Diagnosis and Management of the Infected Shoulder Arthroplasty

  • Ryan L. Eschbaugh
  • Joseph P. Iannotti
  • Eric T. RicchettiEmail author


Infection after shoulder arthroplasty, while representing less than 5% of all complications, can be devastating for the patient. The most common presenting complaint is pain independent of activity, and the diagnosis requires a high degree of suspicion by the treating surgeon. The most common bacteria isolated are Propionibacterium acnes (P. acnes) and coagulase negative Staphylococcus, which due to their indolent nature produce a blunted host response. In an otherwise healthy patient, there is data to support either one- or two-stage revision surgery including culture-specific antibiotics. In cases where salvage is required, resection arthroplasty can offer pain relief with limited functional goals.


Shoulder Arthroplasty Replacement Periprosthetic Infection Propionibacterium 


  1. 1.
    Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. Scholar
  2. 2.
    Padegimas EM, Maltenfort M, Ramsey ML, Williams GR, Parvizi J, Namdari S. Periprosthetic shoulder infection in the United States: incidence and economic burden. J Shoulder Elb Surg. 2015. Scholar
  3. 3.
    Kamal Bohsali BI, Wirth MA, Rockwood CA Jr. Complications of total shoulder arthroplasty. J Bone Joint Surg. 2006;88:2279–92.PubMedGoogle Scholar
  4. 4.
    Gonzalez JF, Alami GB, Baque F, Walch G, Boileau P. Complications of unconstrained shoulder prostheses. J Shoulder Elb Surg. 2011. Scholar
  5. 5.
    Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elb Surg. 2011. Scholar
  6. 6.
    Trappey GJ, O’Connor DP, Bradley Edwards T. What are the instability and infection rates after reverse shoulder arthroplasty? Clin Orthop Relat Res. 2011. Scholar
  7. 7.
    Walch G, Bacle G, Nove-Josserand L, John Smithers C. Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeons experience? J Shoulder Elb Surg. 2012;21:1470–7.CrossRefGoogle Scholar
  8. 8.
    Strickland JP, Sperling JW, Cofield RH, Sperling RJW. The results of two-stage re-implantation for infected shoulder replacement. J Bone Joint Surg Br. 2008;90:460–5.CrossRefGoogle Scholar
  9. 9.
    Cheung EV, Sperling JW, Cofield RH. Infection associated with hematoma formation after shoulder arthroplasty. Clin Orthop Relat Res. 2008;466:1363. Scholar
  10. 10.
    Hatta T, Werthel J-D, Wagner ER, Itoi E, Steinmann SP, Cofield RH, Sperling JW. Effect of smoking on complications following primary shoulder arthroplasty. 2017. Scholar
  11. 11.
    Werthel JD, Hatta T, Schoch B, Cofield R, Sperling JW, Elhassan BT. Is previous nonarthroplasty surgery a risk factor for periprosthetic infection in primary shoulder arthroplasty? J Shoulder Elb Surg. 2017;26:635. Scholar
  12. 12.
    Bala A, Penrose CT, Visgauss JD, Seyler TM, Randell TR, Bolognesi MP, Garrigues GE. Total shoulder arthroplasty in patients with HIV infection: complications, comorbidities, and trends. J Shoulder Elb Surg. 2016;25:1971. Scholar
  13. 13.
    Singh JA, Sperling JW, Schleck C, Harmsen WS, Cofield RH. Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. J Shoulder Elb Surg. 2012;21:1534. Scholar
  14. 14.
    Saltzman MD, Marecek GS, Edwards SL, Kalainov DM. Infection after shoulder surgery. J Am Acad Orthop Surg. 2011;19:208.CrossRefGoogle Scholar
  15. 15.
    Coste JS, Reig S, Trojani C, Berg M, Walch G, Boileau P, Surgeon O. Shoulder the management of infection in arthroplasty of the shoulder. J Bone Joint Surg Br. 2004;86:65–9.CrossRefGoogle Scholar
  16. 16.
    Themistocleous G, Zalavras C, Stine I, Zachos V, Itamura J. Prolonged implantation of an antibiotic cement spacer for management of shoulder sepsis in compromised patients. J Shoulder Elb Surg. 2007;16:701. Scholar
  17. 17.
    Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, Warme WJ, Matsen FA. Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am Vol. 2012;94:2075. Scholar
  18. 18.
    Millett PJ, Yen YM, Price CS, Horan MP, Van Der Meijden OA, Elser F. Propionobacter acnes infection as an occult cause of postoperative shoulder pain: a case series. Clin Orthop Relat Res. 2011;469:2824. Scholar
  19. 19.
    Dodson CC, Craig E V, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF. Propionibacterium acnes infection after shoulder arthroplasty: a diagnostic challenge. Scholar
  20. 20.
    Nelson GN, Paxton ES, Narzikul A, Williams G, Lazarus MD, Abboud JA. Leukocyte esterase in the diagnosis of shoulder periprosthetic joint infection. J Shoulder Elb Surg. 2015;24:1421. Scholar
  21. 21.
    Villacis D, Merriman JA, Yalamanchili R, Omid R, Itamura J, Hatch III GFR. Serum interleukin-6 as a marker of periprosthetic shoulder infection. Scholar
  22. 22.
    Frangiamore SJ, Saleh A, Kovac MF, Grosso MJ, Zhang X, Bauer TW, Daly TM, Ricchetti ET, Iannotti JP. Synovial interleukin-6 as a predictor of periprosthetic shoulder infection. J Bone Joint Surg. 2015;97:63–70.CrossRefGoogle Scholar
  23. 23.
    Grosso MJ, Frangiamore SJ, Saleh A, Kovac MF, Hayashi R, Ricchetti ET, Bauer TW, Iannotti JP. Poor utility of serum interleukin-6 levels to predict indolent periprosthetic shoulder infections. J Shoulder Elb Surg. 2014;23:1277. Scholar
  24. 24.
    Frangiamore SJ, Saleh A, Grosso MJ, Farias Kovac M, Zhang X, Daly TM, Bauer TW, Derwin KA, Iannotti JP, Ricchetti ET. Neer Award 2015: analysis of cytokine profiles in the diagnosis of periprosthetic joint infections of the shoulder. J Shoulder Elb Surg. 2017;26:186–96.CrossRefGoogle Scholar
  25. 25.
    White J, Kelly M, Dunsmuir R. C-reactive protein level after total hip and total knee replacement. J Bone Joint Surg Br. 1998;80–B:909–11.Google Scholar
  26. 26.
    Della Valle C, Parvizi J, Bauer TW, et al. Diagnosis of periprosthetic joint infections of the hip and knee overview and rationale. J Am Acad Orthop Surg. 2010;18:760–70.CrossRefGoogle Scholar
  27. 27.
    Topolski MS, Chin PYK, Sperling JW, Cofield RH. Revision shoulder arthroplasty with positive intraoperative cultures: the value of preoperative studies and intraoperative histology. J Shoulder Elb Surg. 2006;15:402. Scholar
  28. 28.
    Kelly JD, Hobgood ER. Positive culture rate in revision shoulder arthroplasty. Clin Orthop Relat Res. 2009;467:2343. Scholar
  29. 29.
    Nodzo SR, Boyle KK, Bhimani S, Duquin TR, Miller AO, Westrich GH. Propionibacterium acnes host inflammatory response during periprosthetic infection is joint specific. HSS J. 2017;13:159. Scholar
  30. 30.
    Di Cesare PE, Chang E, Preston CF, Liu C. Serum interleukin-6 as a marker of periprosthetic infection following total hip and knee arthroplasty. J Bone Joint Surg Am. 2005;87:1921–7.CrossRefGoogle Scholar
  31. 31.
    Chryssikos T, Parvizi J, Ghanem E, Newberg A, Zhuang H, Alavi A. FDG-PET imaging can diagnose periprosthetic infection of the hip. Clin Orthop Relat Res. 2008;466:1338. Scholar
  32. 32.
    Codd T, Yamaguchi K, Pollock R, Flatow E, Bigliani L. Infected shoulder arthroplasties: treatment with staged reimplantations vs. resection arthroplasty. J Shoulder Elb Surg. 1996;5:2.CrossRefGoogle Scholar
  33. 33.
    Patel A, Calfee RP, Plante M, Fischer SA, Green A. Propionibacterium acnes colonization of the human shoulder. J Shoulder Elb Surg. 2009;18:897–902.CrossRefGoogle Scholar
  34. 34.
    Piper KE, Jacobson MJ, Cofield RH, et al. Microbiologic diagnosis of prosthetic shoulder infection by use of implant sonication. J Clin Microbiol. 2009;47:1878. Scholar
  35. 35.
    Hsu JE, Gorbaty JD, Whitney IJ, Matsen FA III. Single-stage revision is effective for failed shoulder arthroplasty with positive cultures for Propionibacterium. J Bone Joint Surg. 2016;98:2047–51.CrossRefGoogle Scholar
  36. 36.
    Frangiamore SJ, Saleh A, Grosso MJ, Farias Kovac M, Higuera CA, Iannotti JP, Ricchetti ET. α-Defensin as a predictor of periprosthetic shoulder infection. J Shoulder Elb Surg. 2015;24:1021–7.CrossRefGoogle Scholar
  37. 37.
    Tischler EH, Cavanaugh PK, Parvizi J. Leukocyte esterase strip test: matched for musculoskeletal infection society criteria. J Bone Joint Surg Am Vol. 2014;96:1917. Scholar
  38. 38.
    Wetters NG, Berend KR, Lombardi AV, Morris MJ, Tucker TL, Della Valle CJ. Leukocyte esterase reagent strips for the rapid diagnosis of periprosthetic joint infection. J Arthroplast. 2012;27:8–11.CrossRefGoogle Scholar
  39. 39.
    Dilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am Vol. 2014;96:1952. Scholar
  40. 40.
    Della Valle CJ, Scher DM, Kim YH, Oxley CM, Desai P, Zuckerman JD, Di Cesare PE. The role of intraoperative Gram stain in revision total joint arthroplasty. J Arthroplast. 1999;14:500–4.CrossRefGoogle Scholar
  41. 41.
    Oethinger M, Warner DK, Schindler SA, Kobayashi H, Bauer TW. Diagnosing periprosthetic infection false-positive intraoperative Gram stains. 2010. Scholar
  42. 42.
    Morgan PM, Sharkey P, Ghanem E, Parvizi J, Clohisy JC, Burnett RSJ, Barrack RL. The value of intraoperative gram stain in revision total knee arthroplasty. J Bone Joint Surg Am Vol. 2009;91:2124. Scholar
  43. 43.
    Sperling JW, Tomasz KW, Hanssen AD, Cofield RH. Infection after shoulder arthroplasty. Clin Orthop Relat Res. 2001;382:206–2116.CrossRefGoogle Scholar
  44. 44.
    Matsen FA III, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R. Origin of Propionibacterium in surgical wounds and evidence-based approach for culturing Propionibacterium from surgical sites. J Bone Joint Surg. 2013;95–A:e1811–7.Google Scholar
  45. 45.
    Cuff DJ, Virani NA, Levy J, Frankle MA, Derasari A, Hines B, Pupello DR, Cancio M, Mighell M. The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and post- operative antibiotics. J Bone Joint Surg Br. 2008;90:336–42.CrossRefGoogle Scholar
  46. 46.
    Grosso MJ, Frangiamore SJ, Ricchetti ET, Bauer TW, Iannotti JP. Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty. J Bone Joint Surg. 2014;96:442. Scholar
  47. 47.
    Grosso MJ, Frangiamore SJ, Yakubek G, Bauer TW, Iannotti JP, Ricchetti ET. Performance of implant sonication culture for the diagnosis of periprosthetic shoulder infection. J Shoulder Elb Surg. 2018;27:211. Scholar
  48. 48.
    Parvizi J, Jacovides C, Zmistowski B, Kwang Am Jung. Definition of periprosthetic joint infection is there a consensus? 2011. Scholar
  49. 49.
    Parvizi J, Gehrke T. Definition of periprosthetic joint infection. J Arthroplast. 2014;29:1331.CrossRefGoogle Scholar
  50. 50.
    Lee MJ, Pottinger PS, Butler-Wu S, Bumgarner RE, Russ SM, Matsen FA. Propionibacterium persists in the skin despite standard surgical preparation. J Bone Joint Surg Am Vol. 2014;96:1447–50.CrossRefGoogle Scholar
  51. 51.
    Matsen FA, Russ SM, Bertelsen A, Butler-Wu S, Pottinger PS. Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis. J Shoulder Elb Surg. 2015;24:844. Scholar
  52. 52.
    Butler-Wu SM, Burns EM, Pottinger PS, Magaret AS, Rakeman JL, Matsen FA, Cookson BT. Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection. J Clin Microbiol. 2011;49:2490. Scholar
  53. 53.
    Ahsan ZS, Somerson JS, Matsen Iii FA. Characterizing the Propionibacterium load in revision shoulder arthroplasty a study of 137 culture-positive cases. J Bone Joint Surg. 2017;99–A:150–4.CrossRefGoogle Scholar
  54. 54.
    Levy O, Iyer S, Atoun E, Peter N, Hous N, Cash D, Musa F, Narvani AA. Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis? J Shoulder Elb Surg. 2013;22:505. Scholar
  55. 55.
    Maccioni CB, Woodbridge AB, Balestro J-CY, Figtree MC, Hudson BJ, Cass B, Young AA. Low rate of Propionibacterium acnes in arthritic shoulders undergoing primary total shoulder replacement surgery using a strict specimen collection technique. 2015. Scholar
  56. 56.
    Mook WR, Klement MR, Green CL, Hazen KC, Garrigues GE. The incidence of Propionibacterium acnes in open shoulder surgery a controlled diagnostic study. Scholar
  57. 57.
    Frangiamore SJ, Saleh A, Grosso MJ, Alolabi B, Bauer TW, Iannotti JP, Ricchetti ET. Early versus late culture growth of Propionibacterium acnes in revision shoulder arthroplasty. Scholar
  58. 58.
    Assenmacher AT, Alentorn-Geli E, Dennison T, Baghdadi YMK, Cofield RH, Sánchez-Sotelo J, Sperling JW. Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty. J Shoulder Elb Surg. 2017;26:1978. Scholar
  59. 59.
    Verhelst L, Stuyck J, Bellemans J, Debeer P. Resection arthroplasty of the shoulder as a salvage procedure for deep shoulder infection: does the use of a cement spacer improve outcome? J Shoulder Elb Surg. 2011;20:1224. Scholar
  60. 60.
    Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Pain relief and functional results after resection arthroplasty of the shoulder. J Bone Joint Surg Br. 2007;89:1184–7.CrossRefGoogle Scholar
  61. 61.
    Braman JP, Sprague M, Bishop J, Lo IK, Lee EW, Flatow EL. The outcome of resection shoulder arthroplasty for recalcitrant shoulder infections. J Shoulder Elb Surg. 2006;15:549. Scholar
  62. 62.
    Beekman PDA, Katusic D, Berghs BM, et al. One-stage revision for patients with a chronically infected reverse total shoulder replacement. J Bone Joint Surg Br. 2010;92:817–22.CrossRefGoogle Scholar
  63. 63.
    Ince A, Seemann K, Frommelt L, Katzer A, Loehr JF. One-stage exchange shoulder arthroplasty for peri-prosthetic infection. J Bone Joint Surg Br. 2005;87:814–8.CrossRefGoogle Scholar
  64. 64.
    Sabesan VJ, Ho JC, Kovacevic D, Iannotti JP. Two-stage reimplantation for treating prosthetic shoulder infections. Clin Orthop Relat Res. 2011;469:2538. Scholar
  65. 65.
    Coffey MJ, Ely EE, Crosby LA. Treatment of glenohumeral sepsis with a commercially produced antibiotic-impregnated cement spacer. J Shoulder Elb Surg. 2010;19:868. Scholar
  66. 66.
    Stine IA, Lee B, Zalavras CG, Hatch G, Itamura JM. Management of chronic shoulder infections utilizing a fixed articulating antibiotic-loaded spacer. J Shoulder Elb Surg. 2010;19:739. Scholar
  67. 67.
    Buchalter DB, Mahure SA, Mollon B, Yu S, Kwon YW, Zuckerman JD. Two-stage revision for infected shoulder arthroplasty. J Shoulder Elb Surg. 2017;26:939. Scholar
  68. 68.
    Segawa H, Tsukayama DT, Kyle RF, Becker DA, Gustilo RB. Infection after total knee arthroplasty a retrospective study of the treatment of eighty-one infections*. J Bone Joint Surg Am. 1999;81:1434–45.CrossRefGoogle Scholar
  69. 69.
    Khassebaf J, Hellmark B, Davidsson S, Unemo M, Nilsdotter-Augustinsson Å, Söderquist B. Antibiotic susceptibility of Propionibacterium acnes isolated from orthopaedic implant-associated infections. Anaerobe. 2015;32:57–62.CrossRefGoogle Scholar
  70. 70.
    Ricchetti ET, Frangiamore SJ, Grosso MJ, Alolabi B, Saleh A, Bauer TW, Iannotti JP. Diagnosis of Periprosthetic infection after shoulder arthroplasty: a critical analysis review. JBJS Rev. 2013;1:1–9.CrossRefGoogle Scholar
  71. 71.
    Dennison T, Alentorn-Geli E, Assenmacher AT, Sperling JW, Sánchez-Sotelo J, Cofield RH. Management of acute or late hematogenous infection after shoulder arthroplasty with irrigation, débridement, and component retention. J Shoulder Elb Surg. 2017;26:73. Scholar
  72. 72.
    Sperling JW, Cofield RH. Humeral windows in revision shoulder arthroplasty. J Shoulder Elb Surg. 2005;14:258. Scholar
  73. 73.
    Stevens NM, Kim HM, Armstrong AD. Functional outcomes after shoulder resection: the patient’s perspective. J Shoulder Elb Surg. 2015;24:e247–54.CrossRefGoogle Scholar
  74. 74.
    Muh SJ, Streit JJ, Lenarz CJ, et al. Resection arthroplasty for failed shoulder arthroplasty. J Shoulder Elb Surg. 2013;22:247. Scholar
  75. 75.
    Klatte TO, Junghans K, Al-Khateeb H, et al. Single-stage revision for peri-prosthetic shoulder infection outcomes and results. Bone Joint J. 2013;9595:391–5.CrossRefGoogle Scholar
  76. 76.
    McGoldrick E, McElvany MD, Butler-Wu S, Pottinger PS, Matsen FA. Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty. J Shoulder Elb Surg. 2015;24:31. Scholar
  77. 77.
    Foruria AM, Fox TJ, Sperling JW, Cofield RH. Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty. J Shoulder Elb Surg. 2013;22:620. Scholar
  78. 78.
    Jaeblon T. Polymethylmethacrylate: properties and contemporary uses in orthopaedics. J Am Acad Orthop Surg. 2010;18:297–305.CrossRefGoogle Scholar
  79. 79.
    Scalise JJ, Iannotti JP. Glenohumeral arthrodesis after failed prosthetic shoulder arthroplasty. Scholar
  80. 80.
    Stone GP, Clark RE, O’Brien KC, Vaccaro L, Simon P, Lorenzetti AJ, Stephens BC, Frankle MA. Surgical management of periprosthetic shoulder infections. J Shoulder Elb Surg. 2017;26:1222. Scholar
  81. 81.
    Nelson GN, Davis DE, Namdari S. Outcomes in the treatment of periprosthetic joint infection after shoulder arthroplasty: a systematic review. J Shoulder Elb Surg. 2016;25:1337–45.CrossRefGoogle Scholar
  82. 82.
    Grosso MJ, Sabesan VJ, Ho JC, Ricchetti ET, Iannotti JP. Reinfection rates after 1-stage revision shoulder arthroplasty for patients with unexpected positive intraoperative cultures. J Shoulder Elb Surg. 2012;21:754. Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Ryan L. Eschbaugh
    • 1
  • Joseph P. Iannotti
    • 1
  • Eric T. Ricchetti
    • 1
    Email author
  1. 1.Orthopaedic and Rheumatologic Institute, Cleveland ClinicClevelandUSA

Personalised recommendations