Upper limb. Arthrodesis of the shoulder after septic arthritis

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1 Upper limb Arthrodesis of the shoulder after septic arthritis LONG-TERM RESULTS M. Wick, E. J. Müller, T. Ambacher, U. Hebler, G. Muhr, F. Kutscha-Lissberg From the Berufsgenossenschaftliche Kliniken Bergmannsheil, Bochum and Katharinen Hospital, Stuttgart, Germany W e analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = ; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks. The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (<50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients. J Bone Joint Surg [Br] 2003;85-B: Received 10 August 2002; Accepted after revision 4 April 2003 M. Wick, MD E. J. Müller, MD U. Hebler, MD F. Kutscha-Lissberg, MD G. Muhr, MD, Professor of Orthopaedic and Trauma Surgery Department of Surgery, Berufsgenossenschaftliche Kliniken Bergmannsheil, Bürkle-de-la-Camp Platz 1, Bochum, Germany. T. Ambacher, MD Department of Surgery, Katharinen Hospital, Kriegsbergstrasse 60, Stuttgart, Germany. Correspondence should be sent to Dr M. Wick British Editorial Society of Bone and Joint Surgery doi: / x.85b $2.00 With the advent of arthroplasty of the shoulder fewer arthrodeses have been required. Arthrodesis of the shoulder was a well-established operation early in the 20th century, but is now rarely undertaken. 1,2 It is a salvage procedure which results in significant loss of movement. Because of the functional limitations, optimum positioning of the upper limb is a prerequisite for a good result. 3,4 However, despite the clinical improvement after arthroplasty, there remain some indications for arthrodesis in order to achieve relief from pain and to gain at least some function of the upper limb. The main indications are septic arthritis, neuromuscular disorders and destructive joint disease in young heavy workers. 5-7 Chronic infection is one of the most feared complications after shoulder arthroplasty or osteosynthesis for fracture. Unlike for other joints, such as the hip, resection arthroplasty is not a possible alternative form of treatment. 8,9 The diagnosis of septic arthritis of the shoulder represents an absolute indication for urgent surgical intervention, and if it is not undertaken, there is a high risk of irreversible local changes and possible mortality. Esenwein et al 10 described two patients who had died because of delayed initiation of treatment. Our aim in this study was to assess the long-term results of shoulder arthrodesis in 15 patients after infection of the shoulder. Patients and Methods Arthrodesis of the shoulder in patients with septic arthritis was performed on 15 patients between January 1978 and December As proposed by Ambacher et al, 9 the diagnosis of infection was made under the following circumstances: a characteristic history of infection of the shoulder, increasing levels of C-reactive protein (CRP) and a positive Gram stain after ultrasound-guided aspiration. There were four women and 11 men with a mean age of 51.9 years (17 to 85) at the time of arthrodesis. Only three were older than 60 years. In ten patients the dominant side was affected. The details of the previous operations which had been undertaken are shown in Table I. All patients were asked to return for clinical evaluation in June 2002, to answer a questionnaire and to undergo an analysis of function. Three had died from unrelated causes and one (case 7) from abroad had been lost to follow-up 666 THE JOURNAL OF BONE AND JOINT SURGERY

plate osteosynthesis 3 4 57 Infection after plate osteosynthesis 5 5 56 Infection after plate osteosynthesis 4 6 47 Infection after plate osteosynthesis 2 7 17 Gunshot wound 3 8 44 Haematogenous

2 ARTHRODESIS OF THE SHOULDER AFTER SEPTIC ARTHRITIS 667 Table I. Case Clinical details of 15 patients with infection of the shoulder Age (yrs) Indication for arthrodesis of the shoulder 1 44 Infection after injection Gas gangrene Infection after plate osteosynthesis Infection after plate osteosynthesis Infection after plate osteosynthesis Infection after plate osteosynthesis Gunshot wound Haematogenous infection Gunshot wound Infection after injection Infection after injection Infection after injection Infection after injection Haematogenous infection Infection after injection 2 Previous operations because he had returned to his family. For the patients who had died, we contacted their general practitioner to determine the outcome. Three patients who were unable to attend, completed a questionnaire. The remaining eight patients attended for clinical evaluation. The outcome was evaluated according to the modified functional score of Hawkins and Neer 11 and David, Makowski and Muhr. 12 We recorded the complications, further operations, alterations in working habits, pain and patient satisfaction. Operative technique. Arthrodesis of the shoulder may be extra-articular, intra-articular or combined and was performed in all patients with either a single or a double plate (Fig. 1). 13,14 Autogenous bone graft was taken from the ilium in nine patients. The glenohumeral joint was fused in between 20 and 60 of abduction, 20 and 40 of forward flexion and 25 and 40 of internal rotation. In one obese patient (case 1), abduction of 60 was required. Sinuses were marked with Methylene Blue and excised until all the coloured tissue had been removed. If necessary, a sequestrectomy was also performed. Postoperatively, the shoulder was not immobilised externally and the patients started passive exercises on the first postoperative day. Special care was taken to avoid stiffness of the thoracoscapular joint. Intravenous antibiotics were administered for two weeks according to the sensitivity of the organism which was identified, and oral antibiotic treatment continued until the sixth postoperative week. One patient with a negative culture received routine antistaphylococcal treatment. Results The mean follow-up was 8.3 years (3 to 14). A mean of 3.8 (1 to 14) previous procedures had been performed. We concentrated on functional assessment as well as the range of movement. All of the 11 available patients were limited especially in using their arms behind their backs. None was able to perform toilet hygiene and only one patient was able to reach his back pocket. Function at the level of the head in order to shave or to comb hair was difficult for most patients, whereas nine patients were able to work at waist level. Eight were able to put on shoes and socks. Working overhead was limited for all patients. None was able to hammer or paint and only four were able to climb a ladder. Thus four patients who worked mainly overhead had to change their job. All had had pain before surgery. On a visual analogue scale (VAS), the mean preoperative level of pain was 7.9 (1, slight pain, 10, unbearable pain). After arthrodesis, no patient was completely free from pain, but the mean level of pain improved to 3.3. Most patients required occasional oral analgesics. Seven could not sleep on the side of the arthrodesis. One patient (case 15) who was unsatisfied with the cosmetic outcome, wished the metal to be removed. Of the patients, 90% were satisfied with the outcome of the operation mainly because of reduction of pain. The limited movement of the shoulder was not the main problem, because in all there had been severe limitation of shoulder function pre- Fig. 1a Fig. 1b Radiographs showing infection of the shoulder after osteosynthesis (a). Twelve months after the operation (b), there are no signs of a pseudarthrosis. VOL. 85-B, No. 5, JULY 2003

3 668 M. WICK, E. J. MÜLLER, T. AMBACHER, U. HEBLER, G. MUHR, F. KUTSCHA-LISSBERG Table II. The outcome after arthrodesis of the shoulder. Three patients (cases 4, 9 and 12) were already deceased at the time of evaluation and one (case 7) was abroad Case Patient Pain preop Pain postop evaluation Satisfied Yes Dissatisfied No Satisfied Yes 4 8??? Satisfied Yes Satisfied Yes 7 8?? Satisfied Yes 9 6??? Satisfied Yes Satisfied Yes 12 9??? Satisfied Yes Satisfied Yes Satisfied Yes Favour arthrodesis again operatively. Only one patient was very dissatisfied with the outcome (case 2, 14 previous operations) and would not favour arthrodesis again. The outcome after arthrodesis of the shoulder is shown in Table II. Complications. These occurred in five patients (33%) (Table III). The main complication was persistent infection with failure of bony fusion and loosening of the implant, which occurred in three patients (20%). These patients required further surgery. One patient (case 13) did not wish the metal to be removed, despite signs of loosening and a sinus six years after operation, because of a reduction in pain and sound bony union. In one further patient, a sinus healed after removal of the metal. There was no correlation between the use of a cancellous bone graft and bony union, or the incidence of infection. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). In those without complications, there were only two smokers. The mean age of the patients with complications was 58.6 years compared with 48.6 years for those without (p = ; not significant). There were more previous operations in those with complications (6.4 v 2.5, p < 0.05). Staphylococcus aureus was the infecting organism in 14 patients (93.3%). Discussion The indications for arthrodesis of the shoulder are limited since the advent of arthroplasty and advances in the treatment of septic arthritis. Arthrodesis results in limitation of shoulder function. Indications include bacterial infection, paralytic disorders of infancy, destructive inflammatory arthritis with severe involvement of the rotator cuff, failed arthroplasty, post-traumatic paralysis of the brachial plexus in adults, recurrent dislocation, resection of a tumour, painful arthritis in younger patients who do heavy manual work and in whom a prosthesis is unlikely to remain functional for a lifetime, and chronic infection. 5-7,15-17 There are only a few contraindications, which include paralysis of the trapezius, levator scapulae, serratus anterior, latissimus dorsi or rhomboid muscles. These muscles are required to provide motor function to the upper limb. A contralateral shoulder arthrodesis is also a relative contraindication because it severely inhibits activities of daily living. 15 The outcome depends on the individual patient and the indication for arthrodesis. To our knowledge, this is the first study which has investigated the long-term outcome after arthrodesis of an infected shoulder. In 40% of our patients, the infection of the shoulder followed an injection for a painful shoulder and in 27% after internal fixation of a fracture of the proximal humerus. The mean age of the patients in our study was high at 51.9 years compared with 42 years in the patients described by Groh et al 3 and 48.6 years in those described by Hawkins and Table III. Pre- and postoperative details and complications after arthrodesis of the shoulder Position of the fusion Level of CRP (mg/dl) Bacterial culture Case* (degrees) Cancellous bone Preop Postop Preop Postop Antibiotics Bony fusion 1 Abd 60, Ante 20, Iro 40 No S. aureus Neg Clindamycin Yes 2 Abd 45, Ante 40, Iro 30 Yes S. aureus S. aureus Flucloxacillin No 3 Abd 20, Ante 20, Iro 30 Yes S. aureus Neg Clindamycin Yes 4 Abd 30, Ante 20, Iro 30 Yes Neg Neg Clindamycin No 5 Abd 20, Ante 30, Iro 40 Yes S. aureus Neg Ciprofloxacin Yes 6 Abd 30, Ante 20, Iro 30 Yes S. aureus Neg Clindamycin Yes 7 Abd 30, Ante 20, Iro 30 Yes S. aureus Neg Flucloxacillin? 8 Abd 30, Ante 30, Iro 40 No S. aureus Neg Clindamycin Yes 9 Abd 50, Ante 30, Iro 40 No S. aureus S. aureus Clindamycin No 10 Abd 40, Ante 40, Iro 30 Yes S. aureus Neg Ciprofloxacin Yes 11 Abd 30, Ante 30, Iro 30 No S. aureus S. aureus Flucloxacillin Yes 12 Abd 30, Ante 20, Iro 30 Yes S. aureus Neg Ciprofloxacin Yes 13 Abd 40, Ante 20, Iro 30 No S. aureus Neg Flucloxacillin Yes 14 Abd 40, Ante 25, Iro 25 No S. aureus Neg Clindamycin Yes 15 Abd 40, Ante 30, Iro 30 Yes S. aureus Neg Clindamycin Yes *cases 4, 9 and 12, deceased; case 7, abroad normal level < 1 mg/dl THE JOURNAL OF BONE AND JOINT SURGERY

ARTHRODESIS OF THE SHOULDER AFTER SEPTIC ARTHRITIS 669 Fig. 2 Photographs showing extensive soft-tissue scarring of the shoulder due to previous operations. Neer.

Hawkins and Neer 11 concluded that the ideal patient for arthrodesis of the shoulder is a young man whose work is non-manual and involves using his arm at waist level, and with involvement of the

4 ARTHRODESIS OF THE SHOULDER AFTER SEPTIC ARTHRITIS 669 Fig. 2 Photographs showing extensive soft-tissue scarring of the shoulder due to previous operations. Neer. 11 The oldest patient was 85 years at the time of operation, but arthrodesis was considered to be the only way to reduce his pain. The preoperative pain level on the VAS scale was 9. Hawkins and Neer 11 concluded that the ideal patient for arthrodesis of the shoulder is a young man whose work is non-manual and involves using his arm at waist level, and with involvement of the non-dominant side. Unlike previous studies, the main postoperative complication in our study was not the position of the arthrodesis and the limitation of movement but persistent infection. Groh et al 3 reported complications in 50% of 28 patients, the main complication being nonunion and limitations caused by malposition of the shoulder. The rate of union in our patients was 73.3%. They described a wound infection in one patient. Brown, Orme and Richardson 18 described only one infection in 71 patients and 82% were satisfied with the outcome. In patients without sepsis at the time of operation, the reported incidence of infection varies between 3% and 5%; in our patients the incidence of postoperative infection was 26%. 16 Elevated CRP levels reflected persistent infection (Table III). All patients had undergone previous surgery, one having had 14 previous operations, with much local soft-tissue scarring and persistent infection (Fig. 2). If much bone needs to be removed, cancellous bone grafting is required. Patients who developed complications were older and had undergone more previous operations. The number of previous operations is a very important factor in determining the outcome. The effect of smoking should also be taken into account. It has been shown to increase morbidity and mortality in surgery. Josten and Muhr 19 emphasised the adverse effect of smoking in surgery for sepsis and Lavernia, Sierra and Gomez-Martin 20 reported that patients undergoing joint replacement who smoke incur higher hospital charges adjusted for age, the nature of the procedure and anaesthesia times. Brown et al 18 reported a three- to fourfold increase in incidence of nonunion or pseudarthrosis after arthrodesis in patients who smoke. Cigarette smoking delays the formation of new bone and wound healing and increases the risk of necrosis of skin flaps Any disturbance of the microcirculation can adversely affect the outcome of surgery in patients who already have compromised soft tissues and chronic infection and we advise all our patients to stop smoking. Although there was a high incidence of complications, 90% of the patients were satisfied with the outcome. The most important contributory factor was reduction of pain, which was achieved in all cases. Previous levels of satisfaction of about 80% have been reported after arthrodesis of the shoulder. 24 The limitation of function of the shoulder after arthrodesis is usually related to fixation in an inappropriate position. Stability is obtained at the cost of rotation. Many studies have investigated the optimum position for arthrodesis. In 1942, the American Orthopaedic Association proposed 50 of abduction, 15 to 25 of flexion and 25 of internal rotation. 25 Rowe 26 showed that a position with excessive abduction and flexion forces the scapula to rotate and wing when the shoulder is at rest with the arm by the side of the body. He therefore recommended abduction and flexion of 20 to 25 and internal rotation of 40. Hawkins and Neer 11 recommended 25 to 40 of abduction, 20 to 30 of flexion and 25 to 30 of internal rotation. Most authors found that excessive abduction and flexion are associated with persistent pain. Cofield and Briggs, 24 however, and Clare et al 27 found no correlation between the position of the arm and residual pain in a series of 71 patients. Intraoperatively, it is difficult to determine the exact position for fixation. The surgeon should establish whether the position enables the patient to reach his mouth, the contralateral axilla and the anterior perineal area. Single- or double-plate fixation is the most popular technique for arthrodesis of the shoulder and was used in this study (Fig. 1). Kostuik and Schatzker 14 described 18 patients with double-plate fixation with a good outcome in 15 and patient satisfaction in 87%. VOL. 85-B, No. 5, JULY 2003

5 670 M. WICK, E. J. MÜLLER, T. AMBACHER, U. HEBLER, G. MUHR, F. KUTSCHA-LISSBERG The limitations of activities of daily living, particularly at the level of the head, were not as severe as expected because the preoperative range of movement of the shoulder was very limited in all patients. In conclusion, arthrodesis of the shoulder is a well-established but demanding salvage procedure. With the advent of shoulder arthroplasty, the indications are limited. In patients with infection, there is a higher rate of complications and they should be warned preoperatively of the risks of chronic infection and limitations in activities on a daily basis. However, because of significant reduction of pain, arthrodesis is recommended in these cases. The younger the patient with fewer previous operations (<50 years, <four previous operations), the better is the outcome. Bearing in mind the possible complications, we recommend early surgery in these patients. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Steindler A. Arthrodesis of the shoulder. Instr Course Lect 1944;12: Moseley HF. Arthrodesis of the shoulder in the adult. Clin Orthop 1961;20: Groh GI, Williams GR, Jarman RN, Rockwood CA Jr. Treatment of complications of shoulder arthrodesis. J Bone Joint Surg [Am] 1997;79- A: Jonsson E, Lidgren L, Rydholm U. Position of shoulder arthrodesis measured with Moire photography. Clin Orthop 1989;238: Richards RR, Waddell JP, Hudson AR. Shoulder arthrodesis for the treatment of brachial plexus. Clin Orthop 1985;198: González-Díaz R, Rodríguez-Merchán EC, Gilbert MS. The role of shoulder fusion in the era of arthroplasty. Int Orthop 1997;21: Wilde AH, Brems JJ, Boumphrey FR. Arthrodesis of the shoulder: current indications and operative technique. Orthop Clin North Am 1987;18: Esenwein SA, Robert K, Kollig E, et al. Long-term results after resection arthroplasty according to Girdlestone for treatment of persisting infections of the hip joint. Chirurg 2001;72: Ambacher T, Esenwein S, Kollig E, Muhr G. The diagnostic concept of acute infection of the shoulder joint. Chirurg 2001;72: Esenwein SA, Ambacher T, Kollig E, et al. Septic arthritis of the shoulder following intra-articular injection therapy: lethal course due to delayed initiation of therapy. Unfallchirurg 2002;105: Hawkins RJ, Neer CS 2nd. A functional analysis of shoulder fusions. Clin Orthop 1987;223: David A, Makowski S, Muhr G. Posttraumatische Schulterarthrodesen-Indikation, Technik, Ergebnisse. Unfallchirrug 1995;98: Müller ME, Allgöwer M, Schneider R, Willenegger H. Manual of internal fixation: technique recommended by the AO-Group. 2nd ed. New York: Springer 1979: Kostuik JP, Schatzker J. Shoulder arthrodesis: AO technique. In: Bateman JE, Welsh RP, eds. Surgery of the shoulder. St Louis: CV Mosby; 1984: Neer CS. Glenohumeral arthrodesis. Philadelphia. WB Saunders, 1990: Richards RR. Redefining indications and problems of shoulder arthrodesis. Philadelphia. Lippincott-Raven, 1997: Ralston EL. Arthrodesis of the shoulder. Orthop Clin North Am 1975;6: Brown CW, Orme TJ, Richardson HD. The rate of pseudarthrosis (surgical nonunion) in patients who are smokers and patients who are nonsmokers: a comparative study. Spine 1986;11: Josten C, Muhr G. Der Tibiasegmenttransport. Unfallchirurg 1999;102: Lavernia CJ, Sierra RJ, Gomez-Martin O. Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop 1999;367: Ueng SW, Lee MY, Li AF. Effect of intermittent cigarette smoke inhalation on tibial lengthening: experimental studies on rabbits. J Trauma 1997;42: Hunt TK, Linsey M, Sonne M, Jawetz E. Oxygen tension and wound infection. Surg Forum 1972;23: Jensen JA, Goodson Wh, Hopf HW, Hunt TK. Cigarette smoking decreases tissue oxygen. Arch Surg 1991;126: Cofield RH, Briggs BT. Glenohumeral arthrodesis: operative and longterm functional results. J Bone Joint Surg [Am] 1979;61-A: Barr JS, Freiberg JA, Colonna PC, Pemberton PA. A survey on end results on stabilization of the paralytic shoulder. J Bone Joint Surg 1942;24: Rowe CR. Re-evaluation of the position of the arm in arthrodesis of the shoulder in the adult. J Bone Joint Surg [Am] 1974;56-A: Clare DJ, Wirth MA, Groh GI, Rockwood CA Jr. Shoulder arthrodesis. J Bone Joint Surg [Am] 2001;83-A: THE JOURNAL OF BONE AND JOINT SURGERY

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