Introduction
Cutibacterium Acnes (C.Acnes) is recognised as the leading cause of periprosthetic joint infection in the shoulder
(Athwal et al, 2007).
Periprosthetic joint infections (PJI) following shoulder arthroplasty leads to substantial patient morbidity and
significant healthcare costs.
In the U.S., as shoulder arthroplasties have increased, the rate of PJI has risen, with hospital charges growing by
324% from 2011 to 2018. Projections suggest that by 2030, shoulder PJI costs could reach $500 million annually
(Hustedt et al., 2021).
Similar trends in PJI incidence and economic burden have been observed for hip and knee arthroplasties, with
hospital costs projected to reach $1.85 billion by 2030 (Premkumar et al., 2020).
The financial strain of PJI is worsened by extended hospital stays, multiple surgeries, and long-term antibiotic
therapy, making prevention strategies crucial. The economic burden of managing PJI in hip and knee arthroplasties
is 5.6 times higher than uncomplicated procedures (Akindolire et al., 2020).
In Australia, the annual cost of total hip and knee arthroplasties (THA/TKA) is projected to rise from AU$ 2 billion to
AU$ 5.32 billion by 2030, driven by factors including an ageing population and increasing obesity rates (Kurtz,
2012; Kildow et al., 2018).
Shoulder arthroplasties are following a similar trend, highlighting the need for effective preventive strategies to
mitigate the growing healthcare burden. Data from the New South Wales Bureau of Health Information indicates a
significant proportion of readmissions after joint surgeries are due to infections (BHI, 2020).
Given the rising incidence and cost of PJI in shoulder arthroplasties, exploring effective preventive strategies is
imperative to optimize patient outcomes, reduce healthcare costs, and improve resource utilisation.
Aim
To identify and evaluate preventative strategies aimed at reducing C. acnes infections in shoulder
arthroplasty.
To compare the efficacy of different preoperative, perioperative, and postoperative interventions.
To provide an evidence-based summary that clinicians can use to guide infection prevention in
shoulder arthroplasty.
Method/Description
A systematic review conducted in accordance with PRISMA guidelines.
Databases: PubMed, MEDLINE, Embase
Study Designs Included: RCTs, cohort studies, case-control studies, systematic reviews, and large case series (≥10 patients)
Population: Patients undergoing shoulder arthroplasty (primary or revision), including all age groups
Interventions:
Preoperative: Topical agents (e.g., benzoyl peroxide, chlorhexidine), systemic antibiotics, decolonisation
Perioperative: Intraoperative wound irrigation, antibiotic-loaded cement or powder, sterile technique modifications
Postoperative: Wound care regimens, prophylactic antibiotics
Outcomes: Postoperative C. acnes infection rates, revision surgery due to infection, microbiological confirmation, and diagnostic
criteria (e.g., ICM)
Inclusion Criteria:
Peer-reviewed studies published in English from 2015 onward
Studies reporting on infection outcomes specifically related to C. acnes
Orthopaedic shoulder arthroplasty surgeries
Exclusion Criteria:
Animal studies, in vitro studies, or non-orthopaedic surgical procedures
Case reports, conference abstracts, editorials, or letters to the editor
Studies lacking species-specific infection data or full-text availability
Results
N/a
Discussion
Challenges in research which can be mentioned in discussion:
Diagnostic Limitations: ICM Classification of Orthopaedic Infections for the diagnosis of postoperative joint
infections means the diagnosis of C. acnes infections relies heavily on culture-based methods, which can lead to
false negatives and prolonged diagnostic timelines.
Heterogeneity: Significant variability in surgical protocols and infection prevention strategies across studies
complicates comparison.
Limited High-Quality RCTs: A scarcity of large-scale randomised controlled trials on C. acnes infection prevention
necessitates careful interpretation of available evidence
Consclusions
Expected results/impact of paper:
Provide an evidence-based overview of effective C. acnes prevention strategies across the
perioperative timeline, including skin decolonisation, antiseptic protocols, and postoperative
measures, guiding clinical decision-making.
Identify the most clinically feasible interventions and highlight key gaps in current literature, such as
diagnostic inconsistencies, the need for sensitive testing methods, and limited high-quality RCTs.
Encourage the development of standardised perioperative protocols to improve infection
prevention and reduce variability across institutions and practices
Offer practical guidance for surgeons and hospitals to optimise infection control pathways, reduce
revision surgeries, minimise hospital stays, and support cost-effective healthcare delivery
References
Akindolire J, Morcos MW, Marsh JD, Howard JL, Lanting BA, Vasarhelyi EM. The economic impact of periprosthetic infection in total hip arthroplasty. Can J Surg. 2020;63(1):E52-E56. doi:10.1503/cjs.004219
Athwal GS,Sperling JW,Rispoli DM, Cofield RH. Deep infection after rotator cuff repair. J Shoulder Elbow Surg. 2007; 16:306-11.
Bureau of Health Information. Readmission and return to acute care following hospitalisation for eight clinical conditions, July 2015 –June 2018. Sydney (NSW): BHI; 2020.
Fisher, C., Soh, S.-E., Page, R., de Steiger, R., Cuthbert, A., & Ackerman, I. (2023). Forecasting the future burden of primary total shoulder replacement in Australia. Osteoarthritis and Cartilage, 31, 1636–1643. https://doi.org/10.1016/j.joca.2023.08.012
Hustedt JW, Henkel J, McLawhorn AS, et al. The economic impact of periprosthetic joint infections following shoulder arthroplasty: trends and projections. J Shoulder Elbow Surg. 2021;30(5):1025-1032. doi:10.1016/j.jse.2020.12.013
Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012; 27: 61–5.
Kildow BJ, Karas V, Howell E, Green CL, Baumgartner WT, Penrose CT, et al. The utility of basic metabolic panel tests after Total joint Arthroplasty. J Arthroplasty. 2018;33(9):2752–2758. doi: 10.1016/j.arth.2018.05.003.
Premkumar A, Kolin DA, Farley KX, et al. Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. Health Policy & Economics. 2021;36(5):1484-1489.e3. doi:10.1016/j.arth.2020.12.005
DOI
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