Shoulder replacement for postinfectious destructive arthritis

This is a healthy patient in her seventies who presented in our office with right shoulder pain and loss of motion. She had active forward elevation of the shoulder to 20 degrees. She has a history of septic shoulder arthritis which was treated elsewhere 3 years ago with irrigation and debridement and 6 weeks of IV antibiotics via a PICC line. At the time of presentation she had no signs of infection, she had no recurrent infection over the past 43 years and her lab work (WBC, CRP, ESR) was normal. The patient had problems sleeping at night and pain with any motion of the shoulder. Her radiographs were indicative of severe joint destruction, loss of bone stock at the glenoid and humeral head and severe medialization/erosion of the glenoid.

A CT scan demonstrated the severity of the joint destruction.

During surgery we found that the glenoid did not have enough bone stock for insertion of a glenosphere for a reverse shoulder replacement and the rotator cuff (supraspinatus) muscle was torn. The subscapularis was present but was atrophic.

We elected to proceed with a hemiarthroplasty with a large size humeral head to avoid instability and provide some pain relief. Cultures were obtained at the time of surgery that will be held for 3 weeks to look for p. acnes and the patient was placed on oral Augmentin for 3 weeks until cultures finalize.

The post-operative XR shows restoration of the acromion index as described before 

(Association of a Large Lateral Extension of the Acromion with Rotator Cuff Tears

Richard W. Nyffeler, MD, Dipl.Ing. ETH; Clément M.L. Werner, MD; Atul Sukthankar,MD; Marius R. Schmid, MD; Christian Gerber, MD

J Bone Joint Surg Am, 2006 Apr;88(4):800-805.

This case illustrates the complexity involved in the treatment of shoulder arthritis that is associated with (1) loss of soft tissue balance-rotator cuff (2) loss of glenoid bone stock.

Although some surgeons would have suggested bone grafting of the glenoid and implantation of a reverse shoulder prothesis we elected not to proceed with this approach due to the (1) high chance of absorption of the bone graft at the glenoid (2) history of infection increasing the chances of failure of the bone graft (3) early loosening of the glenosphere in shoulders with hypoplastic, dysplastic or atrophic glenoids.