value was 90.2%. Conclusions: In our study, intraoperative histology had a high specificity and negative predictive value, but a low sensitivity and positive predictive value for predicting infection in the setting of revision elbow arthroplasty. Intraoperative histology should be used in conjunction with other studies to definitively establish the diagnosis of infection in the setting of revision elbow arthroplasty.

BACKGROUND: Evidence for the management of periprosthetic joint infection (PJI) after total elbow arthroplasty is sparse, particularly in regard to débridement, antibiotics, and implant retention (DAIR). This study explored the outcomes of DAIR and analyzed risk factors for failure. METHODS: A retrospective cohort study of patients 18 years or older diagnosed with elbow PJI and managed with DAIR between January 1, 2003, and December 31, 2018, at a single institution was performed. Twenty-six elbows met the inclusion criteria during the study period. All DAIR procedures included in this study represented an attempt to manage an acute PJI with surgical irrigation and débridement without removal of the elbow arthroplasty components, followed by long-term systemic antimicrobial therapy. DAIR failure was defined as recurrence of PJI, unplanned re-operation for infection, or death secondary to infection. A Cox proportional hazards model was used to identify possible risk factors for failure. RESULTS: DAIR failed in 17 cases of elbow PJI with a failure rate of 65% at 2 years (95% confidence interval: 41.3%-79.6%). The median time to failure from DAIR was 43 days (interquartile range: 27-114). We found that DAIR failed in all cases with sinus tracts or negative cultures. The group with favorable outcomes had a shorter median duration of symptoms (5 vs. 18 days, P = .65) and a higher proportion of monomicrobial infections (58.8% vs. 88.9%, P = .19) compared to those with unfavorable outcomes. However, with the numbers available, none of the possible risk factors analyzed for association with failure reached statistical significance. CONCLUSION: DAIR for elbow PJI was associated with high rates of failure. Possible risk factors for failure may include the presence of sinus tract, longer duration of symptoms, and culture-negative infection. Although the relatively low morbidity of DAIR compared with total elbow arthroplasty implant resection for a one-stage or two-stage reimplantation is attractive, patients considered for DAIR must know that the chance of success is limited to approximately 35%.

Background: Periprosthetic joint infection (PJI) can be a devastating complication following shoulder arthroplasty. PJI following hip and knee arthroplasties has been found to increase mortality. However, anatomical and bacteriologic differences could potentially result in a different trend after shoulder arthroplasties. Thus, the purpose of the present study was to determine whether there is an association between shoulder PJI and all-cause mortality. Methods: Our institutional Total Joint Registry Database was queried to identify patients who underwent revision shoulder arthroplasty procedures between 2000 and 2018. A total of 1,160 procedures were then classified as either septic (21.8%) or aseptic (78.2%). Septic revisions were further subdivided into (1) debridement, antibiotics, irrigation, and implant retention (9.1%); (2) 2-stage reimplantation for deep infection (61.3%); (3) implant resection without reimplantation (3.6%); and (4) unexpected positive cultures at revision surgery (26.1%). The most common bacterium isolated was Cutibacterium acnes (64.4%). All-cause patient mortality was determined with use of our registry and confirmed with use of a nationwide mortality database. All-cause crude and adjusted mortality rates were then compared between groups. Results: The 1-year crude mortality rate was 1.8% (95% confidence interval [CI], 0.9% to 2.6%) for the aseptic group and 2.8% (95% CI, 0.7% to 4.8%) for the septic group (p = 0.31). Multivariate Cox regression analysis demonstrated an elevated but statistically similar adjusted hazard ratio for 1-year all-cause mortality of 1.9 (95% CI, 0.8 to 4.6) when comparing the septic to the aseptic group (p = 0.17). The risk of 2-year all-cause mortality was significantly higher in the septic group, with a hazard ratio of 2.2 (95% CI, 1.1 to 4.5; p = 0.029). In univariate analyses, increased 5-year mortality in the septic revision group was associated with age, Charlson Comorbidity Index, and methicillin-resistant Staphylococcus aureus infection, whereas C. acnes infection was associated with lower mortality. Conclusions: Shoulder PJI is associated with an adjusted 2-year all-cause mortality rate that is double that of aseptic patients. The results of the present study should be utilized to appropriately counsel patients who are considered to be at risk for infection following shoulder arthroplasty.

Introduction Periprosthetic joint infection (PJI) is a common source of failure following elbow arthroplasty. Perioperative prophylactic antibiotics are considered standard of care. However, there are no data regarding the comparative efficacy of various antibiotics in the prevention of PJI for elbow arthroplasty. Previous studies in shoulder, hip, and knee arthroplasty have demonstrated higher rates of PJI with administration of non-cefazolin antibiotics. The elbow has higher rates of PJI than other joints. Therefore, this study evaluated whether perioperative antibiotic choice affects rates of PJI in elbow arthroplasty. Materials & Methods A single institution prospectively collected Total Joint Registry database was queried to identify patients who underwent primary elbow arthroplasty between 2003 and 2021. Elbows with known infection prior to arthroplasty (25) and procedures with incomplete perioperative antibiotic data (7) were excluded, for a final sample size of 603 total elbow arthroplasties and 19 distal humerus hemiarthroplasties. Cefazolin was administered in 561 elbows (90%) and non-cefazolin antibiotics including vancomycin (32 elbows, 5%), clindamycin (27 elbows, 4%) and piperacillin/tazobactam (2 elbows, 0.3%) were administered in the remaining 61 elbows (10%). Univariate and multivariate analyses were conducted to determine the association between the antibiotic administered and the development of PJI. Infection-free survivorship was estimated using the Kaplan-Meier (KM) method. Results Deep infection occurred in 47 elbows (7.5%) and 16 elbows (2.5%) were diagnosed with superficial infections. Univariate analysis demonstrated that patients receiving non-cefazolin alternatives were at significantly higher risk for any infection (Hazard Ratio (HR) 2.6, 95% confidence interval [CI] 1.4-5.0]; p < 0.01) and deep infection (HR 2.7 [95% CI 1.3 – 5.5]; p < 0.01) compared with cefazolin administration. Multivariable analysis, controlling for several independent predictors of PJI (tobacco use, male sex, surgical indication other than osteoarthritis, and American Society of Anesthesiologists score), showed that non-cefazolin administration had a higher risk for any infection (HR 2.8 [CI 1.4 – 5.3]; p < 0.01) and deep infection (HR 2.9 [95% CI 1.3 – 6.3]; p < 0.01). Survivorship free of infection was significantly higher at all time points for the cefazolin cohort (Figure 1). Discussion In primary elbow arthroplasty, cefazolin administration was associated with significantly lower rates of PJI compared to non-cefazolin antibiotics, even in patients with a greater number of prior surgeries which is known to increase the risk of PJI. For patients with penicillin or cephalosporin allergies, preoperative allergy testing or a cefazolin test dose should be considered prior to administering non-cefazolin alternatives.