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22 PJI After Shoulder andElbow Arthroplasty
01/2022 rst stage: prosthesis removal with intramedullary antibiotic carrier due to PJI
22.3 PJI after Elbow Arthroplasty
22.3.1 Introduction
andEpidemiology
Following the rst successful implantation of a
total elbow prosthesis in the 1970s, the TEA procedure became an orthopaedic standard operation
with steadily increasing numbers [80]. The indications for TEA include primary and posttraumatic osteoarthritis, rheumatoid arthritis, and
cases of non-reconstructible joint fractures.
However, implantation numbers and functional
outcomes lag behind those of total hip and knee
prostheses, despite the past and ongoing developments of new prosthesis designs. This indirectly
affects the available data on periprosthetic elbow
infections and their treatment. Available implants
can be sub-classied into hinged and non-hinged
designs with marginal outcome differences following primary TEA [75]. Following aseptic
component loosening, PJI is the main cause of
revision surgery after TEA with a median rate of
3.3% and a range of 2.5 to 12% in the literature
[37, 74].
325
03/2022 second stage: reimplantation inverse shoulder
prosthesis
22.3.2 Risk Factors
Evidence on specic risk factors for PJI following TEA is rare compared to other arthroplasty
procedures. Nevertheless, it seems safe to say
that most patient-related risk factors for PJI such
as young age at the time of surgery, duration of
the surgery, immunosuppression, malnutrition,
number of revisions as well as prolonged surgical
time and prior local infections play a negative
role in TEA.
Obesity, a common risk factor in total joint
arthroplasty, also has a negative impact on the
PJI rate following TEA.A study including 7580
cases indicated that patients with a BMI under
30 exhibited an infection rate of 2.1%, whereas
those with a BMI ranging from 30 to 40 experienced a rate of 4.7%. For individuals with a BMI
of 40 or higher, the infection rate rose to 7%
[23].
326
G. Hauer et al.
A database analysis of 13,698 individuals who
underwent TEA, with 2270 patients (16.5%) having diabetes, revealed elevated rates of wound
infections (1.6% compared to 0.83%), consequently inuencing the susceptibility to
PJI.Diabetes also has a negative effect on length
of stay, blood transfusion rates, and the overall
number of perioperative complications [52].
A specic risk factor for PJI following TEA
which is commonly discussed is the poor local
soft tissue coverage. This is further exacerbated
by existing rheumatoid arthritis, as this patient
group tends to have impaired wound healing,
resulting in an increased risk for PJI [28]. A
higher overall revision rate for patients with
rheumatoid arthritis was also reported by a systematic review including 1253 cases of primary
TEA (compared to post-traumatic osteoarthritis
and trauma), however, the PJI rate was not signicantly different [54]. This is in contrast to the
results of another study including 1452 patients,
reporting rheumatoid arthritis to be a signicant
risk factor for PJI after TEA (odds ratio
(OR)=3.31; p<0.001) [65].
This study also reported that hypothyroidism
(OR=2.04; p=0.045) and smoking (OR=3.39;
p= 0.003) represent signicant risk factors for
PJI following TEA.Preoperative optimization of
thyroid function, smoking reduction, or complete
abstinence as well as management of rheumatoid
disease is recommended [65]. Further, surgical
procedures prior to the index arthroplasty seem to
increase the risk of subsequent PJI.This is displayed by the mean PJI rate of 11% in 6 studies,
whereas 69% (201/291) of patients were reported
to have had prior surgery before TEA [73].
22.3.3 Diagnosis
The diagnosis of PJI can be challenging, especially in low-grade cases in the absence of the
classic clinical criteria (warmth, swelling, pain,
redness). Systemic symptoms are reportedly less
commonly observed in infected elbow prostheses
compared to hip and knee endoprostheses.
Assessing potential current risk factors for PJI
(see above), as well as the medical history fol-
lowing TEA implantation (i.e. wound drainage,
multiple revision surgeries), provides crucial
information regarding the likelihood of an existing PJI [78].
Studies investigating serum biomarkers in PJI
following TEA are rare, and transferring study
results from hip and knee PJI research must be
done with caution. Especially when considering
that many patients with TEA may suffer from an
underlying inammatory condition and may have
a different baseline level of inammatory markers [66]. Experts therefore recommend considering the classic inammatory markers over time,
in conjunction with clinical symptoms and other
diagnostic tests. It is advised not to make diagnostic decisions solely based on elevated serum
biomarkers, especially following TEA [49]. No
specic studies investigating alternative serum
markers (i.e. brinogen, procalcitonin, interleukin- 6) in PJI following TEA were found.
While joint aspiration as a diagnostic tool in
TEA has not been extensively studied, its value
has been extensively proven in hip and knee
arthroplasty cases. While joint aspiration is useful as a rule-in test (purulence around the joint,
positive culture), a negative result cannot exclude
an underlying PJI following TEA [74]. Elevated
synovial uid white blood cell count, especially
with a high percentage of polymorphonuclear
neutrophils, strongly suggests PJI. In cases of
suspected PJI, joint aspiration is recommended,
as it allows different subsequent analyses including routine culture, white blood cell count, neutrophil percentage determination, and potentially
molecular analyses for pathogen identication
[49].
A 2013 study involving 227 procedures was
conducted to explore intraoperative histology and
compare it to the gold standard of intraoperative
cultures [1]. The results revealed that histology
indicated acute inammation in 33 procedures
(14.5%), whereas cultures tested positive in 39
procedures (17.2%). The study found intraoperative histology to be accurate in 85.9% of cases,
with a sensitivity of 51.3% and a specicity of
93.1%. While intraoperative histology in revision
elbow arthroplasty exhibits high specicity and
negative predictive value, it demonstrates lower
22 PJI After Shoulder andElbow Arthroplasty
327
sensitivity and positive predictive value for
PJI.The combination with other diagnostic methods is necessary to ensure an accurate PJI
diagnosis.
Biolm sonication of removed implants in
revision TEA showed no statistically signicant
diagnostic advantage compared to tissue culture
in a study from 2011 including 36 patients [72].
Based on this study, in 2018, expert recommendations were published against the routine use of
sonication for explanted elbow prosthesis components. However, the severely limited data compared to hip and knee PJI cases was criticized
[49]. A more recent study conducted by the group
led by Robin Patel presented different results in a
larger cohort. In a retrospective analysis of 112
sonicate uid cultures and tissue cultures from
patients who underwent TEA revision between
2007 and 2019, the study identied 49 PJI cases
and 63 aseptic cases. The sensitivity of sonicate
uid culture was 76%, surpassing the 63% sensitivity of tissue culture alone. When combined
with tissue culture, sonicate uid culture demonstrated an even higher sensitivity of 84%, indicating an improved microbiologic diagnosis of PJI
after TEA using sonication [15].
mum of 4weeks, where each day of treatment
delay shows a trend towards worse outcomes
[69].
2. Soft tissue coverage intact, no sinus tract
present.
3. Targeted biolm-active antibiotics available.
A DAIR procedure, even though it may appear
straightforward, should be conducted by an experienced team for optimal results. If all the abovementioned criteria are met and a radical
debridement is performed, infection eradication
rates range between 11.1% and 85.7% (mean
57.7%) [37]. DAIR procedures in PJI cases
caused by S. epidermidis seem to have less
favourable outcomes in some published papers,
however, further research is necessary on this
topic [74]. A small cohort series with 26 included
cases investigated the infection eradication rate
after DAIR and the reasons for failure. The DAIR
procedure was successful in nine cases (35%)
with a median time to failure of 43 days. All
DAIR procedures performed with an existing
sinus tract or negative cultures failed. Short
symptom duration and monomicrobial infections
showed a trend towards a better outcome without
statistical signicance [69].
22.3.4 Treatment
22.3.4.1 Implant Retention
No randomized, controlled trials or prospective
studies have been conducted regarding the surgical management of PJI after TEA. The debate
over which procedure effectively eliminates the
infection, while also yielding improved functional outcomes and reduced complications,
remains ongoing. The treatment options include
DAIR, one-stage exchange, two-stage exchange,
and various salvage procedures. For optimal
infection eradication rates, functional outcomes,
and patient quality of life, choosing the right
therapy for the right patient is crucial.
A DAIR procedure can be performed if:
1. Biolm has not yet reached its mature form.
The duration of this time window, starting
with the onset of clinical symptoms, is currently
being discussed. The authors recommend a maxi-
22.3.4.2 One-Stage Revision Arthroplasty
The removal of a prosthesis and the implantation
of a revision TEA in a single operation is a rarely
executed procedure. This rarity is evident in a
recent review article, which included a small case
series of only nine cases from four different studies. Among these cases, just three papers documented instances of a single-stage exchange. Due
to the limited number of cases, it is challenging to
draw denitive conclusions about eradication
rates, with an average of 66.7% and a wide range
spanning from 0% to 100% [37].
22.3.4.3 Two-Stage Revision Arthroplasty
Two-stage revision surgery for PJI has long been
the gold standard in all PJI procedures of the
upper and lower limbs. This seems slowly changing in total hip and knee replacements based on
recently published, excellent infection eradica-
328
G. Hauer et al.
tion rates in both, one and two-stage exchanges.
Taking the favourable outcomes regarding, function, bone loss, patient comfort, and cost into
account, arguments in favour of one-stage
exchange seem increasingly convincing [47, 68].
In contrast, the available literature on revision
procedures in PJI following TEA indicates that
two-stage exchange remains the undisputed gold
standard. A recent review article identied 11
articles on the subject including 121 patients
treated with a two-stage exchange for PJI following TEA. The mean infection eradication rate
was 76% (range 44.4% to 100%). This was signicantly higher compared to the infection eradication rates for the DAIR procedure, but not
signicantly different compared to other procedures [37].
A recent study including 52 elbows undergoing two-stage exchange for PJI following TEA
reports an infection eradication rate of 69% at a
mean follow-up of 6years. The risk for treatment
failure, determined as recurrent infection, was
3.3 times higher in elbows with residual bone
cement (p= 0.04), and 3.5 times higher in PJI
cases due to Staphylococcus epidermidis
(p=0.06) [34].
52months. One elbow had to be re-revised due to
recurrent infection. The mean Disabilities of the
Arm, Shoulder, and Hand (DASH) score changed
signicantly from 46.5 (range, 29–67) preoperatively to 53.0 (range, 33–65) at the last follow-up.
The authors considered the procedure suitable for
low-demand patients where both columns of the
distal humerus can be retained during implant
removal [55].
Generally, an elbow arthrodesis leads to poor
functional results due to the inability to compensate for shoulder motion [43]. A case series
involving four patients who underwent arthrodesis following the failure of staged reimplantation
for infection at the site of a total elbow arthroplasty showed discouraging results. Despite thorough debridement and the use of an antibiotic
cement spacer, none of the four elbows achieved
bone healing after a minimum follow-up of
12months [45].
If further surgery is technically not possible or
not feasible due to the patient’s health condition,
an antibiotic suppression therapy may be
employed. However, there is not enough data
available to justify specic therapy recommendations in PJI following TEA.
22.3.4.4 Salvage Procedures
Resection arthroplasty, arthrodesis/fusion and
antibiotic suppression are considered possible
salvage procedures in cases where a complete PJI
eradication cannot be achieved. Currently, there
is very limited data available in the literature to
support a treatment recommendation.
In cases of extensive bone loss, a resection
arthroplasty with or without a temporary spacer
may be considered. A study including 49 elbows
reported frequently encountered complications
comprised of infections in 24 elbows (47%),
intraoperative fractures in eighteen (35%), and
lasting nerve damage in nine elbows (18%).
Improved stability post-resection demonstrated a
signicant association with higher long-term
Mayo Elbow Performance Scores (p<0.05) [79].
A different study presented the results of resection arthroplasty in ten elbows belonging to nine
patients, with an average follow-up duration of
2011/1 elbow prosthesis (septic loosening and humeral
periprosthetic fracture)
22 PJI After Shoulder andElbow Arthroplasty
2012/2 Coonrad morrey total elbow prosthesis
2014/9 proximal Ulna
2021/11 total elbow prosthesis
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Periprosthetic Joint Infection
inMegaprostheses
AndreaAngelini, ElisaPala, GiuliaTrovarelli,
MariachiaraCerchiaro, ElisaPagliarini,
AlessiaFiumini, andPietroRuggieri
23
23.1 Introduction
Treatment of malignant bone tumors has always
represented a signicant challenge for orthopedic
surgeons, which is why the exploration of innovative approaches has been necessary. In the past,
amputation was the primary method employed to
eradicate cancerous tissue, although with considerable physical and psychological repercussions
for patients [1]. The complete removal of the
affected limb not only impacted mobility and
functionality but also had far-reaching consequences on overall quality of life [2]. With the
evolution of medical practices, amputation has
gradually taken a backseat, and limb-sparing surgeries have made a gain in both acceptance and
use. This paradigm shift can be attributed to several factors, including advancements in imaging
studies, the upgrade in adjuvant therapies, a more
comprehensive understanding of tumor biology,
and the intricacies of tumor–host interactions [3].
Improvements in surgical techniques and prosthetic technologies have also contributed to the
growing popularity of limb-sparing surgeries.
A. Angelini · E. Pala · G. Trovarelli · M. Cerchiaro ·
E. Pagliarini · A. Fiumini · P. Ruggieri (*)
Department of Orthopedics and Orthopedic
Oncology, University of Padova, Padova, Italy
e-mail: andrea.angelini@unipd.it;
elisa.pala@unipd.it; giulia.trovarelli@unipd.it;
mariachiara.cerchiaro@unipd.it;
elisa.pagliarini@aopd.veneto.it;
pietro.ruggieri@unipd.it
Surgeons now have access to a wide range of
innovative implants and prostheses that not only
restore functionality but also enable patients to
maintain their mobility and engage in regular
activities with minimal restrictions [2–4].
Megaprosthetic reconstruction has become a viable option in approximately 80–85% of cases
[1–2]. This surgical technique offers numerous
benets, including early skeletal stability, accelerated rehabilitation, and improved functional
outcomes [2].
Nevertheless, it is important to acknowledge
that the reported complication rate following the
implantation of tumor prostheses is signicantly
higher compared to conventional total joint
arthroplasties, with a range of 5–10 times higher
[1]. These complications can be categorized as
either biological failures, such as infections,
aseptic loosening, and wound/soft tissue breakdowns, or mechanical failures, such as implant
breakages and instability [4–5]. Unfortunately,
most of these complications necessitate additional procedures, and in many cases, revision of
the implants becomes necessary. Therefore,
while limb salvage surgery with megaprosthesis
or allograft reconstruction has shown promising
results in terms of improved survival rates and
patient satisfaction, it is crucial to address and
manage the associated complications effectively
to ensure optimal outcomes [5]. Infection is one
of the most frequently observed complications
that arise after the initial procedure in the
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_23
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A. Angelini et al.
implantation of tumor prostheses, accounting for
8% to 15% [1, 6]. However, the risk of infection
escalates signicantly following revision surgeries, with rates soaring up to 60% [6–7].
Interestingly, the infection rate remains fairly
consistent across various limb-salvage reconstruction techniques, and this suggests that the
risk of infection is not inuenced by the specic
method employed for reconstructing the affected
limb [8]. However, it is disconcerting to note that
infection of tumor prostheses can lead to the
necessity of subsequent amputation, with a risk
that spans a wide range, varying from 23.5% to a
staggering 87% [6–8]. This highlights the severe
consequences that can arise from an infection in
the implantation of tumor prostheses and underscores the importance of preventing and managing infections effectively in this procedure. In
this chapter, all the aspects related to periprosthetic joint infection (PJI) in megaprostheses will
be discussed.
23.2 Epidemiology
The infection rate following megaprosthetic
reconstruction can vary widely. On average, the
overall rate of PJIs after the initial surgery is
approximately 10%, but this rate signicantly
increases to 43–60% after revision surgeries [1,
9–11]. Tumor prostheses are associated with a
higher risk of infection in comparison to conventional arthroplasties due to various factors. First,
the reconstructive procedures for tumor prostheses are more complex, involving extensive tissue
dissection which results in larger bone and soft
tissue defects [12]. These larger defects provide a
greater opportunity for bacterial colonization and
subsequent infection. When analyzing infection
rates in relation to specic diagnoses, it has been
found that sarcomas exhibit the highest infection
rate, reaching 21.7% [11]. This rate surpasses
those observed in cases of metastatic or nonmetastatic diseases [11]. Interestingly, the highest infection rates are often observed after the
resection of chondrosarcomas in comparison to
other pelvic tumors [11, 13–15]. This could be
attributed to factors such as the large tumor vol-
ume and frequent involvement of the acetabulum,
which subsequently leads to increased operating
time during resection.
The challenges associated with prosthetic
reconstruction following the resection of a bone
tumor in the proximal tibia are worth noting. The
issue of infection after prosthetic replacement
following tumor resection is directly related to
the difculties encountered in achieving sufcient soft-tissue coverage [5, 11, 16]. Specically,
patients who undergo proximal tibia replacements are at a signicantly higher risk of experiencing PJIs, with reported infection rates of 31%
prior to the implementation of the gastrocnemius
ap procedure, which decreased the rate to 19.7%
[5, 16]. In contrast, proximal femur replacements
demonstrate infection rates of only 8% [5].
Larger sizes of tumor implants also contribute
because of the larger surface area that provides a
wider area for bacterial adhesion and the formation of biolms, which can further enhance the
likelihood of infection [12]. Moreover, the complexity of tumor prosthesis surgery often leads to
longer durations and exposure times of surgery.
Patients undergoing megaprostethic implants
also tend to have a higher number of previous
surgeries. Multiple surgeries can create scar tissue and compromise tissue integrity, making it
more difcult for the body to defend against
infections. Furthermore, poor nutritional status
and immunosuppression commonly found in
patients undergoing tumor prosthesis surgery can
compromise the immune system’s ability to ght
off infections [11].
23.3 Pathophysiology
The primary cause of PJIs is direct inoculation
during surgery or through the spread of infection
from a distant source through the bloodstream.
All prosthetic implants are susceptible to hematogenous seeding, especially during the initial
years following surgery when the surrounding
periprosthetic tissues have a high vascularity,
which increases the risk of infection. Infections
associated with prosthetic joints are typically
caused by microbes that grow in biolms [12,