JBJS | Management of Chronic Deep Infection Following Rotator Cuff Repair*

The Journal of Bone & Joint Surgery, Volume 82, Issue 8

Articles | August 01, 2000

Management of Chronic Deep Infection Following Rotator Cuff Repair*

Raffy Mirzayan, M.D.†; John M. Itamura, M.D.†; Thomas VangsnessJr., M.D.†; Paul D. Holtom, M.D.†; Randy Sherman, M.D.†; Michael J. Patzakis, M.D.†

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Investigation performed at the Department of Orthopaedic Surgery, University of Southern California School of Medicine, University Hospital, Los Angeles, California
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Department of Orthopaedic Surgery, University of Southern California School of Medicine, 1200 North State Street, GNH 3900, Los Angeles, California 90033.

The Journal of Bone & Joint Surgery. 2000; 82:1115-1115

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Abstract

Background: Deep infection of the shoulder following rotator cuff repair is uncommon. There are few reports in the literature regarding the management of such infections.

Methods: We retrospectively reviewed the charts of thirteen patients and recorded the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management.

Results: The average age of the patients was 63.7 years. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months. An average of 2.4 procedures were performed prior to referral because of infection, and an average of 2.1 procedures were performed at our institution. All patients had pain on presentation, and most had a restricted range of motion. Most patients were afebrile and did not have an elevated white blood-cell count but did have an elevated erythrocyte sedimentation rate. The most common organisms were Staphylococcus epidermidis,Staphylococcus aureus, and Propionibacterium species. At an average of 3.1 years, all patients were free of infection. Using the Simple Shoulder Test, eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. However, most patients had poor overhead function.

Conclusions: Extensive soft-tissue loss or destruction is associated with a worse prognosis. Extensive dè¡²idement, often combined with a muscle transfer, and administration of the appropriate antibiotics controlled the infection, although most patients were left with a substantial deficit in overhead function of the shoulder.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

Rotator cuff tear is one of the most common afflictions of the shoulder and is commonly treated surgically. The prevalence of infection after open rotator cuff repair has ranged from 0.27 percent¹⁷ to 1.7 percent¹¹. Deep infection following rotator cuff repair can be missed because of a low index of suspicion. This may lead to chronic infection of the shoulder, which can result in devastating limitations of function. However, there are few reports in the literature regarding the management of chronic deep infection of the shoulder following surgery^14,17,21.

In this retrospective report, we analyzed the demographic data, clinical and laboratory findings, risk factors, bacteriological findings, and results of surgical management in thirteen patients with deep shoulder infection following rotator cuff surgery.

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Fig. 1-A:: Figs. 1-A through 1-F: A sixty-year-old woman in whom an infection developed following an open rotator cuff repair. She had three risk factors, including an age of sixty years, cortisone injections prior to the rotator cuff surgery, and an ipsilateral mastectomy. Two irrigations and dè¡²idements were performed prior to referral for the infection.
Fig. 1-A: Photograph made at the time of presentation, showing a two by three-centimeter open wound with the humeral head exposed.

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Fig. 1-B:: Anteroposterior radiograph of the right shoulder, showing a retained suture anchor.

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Fig. 1-C:: Proton-density magnetic resonance image (top) and T2-weighted magnetic resonance image (bottom) showing involvement of the humeral head and the glenoid.

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Fig. 1-D:: Photograph showing wound coverage with a rotational myocutaneous latissimus dorsi flap following another irrigation and dè¡²idement.

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Fig. 1-E:: Anteroposterior and axillary radiographs made at one year. There were no signs of infection, and the patient had no pain with the arm at rest by the side, could sleep comfortably, and could perform activities that did not require overhead function.

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Fig. 1-F:: Anteroposterior and axillary radiographs made at one year. There were no signs of infection, and the patient had no pain with the arm at rest by the side, could sleep comfortably, and could perform activities that did not require overhead function.

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Fig. 2-A:: Figs. 2-A through 2-D: A sixty-year-old man in whom an infection developed following an open rotator cuff repair.
Figs. 2-A and 2-B: Anteroposterior and axillary radiographs of the right shoulder, made at the time of presentation, demonstrating loss of joint space and erosive changes of the humeral head and the glenoid.

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Fig. 2-B:: Figs. 2-A and 2-B: Anteroposterior and axillary radiographs of the right shoulder, made at the time of presentation, demonstrating loss of joint space and erosive changes of the humeral head and the glenoid.

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Fig. 2-C:: Coronal and axial T1-weighted magnetic resonance images with contrast medium, demonstrating osteomyelitis of the humeral head and the glenoid as well as a synoviocutaneous fistula (arrow).

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Fig. 2-D:: Coronal and axial T1-weighted magnetic resonance images with contrast medium, demonstrating osteomyelitis of the humeral head and the glenoid as well as a synoviocutaneous fistula (arrow).

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Table I: Risk Factors According to the Cierny-Mader Classification3

	No. of Patients
I. A-host	1
II. B-host
A. Systemic compromise
1. Age 60 years
a. No other medical problems	7
b. With type-II diabetes and coronary artery disease	1
2. Hypothyroidism
a. With primary IgA deficiency	1
b. Without primary IgA deficiency	2
3. Smoking	6
4. Alcoholism	2
B. Local compromise
1. Mastectomy
a. With lymphedema	1
b. Without lymphedema	1
2. Steroid injections	2

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Table I: Risk Factors According to the Cierny-Mader Classification3

	No. of Patients
I. A-host	1
II. B-host
A. Systemic compromise
1. Age 60 years
a. No other medical problems	7
b. With type-II diabetes and coronary artery disease	1
2. Hypothyroidism
a. With primary IgA deficiency	1
b. Without primary IgA deficiency	2
3. Smoking	6
4. Alcoholism	2
B. Local compromise
1. Mastectomy
a. With lymphedema	1
b. Without lymphedema	1
2. Steroid injections	2

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Table II: Results of Simple Shoulder Test10

	No. of Patients Capable of Activity
Shoulder comfortable with arm at rest by side	8
Shoulder allows comfortable sleep	8
Tuck in shirt at small of back	8
Place hand behind head	5
Place coin on shelf at level of shoulder without bending elbow	4
Lift 1 pound (0.5 kilogram) to level of shoulder without bending elbow	3
Lift 8 pounds (3.6 kilograms) to level of shoulder without bending elbow	0
Carry 20 pounds (9.1 kilograms) at side with affected extremity	8
Toss softball underhand 10 yards (9.1 meters)	8
Toss softball overhand 10 yards (9.1 meters)	1
Wash back of contralateral shoulder	6
Work full-time at regular job	5

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Table II: Results of Simple Shoulder Test10

	No. of Patients Capable of Activity
Shoulder comfortable with arm at rest by side	8
Shoulder allows comfortable sleep	8
Tuck in shirt at small of back	8
Place hand behind head	5
Place coin on shelf at level of shoulder without bending elbow	4
Lift 1 pound (0.5 kilogram) to level of shoulder without bending elbow	3
Lift 8 pounds (3.6 kilograms) to level of shoulder without bending elbow	0
Carry 20 pounds (9.1 kilograms) at side with affected extremity	8
Toss softball underhand 10 yards (9.1 meters)	8
Toss softball overhand 10 yards (9.1 meters)	1
Wash back of contralateral shoulder	6
Work full-time at regular job	5

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Patient Population

Between 1991 and 1997, thirteen patients were referred to our center for the treatment of chronic deep infection following open rotator cuff surgery. There were seven men and six women. The average age was 63.7 years (range, twenty-six to eighty-one years). The dominant shoulder was involved in eleven patients. Four patients were receiving Workers' Compensation. Five patients were laborers, and eight patients had a sedentary job. The interval between the rotator cuff repair and the referral because of infection averaged 9.7 months (range, three to twenty-five months). An average of 2.4 (range, one to six) procedures were performed prior to referral, and an average of 2.1 (two, three, or four) procedures were performed at our institution. The average duration of follow-up was 3.1 years (range, one to 6.6 years).

Risk Factors

The classification system for osteomyelitis described by Cierny and Mader³ (Table I) was used since eleven patients had osteomyelitis of the humeral head or the clavicle. One patient was an A-host - that is, there were no risk factors for infection or compromised wound-healing. Eight patients who were B-hosts with systemic compromise were sixty years of age or older, and one of the eight had adult-onset diabetes and coronary artery disease. Three B-hosts with systemic compromise had hypothyroidism, and one of the three also had a primary IgA deficiency. Six B-hosts with systemic compromise were smokers, and two drank alcohol on a daily basis. Four patients were B-hosts with local compromise. Two of these patients had had an ipsilateral mastectomy⁴. One of the two had had a radical mastectomy and axillary lymph-node dissection without radiation or chemotherapy. Chronic lymphedema developed in the involved extremity. The other patient had had a mastectomy followed by three reconstructive breast procedures. The other two B-hosts with local compromise had had two steroid injections each prior to surgery. No documentation of steroid injections could be found for the other patients. Six patients had more than one risk factor.

Surgical Procedures

The surgery included drainage of the infected glenohumeral joint in all thirteen patients and drainage of the acromioclavicular joint in two. Dè¡²idement of infected and necrotic bone was carried out in seven humeral heads, four clavicles, four acromions, and three glenoids. Eleven patients had synovectomy, six had bursectomy, and nine had sinus tract excision. Nonabsorbable sutures were removed in all thirteen patients. The biceps tendon sheath was identified and explored for purulence in four patients. Irrigation with ten liters of fluid, with the last liter containing 100,000 units of bacitracin and 1,000,000 units of polymyxin, was performed in all patients. After the initial dè¡²idement, dead spaces were managed with suction drainage in ten of the patients and with insertion of antibiotic-impregnated beads in three. All patients returned to the operating room for serial irrigations and dè¡²idements. Intraoperative specimens of fluid, soft tissue, bone shavings, and curetted material from the intramedullary canal were obtained from all thirteen patients and were sent for aerobic, anaerobic, fungal, and acid-fast-bacillus culture. The patients received parenteral antibiotics for six weeks on the basis of the culture results.

Four patients required a latissimus dorsi flap (Fig. 1-A, Fig. 1-B, Fig. 1-C, Fig. 1-D, Fig. 1-E, and Fig. 1-F), and three required a pectoralis major flap. When available local soft tissue was found to be inadequate for tension-free wound closure with complete obliteration of any residual dead space, the patient was returned to the operating room for muscle flap transfer. The addition of vascularized soft tissue to the wound maximized the chance of successful closure and minimized the possibility of late recurrence. The latissimus dorsi and pectoralis major muscles both offer a generous amount of vascularized tissue for the management of nearly all types of shoulder wounds. Because of its long vascular pedicle and broad dimensions, the latissimus dorsi flap is preferable for larger, more complex wounds^12,19. Also, there is less deformity and morbidity when the latissimus flap, as opposed to the pectoralis flap, is used. At times, however, it may be better to manage a medially based lesion by rotating a small portion of the pectoralis into it^13,16. If the thoracodorsal pedicle has been injured during previous dissections, the latissimus muscle may be unusable.

Method of Outcome Evaluation

The Simple Shoulder Test¹⁰ was administered to twelve patients (Table II). Five patients were examined in our clinic, and seven were interviewed over the telephone. The Simple Shoulder Test is a function-based outcome-assessment tool consisting of twelve questions, some of which were derived from the evaluation devised by Neer and the American Shoulder and Elbow Surgeons¹⁰. It is a quick, practical, and inexpensive method for assessing a patient's satisfaction with treatment. In addition, it indirectly assesses the patient's range of motion by asking such questions as "Can you reach the small of your back to tuck in your shirt with your hand?" and "Can you place a coin on a shelf at the level of your shoulder without bending your elbow?" The questions require a yes-or-no response. Little equipment is needed, and the test can be carried out over the telephone or by mail.

Results

Introduction | Materials and Methods | Results | Discussion | References

Clinical and Laboratory Findings

All patients had pain on presentation. In addition, eight patients had swelling and erythema. Four patients reported fevers prior to presentation. Nine patients had a draining sinus or a synoviocutaneous fistula (Fig. 2-A, Fig. 2-B, Fig. 2-C, and Fig. 2-D). The humeral head was exposed in three patients, and the clavicle was exposed in one. All thirteen patients had less than 90 degrees of forward elevation. The average temperature at presentation was 98.0 degrees Fahrenheit (36.7 degrees Celsius) (range, 96.6 to 99.7 degrees Fahrenheit [35.9 to 37.6 degrees Celsius]). The average white blood-cell count was 7700 per cubic millimeter (7.7 Â¥ 10⁹ per liter) (range, 4800 to 10,300 per cubic millimeter [4.8 to 10.3 Â¥ 10⁹ per liter]) with an average neutrophil count of 58 percent (range, 43 to 77 percent). The erythrocyte sedimentation rate was available for eight patients; it averaged fifty-seven millimeters per hour (range, six to 135 millimeters per hour). All but one patient had an abnormal erythrocyte sedimentation rate.

One of the drawbacks of a retrospective study is incomplete information. The only information that was available about the patients was that they had had an open rotator cuff repair. There was no information regarding the size of the original tear, the method of repair, whether the axilla had been shaved, use of perioperative antibiotics, or whether diagnostic arthroscopy had been performed prior to the open procedure.

Intraoperative Findings

All thirteen patients had an infected glenohumeral joint, and two had an infected acromioclavicular joint. Seven patients had osteomyelitis of the humeral head alone, two had osteomyelitis of the humeral head and the glenoid, two had osteomyelitis of the clavicle and the acromion, and two did not have osteomyelitis but had a subdeltoid abscess. Four patients had eburnated cartilage of the humeral head. All thirteen patients were found to have a deficiency of the rotator cuff at the time of the surgery for the infection. Five had immediate repair of the rotator cuff at the time of repeat dè¡²idement, which allowed coverage of the glenohumeral joint. One patient had a delayed repair of the rotator cuff six months after the surgery for the infection. Seven patients required a rotational flap to allow for coverage of the joint.

Culture Results

Staphylococcus aureus (five patients) and Staphylococcus epidermidis (four patients) were the most common organisms isolated, followed by Propionibacterium species (three), diphtheroids (one), coagulase-negative Staphylococcus aureus (one), and streptococcal species (one). Three patients had a polymicrobial infection. Three patients had no growth on intraoperative culture, but purulent material was noted intraoperatively.

Functional Results

At an average of 3.1 years, all patients were free of infection.

The results of the Simple Shoulder Test are presented in Table II. Eight patients stated that the shoulder was comfortable with the arm at rest by the side, they could sleep comfortably, and they were able to perform activities below shoulder level. Three patients could lift a one-pound (0.5-kilogram) weight and none could lift an eight-pound (3.6-kilogram) weight to the level of the shoulder without bending the elbow. Eight patients could throw underhand, but only one could throw overhand.

Of the five patients who were examined in our office at the time of follow-up, two had reflex sympathetic dystrophy and two had a deficient deltoid. All four of these patients stated that the shoulder was uncomfortable with the arm at rest by their side and that it did not allow them to sleep comfortably at night. At the time of follow-up, none of the four patients who had been receiving Workers' Compensation preoperatively had returned to work, while all eight who had not been receiving Workers' Compensation had returned to work.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Chronic deep shoulder infection following rotator cuff repair is a rare and debilitating complication¹⁵. In a review of forty reports published between 1982 and 1995, Mansat et al.¹¹ found that, of 2948 rotator cuff repairs, thirty-one (1.1 percent) were complicated by deep infection. In their own series of 116 cuff repairs, Mansat et al.¹¹ reported a deep infection in two patients (1.7 percent). Settecerri et al.¹⁷ reported an infection rate of 0.27 percent (eight of 2927) after open rotator cuff repairs performed at the Mayo Clinic. Eight additional patients who had had the index procedure at other institutions were referred for treatment. Propionibacterium species grew on culture of specimens from five patients; Staphylococcus epidermidis and Staphylococcus aureus grew on culture of specimens from four each; and Peptostreptococcus magnus, Corynebacterium, and both Staphylococcus epidermidis and Propionibacterium species grew on culture of specimens from one each. An average of 3.5 operative procedures were required to eradicate the infection. At the time of follow-up, six of the sixteen patients were pain-free, five had mild pain, and five had moderate pain. Nearly half were able to actively elevate the arm beyond 90 degrees. The results of that study were similar to those of the present study with respect to the findings on culture and the functional outcomes.

Recently, Torres and Wright²¹ reported on three cases of postoperative infection and a synovial cutaneous fistula after failed acromioplasty and rotator cuff repair. All three patients were seventy years of age or older. Similar to our findings, the average duration of infection was 10.2 months; however, unlike our patients, the patients had a normal erythrocyte sedimentation rate on presentation. In all three patients, dehiscence at the site of the rotator cuff repair was found at the time of irrigation and dè¡²idement. The wounds were closed primarily by elevation of skin flaps and other portions of the rotator cuff. The shoulders were immobilized for six weeks. At an average of nineteen months, the patients were free of infection and pain, shoulder elevation averaged 130 degrees, and external rotation averaged 50 degrees. The success in controlling the infection in these patients, as well as in ours, was apparently due to complete excision of the fistulous tract, wide resection of infected tissues, and restoration of the soft-tissue envelope. Torres and Wright reported that, in all three patients, the rotator cuff was easily mobilized and rerepaired, the deltoid was directly closed, and skin edges were sutured without tension; therefore, a flap was not required.

Several factors increase the risk of postoperative infection. One of these factors is an age of greater than sixty years^1,22. Eight patients in our series were sixty years of age or older. Six patients had a known underlying medical condition that could have predisposed them to infection. Chaudhuri et al.⁴ reported on five patients in whom septic arthritis of the shoulder developed after surgery and radiation therapy for breast cancer. All patients had chronic lymphedema. The authors believed that radiation therapy may damage local tissues. In addition, local host-defense mechanisms may be compromised by the lymphatic stasis and lymphedema. Four patients had a delay in diagnosis and treatment, which resulted in a poor outcome. Two patients in our series had a mastectomy, and one of them had chronic lymphedema. Six patients were habitual smokers, and two consumed alcohol daily. Although the number of patients in our series is too small for us to draw significant conclusions, the recording of a detailed history and the performance of an examination prior to surgery with particular attention paid to the above factors may help to identify patients who are at risk for deep infection following shoulder surgery.

Staphylococcus epidermidis and Staphylococcus aureus were the most common infecting organisms. However, an unusual organism, Propionibacterium, which is not commonly seen in musculoskeletal infections, was the third most commonly isolated organism. Propionibacterium species are anaerobic, gram-positive, non-spore-forming bacilli⁷. They are the dominant anaerobic organism isolated from normal skin flora¹⁸. They are often found in lipid-rich areas, such as hair follicles and sebaceous glands, and in moist areas, such as the axilla². Propionibacterium species are rarely associated with infections; descriptions of musculoskeletal infections with this organism have been limited to isolated case reports⁶. The vast majority of blood isolates appear to be skin contaminants and are detected only after prolonged incubation of blood cultures². The organisms are susceptible to penicillins, cephalosporins, erythromycin, and clindamycin20. However, they are resistant to nitroimidazoles such as metronidazole²³. Since most of the infecting organisms are present in the normal skin flora, careful preparation and draping can prevent contamination. There is no consensus in the literature regarding the routine shaving of axillary hair. Since Propionibacterium species were commonly isolated in our series, additional studies need to be carried out to identify the usefulness of shaving the axilla prior to surgery.

The presentation of our patients was similar to that in other studies of patients with infection of the glenohumeral joint^9,22. The patients were afebrile and had a normal white blood-cell and neutrophil count on presentation. The erythrocyte sedimentation rate was almost always elevated and is the most useful laboratory test for diagnostic purposes and for following the course of treatment.

The key to infection control is radical dè¡²idement of infected necrotic tissue. This was carried out in a systematic fashion by excision of infected skin and subcutaneous tissue, sinus tract, bursa, capsule, synovial tissue, tendon, and bone. Postoperative function depends on residual muscle power¹⁹. Therefore, every attempt must be made to maintain the deltoid attachment, the tuberosities, and the rotator cuff. However, eradication of the infection should be the primary goal. If the deltoid is detached, it should be repaired primarily with absorbable monofilament sutures. Elek and Conen⁵ showed that fewer bacteria are required for infection to occur in the presence of suture material. They concluded that the type of suture material, the infecting organism, and the duration of contact influence the adherence of bacteria. Compared with monofilament sutures, braided sutures have a higher surface area for bacterial adhesion. Since most rotator cuff repairs are done with braided sutures, these sutures must be evaluated carefully during the operation. If the sutures are not contaminated, they can be left in place. In our study, the average duration between the rotator cuff repair and the referral for the infection was 9.7 months. All nonabsorbable braided sutures were considered contaminated and were removed.

One of the factors in the success of treatment of these chronic infections was the presence of a rotator cuff. The glenohumeral joint should be covered after all nonviable tissues have been removed during serial dè¡²idements. If the rotator cuff cannot be repaired primarily, the glenohumeral joint is left exposed or is covered only by thin subcutaneous tissue that is not adequate in the presence of an infected joint. Inadequate soft-tissue coverage leads to breakdown of the skin and subcutaneous tissue, leading to the formation of sinus tracts. Muscle coverage can seal off the joint and improve the biological environment by bringing in a fresh blood supply and promoting host defense mechanisms for control of the infection. This was the case in our seven patients who were managed with a rotational flap for wound coverage. The latissimus dorsi flap is a commonly used flap in the upper extremity and the shoulder because of its large arc of rotation and the size of the muscle^12,19. The clavicular head of the pectoralis major muscle can be safely rotated to cover the superior aspect of the clavicle and shoulder without detachment of the sternocostal head^13,16.

The presentation of a deep shoulder infection following surgery may be subtle and often leads to a delay in diagnosis. Delay in treatment results in the worst outcome^1,8,14. Patients with deep shoulder infection usually report pain and restricted motion of the shoulder, which often are regarded as expected postoperative symptoms. The lack of systemic symptoms may make the physician less suspicious of an infection. One must have a high index of suspicion for infection, especially if symptoms do not resolve in an expected time frame. The risk factors for an infection should also be kept in mind when making a diagnosis. Chronic deep infection following rotator cuff repair can be controlled, although most patients are left with a substantial deficit in overhead function of the shoulder due to this devastating complication.

References

Introduction | Materials and Methods | Results | Discussion | References

Bettin, D.; Schul, B.; and Schwering, L.: Diagnosis and treatment of joint infections in elderly patients. Acta Orthop. Belgica,64: 131-135, 1998.64131 1998

Brook, I.: Anaerobic gram-positive non-sporulating bacilli. In Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases, edited by G. L. Mandell, J. E. Bennett, and R. Dolin. Ed. 4, pp. 2206-2209. New York, Churchill Livingstone, 1995.

Calhoun, J. H.; Cierny, G., III; Holtom, P.; Mader, J.;; and Nelson, C. L.: Symposium: current concepts in the management of osteomyelitis. Contemp. Orthop.,28: 157-185, 1994.28157 1994 [PubMed]

Chaudhuri, K.; Lonergan, D.; Portek, I.;, and McGuigan, L.:: Septic arthritis of the shoulder after mastectomy and radiotherapy for breast carcinoma. J. Bone and Joint Surg.,75-B(2): 318-321, 1993.75-B(2)318 1993

Elek, S. D., and Conen, P. E.: The virulence of Staphylococcus pyogenes for man. A study of the problems of wound infection. British J. Exper. Pathol.,38: 573-586, 1957.38573 1957

Estoppey, O.; Rivier, G.; Blanc, C. H.; Widmer, F.; Gallusser, A.; and So, A. K.: Propionibacterium avidum sacroiliitis and osteomyelitis. Rev. Rheumat., English Ed.,64: 54-56, 1997.6454 1997

Finegold, S. M.: Anaerobic bacteria: general concepts. In Mandell, Douglas and Bennett's Principles and Practice of Infectious Diseases, edited by G. L. Mandell, J. E. Bennett, and R. Dolin. Ed. 4, pp. 2156-2173. New York, Churchill Livingstone, 1995.

Gelberman, R. H.; Menon, J.; Austerlitz, M. S.; and Weisman, M. H.: Pyogenic arthritis of the shoulder in adults. J. Bone and Joint Surg.,62-A: 550-553, June 1980.62-A550 1980

Leslie, B. M.; Harris, J. M.; and Driscoll, D.: Septic arthritis of the shoulder in adults. J. Bone and Joint Surg., 71-A: 1516-1522, Dec 1989. 71-A1516 1989

Lippitt, S. B.; Harryman, D. T., II; and Matsen, F. A., III: A practical tool for evaluating function: the Simple Shoulder Test. In The Shoulder: A Balance of Mobility and Stability, pp. 501-518. Edited by F. A. Matsen, III, F. H. Fu, and R. J. Hawkins. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1993.

Mansat, P.; Cofield, R. H.; Kersten, T. E.; and Rowland, C. M.: Complications of rotator cuff repair. Orthop. Clin. North America,,28: 205-213, 1997.28205 1997

Minami, A.; Ogino, T.; Ohnishi, N.; and Itoga, H.: The latissimus dorsi musculocutaneous flap for extremity reconstruction in orthopaedic surgery. Clin. Orthop.,260: 201-206, 1990.260201 1990 [PubMed]

Palmer, R. S., and Miller, T. A.: Anterior shoulder reconstruction with pectoralis minor muscle flap. Plast. and Reconstr. Surg.,81: 437-439, 1988.81437 1988

Pfeiffenberger, J., and Meiss, L.: Septic conditions of the shoulder - an up-dating of treatment strategies. Arch. Orthop. and Trauma Surg.,115: 325-331, 1996.115325 1996

Post, M.: Complications of rotator cuff surgery. Clin. Orthop.,254: 97-104, 1990.25497 1990 [PubMed]

Rosenberg, L., and Mahler, D.: Extended rotation-transposition of the pectoralis major myocutaneous flap in the repair of lesions over the shoulder. British J. Plast. Surg.,34: 322-325, 1981.34322 1981

Settecerri, J. J.; Pitner, M. A.; Rock, M. G.; Hanssen, A. D.; and Cofield, R. H.: Infection following open repair of the rotator cuff. Orthop. Trans.,20: 949, 1996-1997.20949 1996-1997

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Torres, J. A., and Wright, T. W.: Synovial cutaneous fistula of the shoulder after failed rotator cuff repair. Orthopedics,22: 1095-1097, 1999.221095 1999 [PubMed]

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Topics

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Fig. 1-B:: Anteroposterior radiograph of the right shoulder, showing a retained suture anchor.

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Fig. 1-C:: Proton-density magnetic resonance image (top) and T2-weighted magnetic resonance image (bottom) showing involvement of the humeral head and the glenoid.

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Fig. 1-D:: Photograph showing wound coverage with a rotational myocutaneous latissimus dorsi flap following another irrigation and dè¡²idement.

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Fig. 2-C:: Coronal and axial T1-weighted magnetic resonance images with contrast medium, demonstrating osteomyelitis of the humeral head and the glenoid as well as a synoviocutaneous fistula (arrow).

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Fig. 2-D:: Coronal and axial T1-weighted magnetic resonance images with contrast medium, demonstrating osteomyelitis of the humeral head and the glenoid as well as a synoviocutaneous fistula (arrow).

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Table I: Risk Factors According to the Cierny-Mader Classification3

	No. of Patients
I. A-host	1
II. B-host
A. Systemic compromise
1. Age 60 years
a. No other medical problems	7
b. With type-II diabetes and coronary artery disease	1
2. Hypothyroidism
a. With primary IgA deficiency	1
b. Without primary IgA deficiency	2
3. Smoking	6
4. Alcoholism	2
B. Local compromise
1. Mastectomy
a. With lymphedema	1
b. Without lymphedema	1
2. Steroid injections	2

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Table I: Risk Factors According to the Cierny-Mader Classification3

	No. of Patients
I. A-host	1
II. B-host
A. Systemic compromise
1. Age 60 years
a. No other medical problems	7
b. With type-II diabetes and coronary artery disease	1
2. Hypothyroidism
a. With primary IgA deficiency	1
b. Without primary IgA deficiency	2
3. Smoking	6
4. Alcoholism	2
B. Local compromise
1. Mastectomy
a. With lymphedema	1
b. Without lymphedema	1
2. Steroid injections	2

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Table II: Results of Simple Shoulder Test10

	No. of Patients Capable of Activity
Shoulder comfortable with arm at rest by side	8
Shoulder allows comfortable sleep	8
Tuck in shirt at small of back	8
Place hand behind head	5
Place coin on shelf at level of shoulder without bending elbow	4
Lift 1 pound (0.5 kilogram) to level of shoulder without bending elbow	3
Lift 8 pounds (3.6 kilograms) to level of shoulder without bending elbow	0
Carry 20 pounds (9.1 kilograms) at side with affected extremity	8
Toss softball underhand 10 yards (9.1 meters)	8
Toss softball overhand 10 yards (9.1 meters)	1
Wash back of contralateral shoulder	6
Work full-time at regular job	5

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Table II: Results of Simple Shoulder Test10

	No. of Patients Capable of Activity
Shoulder comfortable with arm at rest by side	8
Shoulder allows comfortable sleep	8
Tuck in shirt at small of back	8
Place hand behind head	5
Place coin on shelf at level of shoulder without bending elbow	4
Lift 1 pound (0.5 kilogram) to level of shoulder without bending elbow	3
Lift 8 pounds (3.6 kilograms) to level of shoulder without bending elbow	0
Carry 20 pounds (9.1 kilograms) at side with affected extremity	8
Toss softball underhand 10 yards (9.1 meters)	8
Toss softball overhand 10 yards (9.1 meters)	1
Wash back of contralateral shoulder	6
Work full-time at regular job	5