title: Patient and procedure-specific risk factors for deep infection after primary shoulder arthroplasty.
abstract: BACKGROUND
  Deep infection after shoulder arthroplasty is a diagnostic and therapeutic challenge. The current literature on this topic is from single institutions or Medicare samples, lacking generalizability to the larger shoulder arthroplasty population.
  
  
  OBJECTIVE
  We sought to identify (1) patient-specific risk factors for deep infection, and (2) the pathogen profile after primary shoulder arthroplasty in a large integrated healthcare system.
  
  
  METHODS
  A retrospective cohort study was conducted. Of 4528 patients identified, 320 had died and 302 were lost to followup. The remaining 3906 patients had a mean followup of 2.7 years (1 day-7 years). The study endpoint was the diagnosis of deep infection, which was defined as revision surgery for infection supported clinically by more than one of the following criteria: purulent drainage from the deep incision, fever, localized pain or tenderness, a positive deep culture, and/or a diagnosis of deep infection made by the operating surgeon based on intraoperative findings. Risk factors evaluated included age, sex, race, BMI, diabetes status, American Society for Anesthesiologists (ASA) score, traumatic versus elective procedure, and type of surgical implant. For patients with deep infections, we reviewed the surgical notes and microbiology records for the pathogen profile. Multivariable Cox regression models were used to evaluate the association of risk factors and deep infection. Adjusted hazard ratios and 95% CI are presented.
  
  
  RESULTS
  With every 1-year increase in age, a 5% (95% CI, 2%-8%) lower risk of infection was observed. Male patients had a risk of infection of 2.59 times (95% CI, 1.27-5.31) greater than female patients. Patients undergoing primary reverse total shoulder arthroplasty had a 6.11 times (95% CI, 2.65-14.07) greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty. Patients having traumatic arthroplasties were 2.98 times (95% CI, 1.15-7.74) more likely to have an infection develop than patients having elective arthroplasties. BMI, race, ASA score, and diabetes status were not associated with infection risk (all p > 0.05). Propionibacterium acnes was the most commonly cultured organism, accounting for 31% of isolates.
  
  
  CONCLUSIONS
  Younger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. Reverse total shoulder arthroplasty and traumatic shoulder arthroplasties also carry a greater risk for infection. Propionibacterium acnes was the most prevalent pathogen causing infection in our primary shoulder arthroplasty population.
  
  
  METHODS
  Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Southern California Permanente Medical Group, Orange, CA, USA.
authors.forename: Jason
authors.initials: J
authors.lastname: Richards
authors.forename: Maria C S
authors.initials: MC
authors.lastname: Inacio
authors.forename: Michael
authors.initials: M
authors.lastname: Beckett
authors.forename: Ronald A
authors.initials: RA
authors.lastname: Navarro
authors.forename: Anshuman
authors.initials: A
authors.lastname: Singh
authors.forename: Mark T
authors.initials: MT
authors.lastname: Dillon
authors.forename: Jeff F
authors.initials: JF
authors.lastname: Sodl
authors.forename: Edward H
authors.initials: EH
authors.lastname: Yian
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D019643:Arthroplasty, Replacement / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007592:Joint Diseases / Q000601:surgery*; D007595:Joint Prosthesis / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000453:epidemiology*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012785:Shoulder Joint / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology