Although infection after rotator cuff repair occurs infrequently, it can be a catastrophic complication. To the best of my knowledge, there are only a small number of reports in the literature regarding management of these infections, and none of these report the outcome of a staged arthroscopic approach1-6. Once the infection has resolved, reconstruction of the residual rotator cuff defect can present a substantial challenge for the treating orthopaedic surgeon.
The purpose of this report is to present the clinical, functional, and magnetic resonance imaging (MRI) results of an all-arthroscopic approach for the management of a massive rotator cuff tear defect resulting from an infection after an initial open rotator cuff repair. The patient was informed that data concerning his case would be submitted for publication, and he provided consent.
Infection after rotator cuff repair is an infrequently reported but potentially devastating complication. Reported rates of infection following rotator cuff repair range from 0.27%6 to 1.7%7 for open repairs and 1.9%4 for mini-open repairs. There are other potential complications stemming from infection following rotator cuff repair, including acute adhesive capsulitis, chondrolysis, osteomyelitis, secondary osteoarthritis, and failure of the rotator cuff repair5,8. Traditionally, the key to success is early detection, radical debridement, and long-term antibiotic therapy. Many authors report a mean of two-and-a-half serial procedures in concert with antibiotics to treat this problem2,4-6.
Infection after open rotator cuff repair in the studies in the literature presents as two distinct populations: one acute or subacute, presenting within ninety days of the index procedure, and the other a chronic infection typically referred and/or treated at an interval greater than ninety days. Delay in diagnosis and treatment can result in poorer outcomes5.
Mirzayan et al. outlined several factors associated with an increased risk of infection after open rotator cuff repair5. Chen et al. noted an increased rate (10%) of infection after open rotator cuff repair in thirty diabetic patients9. Our patient also had diabetes as an identifiable risk factor. As noted by Mirzayan et al. and reflected in our report, the number of patients in our experience is too small to draw any meaningful conclusions; however, a thorough evaluation preoperatively can help identify patients who are at risk for deep infection following shoulder surgery. Because there appears to be a lower rate of infection associated with arthroscopic surgery than with an open approach, these patients may benefit when it is possible to use an arthroscopic approach10.
The most common pathogens cited in rotator cuff infections include Staphylococcus aureus, Staphylococcus epidermidis, Propionibacterium acnes, and coagulase-negative staphylococci. Other reported organisms include Peptostreptococcus magnus, Pseudomonas aeruginosa, streptococcal species, and Clostridium species2,5.
Presenting signs, symptoms, and laboratory parameters can also vary based on the offending pathogen, as well as the severity and duration of infection. Acute infection, especially with a virulent organism, can present with a draining wound, elevated erythrocyte sedimentation rate, and elevated C-reactive protein level. Conversely, a chronic indolent infection with a fastidious organism may present with few or no clear indicators of deep infection. As noted by Mirzayan et al. and Settecerri et al., given the variable nature of presentation, a high index of suspicion is paramount because delay in treatment can affect outcomes5,6.
As elegantly outlined by Mirzayan et al.5, the principles of treatment for deep infection after rotator cuff repair include radical debridement of all devitalized and infected tissue while preserving as much residual muscle function as possible. Furthermore, when possible, all foreign material, including sutures (given that a lower bacterial load can result in infection in the presence of suture material11), should be removed to avoid any persistent nidus for infection5. In addition, adequate soft-tissue coverage can help promote host defense mechanisms to control the infection. It is important to note that fibrosis or dysfunction of the deltoid muscle also affects shoulder function12.
A more minimally invasive approach has been cited to reduce morbidity to the deltoid muscle13. While remaining true to the principles of treatment outlined in previous studies, we chose an arthroscopic approach to debridement in order to preserve the soft-tissue envelope, minimize collateral trauma to healthy tissues, and allow comprehensive access to the entire glenohumeral joint and subacromial space for removal of devitalized tissue and foreign material. Additionally, we combined the initial radical arthroscopic debridement with excision of the arthrocutaneous fistula and repair of the deltoid dehiscence to provide a closed soft-tissue envelope1,5. Given the favorable results reported previously for a staged protocol for septic arthroplasty14-16, we felt that a similar protocol may provide a more favorable outcome, reduce the number of surgical procedures, and reduce morbidity. Because of the advanced atrophy and retraction of our patient’s rotator cuff muscles at the time of final reconstruction, complete primary repair was not possible. Rather than proceed with tendon transfers, based on our own experience and favorable reports in the literature, we elected to proceed with an entirely arthroscopic approach utilizing a bridging and reinforcement graft technique17-19.
Regardless of the approach (open or arthroscopic), given the variable nature of presenting symptoms and delay in diagnosis, a high index of suspicion should be maintained when evaluating patients with persistent difficulty after shoulder surgery. An arthroscopic approach to debridement, followed by a staged reconstructive procedure, may be an alternative to serial debridement. For those patients with a residual rotator cuff defect after successful eradication of shoulder infection, an arthroscopic staged approach to treatment with use of an acellular dermal graft (Allopatch HD) may be a viable option.