A Novel Approach to Acute Infection of the Glenohumeral Joint Following Rotator Cuff Repair—A Case Series

G lenohumeral joint infection (GJI) is a rare but devastating and difficult-to-treat complication of rotator cuff repair (RCR).^1,2 Traditional management includes serial drainage and debridement, including debridement of cartilage and bone, suction, and intravenous and local antibiotics.^1,2 Joint damage due to original infection, superinfection of exposed structures (if infection is treated in an “open manner”), desiccation of cartilage and ligaments, and tissue loss due to invasive but necessary debridement obviate the need for aggressive diagnostic surveillance and early intervention. Surgical intervention should utilize modalities that result in immediate control of inflammation and should manage all secondary and collateral processes that are detrimental to the already diseased glenohumeral joint.^2–4 The authors present a method of GJI management by debridement, drainage, and simultaneous joint sealing with negative pressure wound therapy (NPWT, V.A.C.® Therapy™ System, KCI, San Antonio, Tex) followed by muscle flap coverage. Materials and Methods Glenohumeral joint infection has been defined as a deep tissue infection of the shoulder with signs of inflammation of deltoid-area soft tissue and positive culture of the glenohumeral joint fluid.⁴ Six male patients aged 22 to 69 years with posttraumatic loss of rotator cuff integrity developed acute infection following arthroscopic RCR with spontaneous drainage of purulent material in 5 of 6 cases. All patients had fever, pain, swelling of the shoulder, and erythema of the deltoid-area skin, and 5 of 6 patients had purulent discharge through postarthroscopic surgery wounds (Figure 1). The period of time between the original surgery and presentation with infection ranged from a few days to 6 weeks. Cultures revealed the presence of Staphylococcus aureus in all cases and methicillin-resistant Staphylococcus aureus (MRSA) in 4 cases. All patients were treated with the antibiotic levofloxacin (Levaquin®, Ortho-McNeil Pharmaceutical Inc., Raritan, NJ) administered orally or intravenously from the initial inflammatory symptoms and signs (or in continuation of perioperative antibiotic coverage) until skin graft overlying the muscle flap covering the joint was healed (approximately 2 weeks after flap transfer). Patients underwent serial debridements (every 4 to 5 days) through deltoid sparing access utilizing the pulse lavage joint space irrigation technique, followed by NPWT application with the negative pressure set to 125mmHg.^5,6 The device works through application of an open-cell polyurethane foam material to the wound surface/cavity, attached via tubing to the vacuum-producing pump through otherwise impermeable film drape sealing the wound and entire negative pressure therapy system. The NPWT device was changed intraoperatively under sterile conditions. The polyurethane sponge (V.A.C.® GranuFoam®, KCI, San Antonio, Tex) was cut to the size and configuration of the soft tissue wound cavity (approximately 12cm x 5cm x 3cm in size) and placed into the soft tissue wound but not packed into the joint space (Figure 2). Joint fluid samples were obtained for Gram stain and microbial cultures during subsequent debridements. When discharge of purulent material ceased and Gram stains and cultures were negative for microbial presence, the joint and overlying wound were covered with the latissimus dorsi or pectoralis major muscle flap and a split-thickness skin graft to the muscle surface (Figures 3 and 4).⁷ Results Treatment of GJI with debridement by irrigation, drainage, and simultaneous joint and overlying soft tissue wound sealing with NPWT resulted in effective acute infection resolution in all 6 cases. The grossly purulent discharge ceased after the first debridement in 5 patients who developed spontaneous drainage (through postarthroscopic access wounds). Following debridement and NPWT, the Gram stain and culture results were negative upon second exploration in all 6 cases. However, by the time the final results were known, patients underwent the third wash-out and NPWT device exchange. The joint was covered with the muscle flap and a split-thickness skin graft to the flap surface within 2 weeks of the first treatment. Physical therapy and range of motion were resumed within 1 month following the first NPWT application. A minimum 1-year follow-up demonstrated no recurrence of infective complications in any of the patients in the series. Figure 4 depicts the treatment outcome of 1 patient. Shoulder functionality was evaluated 1 year after treatment. The follow-up examination utilized the Simple Shoulder Test (an outcomes assessment tool that utilizes standardized questions related to shoulder/upper extremity function) and showed relatively good functional results.¹ Two of the 6 patients claimed that they redeveloped “normal” function and returned to work full time—the remaining patients were also free of pain regardless of arm position and were able to lift a 1-lb weight to the shoulder level without elbow flexion. Two patients who returned to work were able to lift 8-lb weights to shoulder level without elbow flexion. All patients were able to throw underhand, but only 1 was able to throw overhand (1 of the 2 who returned to full-time work). Discussion Infection of the glenohumeral joint after RCR is a rare but potentially devastating complication. The incidence of acute infection following open RCR has been reported to range from 0.27 to 1.7%.¹ The incidence of GJI was 1.9% following the mini-open technique and 3.4% following arthroscopy.^1,2,4,8 The conventional surgical management of GJI consists of aggressive debridement procedures, interim wound packing, and long-term antibiotic therapy followed by soft tissue coverage within a few weeks to months after the first treatment.^1,2 Traditional suction irrigation, which is cumbersome to implement, was found to be associated with occasional superinfections.² The success in an “immediate” control of infection without wide resection of infected tissues during debridements is attributed to NPWT, which has been shown to increase blood flow, reduce edema, and decrease microbial counts in subatmospheric pressure.^5,6 Conclusion Application of NPWT leads to a relatively quick conversion of the wound to an easily verifiable culture-negative environment, minimizing the possibility of external superinfection and secondary joint cartilage or soft tissue loss due to desiccation, which is practically inevitable in somewhat “open” methods of treatment involving a traditional debridement/packing regimen.^3,6,9 Negative pressure wound therapy clinically converts an open wound to a controlled, closed wound, allowing simultaneous wound sealing and effective drainage. Therefore, NPWT allows relatively rapid bridging between the debridement stage and the definitive closure stage of complicated wounds with some degree of joint exposure. Muscle flaps covered with skin grafts were preferred over myocutaneous flaps (or direct secondary closure) because of superior pliability of the muscle tissue and ease of inset into irregularly shaped cavities. A muscle flap provides a vascularized, durable, tension-free wound space obliteration and defect closure with a possibility of relatively easy access (by flap re-elevation) for secondary repairs. None of the patients in this series underwent any attempts for the secondary repair.¹ In conclusion, an acute, severe GJI with overlying soft tissue breakdown can be effectively managed by serial debridement and NPWT followed by muscle flap coverage of exposed joint.