Keywords
shoulder arthroscopy - prophylactic antibiotics - arthroscopic surgery - infection
Introduction
Shoulder arthroscopy is a well-established technique in dealing with a variety of
shoulder conditions. The most common pathologies treated are instability, rotator
cuff tears, subacromial impingement, acromioclavicular joint osteoarthritis, and loose
bodies within the joint. As with many areas of orthopaedics, intravenous antibiotics
are usually administered prior to surgery to reduce the potentially catastrophic sequelae
of infection, which in the United States stands at 0.27%.[1] Though there is no doubt that antibiotics have been one of the most important factors
in reduction of infection following surgery over the past century, their continued
use given advancement in surgical techniques should be looked at in detail. They are
not as benign as previously thought, with increasing cases of colitis and other gastrointestinal
upsets, phlebitis, allergies, hypersensitivity,[2] and perhaps most worryingly the promotion of antibiotic-resistant strains of bacteria
putting at risk vulnerable patient groups.
Shoulder arthroscopy benefits from small incisions, constant lavage with isotonic
saline, minimal hardware, and, usually, relatively short operating times, all of which
reduce the chances of infection.
The objective of this systematic review was to assess the postoperative infection
rate in patients undergoing shoulder arthroscopy who had antibiotics around the time
of the procedure and in those who did not, in an attempt to determine definitively
whether antibiotics are required when performing routine arthroscopic procedures of
the shoulder. The hypothesis was that there would be an increase in infection in patients
who had not been administered with prophylactic antibiotics.
Methods
We conducted a comprehensive search of the literature using Medline Ovid from 1946
to present. Articles published in English-language journals that looked at infection
as the primary outcome following shoulder arthroscopy were selected and analyzed.
The search strategy used is reported in [Table 1].
Table 1
Search strategy
|
Database: Ovid MEDLINE(R) Epub Ahead of Print, In-Process, and Other Non-Indexed Citations,
Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) <1946 to Present>
|
|
Search strategy
|
|
1
|
exp antibacterial agents/ (653813)
|
|
2
|
Antibiotic*.mp. (329304)
|
|
3
|
Arthroscopy and shoulder.mp. (4529)
|
|
4
|
Shoulder arthroscopy.mp. (822)
|
|
5
|
Bankart repair.mp. (531)
|
|
6
|
(Rotator cuff repair and arthroscopy).mp. (901)
|
|
7
|
Joint instability and shoulder.mp. (3454)
|
|
8
|
Rotator cuff injuries/su [Surgery] (169)
|
|
9
|
Surgical wound infection and shoulder.mp. [mp = title, abstract, original title, name
of substance word, subject heading word, keyword heading word, protocol supplementary
concept word, rare disease supplementary concept word, unique identifier, synonyms]
(156)
|
|
10
|
Bankart lesions/(10)
|
|
11
|
1 or 2 (801835)
|
|
12
|
3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 (7788)
|
|
13
|
11 and 12 (79)
|
The authors then assessed the articles for quality, methods, study design, outcome,
and relevance to the specific clinical question.
Results
Seventy nine articles were obtained from the search. None of the 79 articles directly
addressed our main study question by prospectively comparing infection in patients
who had prophylactic antibiotics versus those who did not in shoulder arthroscopy.
There were eight articles that were partially relevant to our study question ([Fig. 1]). Two articles discussed the incidence, risk factors, and prophylaxis of infections
following rotator cuff repairs.[3]
[4] The remaining six articles were only of limited interest to the authors, because
they did not address the study question. One was a review article on septic arthritis
after arthroscopy,[5] and another was a case report of pseudomonas osteomyelitis of the proximal humerus
after arthroscopic rotator cuff repair.[6] One article discussed the incidence of Propionibacterium acnes (P. acnes) in shoulder arthroscopy;[7] one article looked at deep infection after rotator cuff repair;[8] one article focused on infection following shoulder instability surgery;[9] and one was a cost–benefit analysis of antibiotic prophylaxis in septic arthritis
following arthroscopy, though the focus was not solely on the shoulder.[10]
Fig. 1 PRISMA 2009 flow diagram.
The article by Pauzenberger et al[3] was a retrospective comparative study of 3,294 arthroscopic rotator cuff repairs
performed in a single department over a 10-year period. This study was interesting,
as in the first half of the study period, there was no routine perioperative administration
of antibiotics, but this changed in the second half of the study period when administration
of antibiotics (cephalosporin or clindamycin in the case of allergies) became the
norm. Altogether, they had 28 deep infections during the study period (8.5/1000) with
the leading pathogen being Staphylococcus epidermidis followed by P. acnes and Staphylococcus aureus. After introduction of perioperative antibiotics, there was a statistically significant
reduction in infection rate from 1.54% to 0.28%. There was no statistically significant
reduction in infection with P. acnes though. They found that other factors that correlated with increased risk of infection
were male gender, possible due to different pathogen pattern in males and/or the presence
of more body hair, increasing age and prolonged length of surgery. The main weakness
of the study, as pointed out by the authors, was the retrospective design. Another
weakness, perhaps as a corollary to the first, was the lack of a control group over
the same study period to compare rates of infection. This significantly lowered the
validity of the study, as several other changes responsible for the drop in infections
may have taken place over the study period. Furthermore, the focus was on rotator
cuff surgery alone, arguably the most technically demanding and lengthy shoulder procedure,
while our question was on all arthroscopic procedures of the shoulder thought to require
antibiotics. Nonetheless, it is a valuable study given the length of follow-up and
the large number of patients and added some information on expected infection rates
following arthroscopic rotator cuff repairs, which are useful when discussing perioperative
risks with patients.
Vopat et al[4] performed a retrospective case–control study on patients who had an infection following
rotator cuff repair in comparison with a randomly selected group of patients who had
undergone cuff repair but not suffered an infection. The authors found an increased
infection rate with open or mini-open rotator cuff repair when compared with arthroscopic
techniques, and reiterated the male gender as another significant risk factor. The
overall infection rate was 14/1,822 (7.6/1000). All the patients received prophylactic
preoperative intravenous antibiotics. Limitations of the study were mainly related
to characteristic of the participants and treatments (there were a mixture of arthroscopic
and open cases) and again the lack of a comparison group, so it was not directly relevant
to our review.
Bauer et al[5] showed that infection following joint arthroscopy was rare (<1%), but again there
was no mention of the role of antibiotics and the article was more focused on the
treatment of septic arthritis with no particular interest on shoulder arthroscopy.
The study by Chuang et al[7] highlighted the high incidence of P. acnes skin colonization on arthroscopic portal sites and the inoculation of this pathogen
within the deep tissues despite the use of perioperative antibiotics, though because
of its low virulence it does not always manifest itself as a clinical infection.
Aydin et al[6] reported a rare case of pseudomonas osteomyelitis in the shoulder after arthroscopic
rotator cuff repair, and in an age of antibiotic overuse, it is a reminder of the
potential of unusual organisms to cause infection to the shoulder.
Athwal et al[8] detailed infections following rotator cuff repair, but majority of them underwent
open repair. Similarly, the work done by Sperling et al[9] explored infection after instability surgery, although it did not limit the analysis
to patients who only underwent arthroscopic surgery. Finally, D'Angelo and Ogilvie-Harris[10] reported a cost–benefit analysis in infection prevention for arthroscopy of both
the knee and the shoulder. The authors concluded that prevention of infection with
prophylactic antibiotics may be beneficial from an economic standpoint, albeit prophylaxis
should be balanced against the risks and increasing cost of widespread antibiotic
use in a complication that is rare.
Discussion
The use of prophylactic antibiotics in shoulder arthroscopy that involves implants
has become routine. Certainly, in the past, when procedures were lengthy, incisions
larger, and equipment not as ergonomic, there was a higher chance of the patient contracting
an infection. Antibiotics have reduced this potential for infection[3] and have, therefore, been adopted in arthroscopic practice, but their continued
widespread use does, however, pose potentially serious risks: gastrointestinal upsets,
phlebitis, allergies, promotion of antibiotic-resistant strains of bacteria, and hypersensitivity,[2] not to mention the cost.
In recent times, with the advent of subspecialty training and expertise, improved
instrumentation and operative techniques have meant a reduction in the length of procedures,
hardware required, and anecdotally a reduction in the rate of infections. Furthermore,
it has been shown that one of the most common pathogens found around the shoulder,
P. acnes, inoculates portal sites and colonizes deep tissue irrespective of perioperative
broad-spectrum antibiotic use and skin prepping solution.[7]
[11] Conversely, the other two commonly found pathogens S. aureus and S. epidermidis are readily controlled with chlorhexidine-based skin preparation and the use of broad-spectrum
intravenous antibiotics. Despite a low rate of infection with P. acnes in shoulder arthroscopic surgery, its continued presence raises concern, as it is
implicated as the main infection-causing pathogen following open surgical procedures
of the shoulder.[9]
[12]
[13]
[14]
[15]
In addition to antibiotics and skin prepping solution, superficial infections of the
shoulder may be influenced by the presence of nonabsorbable sutures in the skin or
subdermis.[9] Stitch abscesses and sinuses have long been known to occasionally occur following
wound closure with nonabsorbable sutures, and in shoulder arthroscopy their use is
now relatively uncommon, with most surgeons opting for adhesive strips or an absorbable
subcuticular suture. In many modern units, shoulder arthroscopy is done expeditiously,
with a standard aseptic prepping technique, portal site closure method, often as a
day case and it is important that surgeons now look at new evidence regarding the
use of perioperative antibiotics in shoulder arthroscopy. Unfortunately, there is
no study in the literature or in trial registries comparing the infection rate in
these two groups of patients undergoing shoulder arthroscopy. Ideally, this question
would be answered by a prospective randomized control trial.
Given the rapid advances that have taken place over the past decade, our greater understanding
of the risks of casual antimicrobial administration, and the changing surgical landscape,
there is now a real need for an up to date study comparing infection rates in patients
who receive and those who do not receive perioperative antibiotics in routine shoulder
arthroscopic procedures.
