How to Prevent Postop Infection in TSA Patients: A Conversation with Dr. Eric Ricchetti

Editor’s note: During the upcoming 30th Annual Tampa Shoulder Course: Arthroplasty & Sports, Dr. Eric Ricchetti will present on the topic, The Steps I Take to Prevent Shoulder Infection. We asked Dr. Ricchetti to preview the key points of this talk.

FORE: One of your topics is prevention of shoulder infections. Why is it important to include this topic in the agenda for the Tampa Shoulder Course? Are shoulder infections a common occurrence after shoulder arthroplasty?  

Eric T. Ricchetti, MD: Infection after shoulder arthroplasty has a reported prevalence ranging from 0% to 4% in primary total shoulder arthroplasty (TSA), and up to 32% in revision TSA. Although not common, it is a potentially devastating complication of shoulder arthroplasty because treatment to cure an infection can require complex revision surgery and extended antibiotic therapy. With the increasing volume of shoulder arthroplasties performed each year in the US, the number of cases of infection after shoulder arthroplasty will likely increase.

Periprosthetic joint infection (PJI) of the shoulder is a diagnostic and therapeutic challenge due to the low virulence of the most common causative organisms, Cutibacterium acnes (C. acnes) and coagulase-negative Staphylococcus species. As a result, established diagnostic tests can be less effective in the shoulder, making it difficult to detect and treat the infection.

C. acnes can also persist on the skin and in the surgical wound despite standard skin preparation and intravenous (IV) antibiotics.

RELATED: Register for the 30th Annual Tampa Shoulder Course, February 1-3, 2024

FORE: Are there any new research findings or new technologies that are advancing the prevention of shoulder infections after shoulder arthroplasty?

Dr. Ricchetti: A number of studies have investigated new methods to prevent infection after shoulder arthroplasty, including strategies to decrease or eliminate the bacteria at the surgical site prior to and at the time of surgery.

However, the most important tactic for preventing infection is the use of appropriate IV antibiotics at the time of surgery.  The recommended antibiotic prophylaxis for shoulder arthroplasty is 2 grams of IV cefazolin given within 1 hour of surgery and continued for 24 hours postoperatively unless an allergy or contraindication is present.

Recent research has shown that cefazolin administration is associated with a significantly lower rate of PJI compared with non-cefazolin alternatives, including both vancomycin and clindamycin, in primary shoulder arthroplasty.

FORE: What do you want attendees to remember about your presentation? For example, what actions do you recommend they take to prevent postop infections? 

Dr. Ricchetti: My recommended protocol to prevent infection includes:

  • Addressing modifiable risk factors for infection prior to surgery, such as counseling smokers on smoking cessation, optimizing glucose control in patients with diabetes (HgA1C < 8.0%), and avoiding cortisone injections 2 to 3 months prior to surgery
  • Prescribing the use of preoperative skin washes with chlorhexidine gluconate (CHG) wipes in the days prior to surgery; topical benzyl peroxide can be added in higher-risk patients
  • Cleansing the surgical skin site on the day of surgery with 2% chlorhexidine gluconate with 70% isopropyl alcohol; 3% hydrogen peroxide can be added for higher-risk patients
  • Administering antibiotic prophylaxis as described above
  • Using a separate knife for the skin incision, with fresh knife blades used after that
  • Thoroughly irrigating the surgical site with saline
  • Using antibiotic cement if the humeral component is cemented
  • Considering the use of vancomycin powder and dilute povidone-iodine in the surgical wound as additional antiseptics during surgery In high-risk patients

About the Author

Eric T. Ricchetti, MD, is a board-certified orthopaedic surgeon specializing in treating shoulder and elbow conditions at the Cleveland Clinic in Cleveland, Ohio. He is an Associate Professor at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Director of the Cleveland Clinic’s Shoulder Center, and Director of the Shoulder and Elbow Surgery Fellowship Program at Cleveland Clinic.

The Tampa Shoulder Course: Arthroplasty & Sports will take place February 1-3, 2024, at the JW Marriott Tampa Water Street and FIVE Labs in Tampa, Florida. Please click here for more information and to register for the course.

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