Abstract
Background
We evaluated the detection rate of Cutibacterium acnes (C. acnes) for patients who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability.
Methods
Study subjects included 36 patients who underwent arthroscopic Bankart repair. Skin swabs prior to antisepsis, intraoperative synovial swabs of the glenohumeral joint (immediately after incision and prior to wound closure), and the suture of the suture anchor were cultured. Evaluation criteria included the detection rate of C. acnes in multiple regions of the body.
Results
Using a skin swab culture test, C. acnes was detected in 63 of 108 samples (58.3%). The bacterium was detected in 2 of 36 samples (5.5%) and 4 of 36 (11.1%) in the synovial swab culture of the glenohumeral joint immediately after surgical incision and immediately before wound closure, respectively. In the suture culture of the suture used in the arthroscopic Bankart repair, C. acnes was detected in 1 of 36 samples (2.8%).
Conclusions
C. acnes was detected in patients undergoing surgeries for shoulder instability. The relationship between C. acnes and the pathological condition of shoulder instability remains unknown.
Keywords: Cutibacterium acnes, Arthroscopic Bankart repair, Recurrent shoulder dislocations
1. Introduction
Arthroscopic Bankart repair has become a common operation as its re-dislocation rate has become comparable to open Bankart repair due to the advancement of arthroscopic techniques.10,15 In recent years, Cutibacterium acnes (C. acnes) is gaining attention for its association with clinical outcomes after rotator cuff tear, shoulder contracture, and total shoulder replacement.2,3,8,11, 12, 13,20 C. acnes is a slow-growing Gram-positive facultative anaerobic rod and a skin commensal bacterium that resides in relatively hairy areas such as the head, back and axilla.8 However, to the best of our knowledge, there are no reports that describe the relationship between shoulder instability and C. acnes. Moreover, the route of infection in C. acnes and its effect on shoulder joint disease remain largely unclear. Yeranosian et al.24 reported a postoperative infection rate of 0.29% for arthroscopic rotator cuff repair, and Pauzenberger et al.17 reported that 39.3% of its pathogens were identified as Staphylococcus epidermidis, followed by 28.6% that were identified as C. acnes. On the other hand, Owens et al.15 reported a deep infection rate of 0.22% from a database of 4562 arthroscopic Bankart repair cases, and the authors showed that the major pathogens of infection were Staphylococcus aureus and Staphylococcus epidermidis with no mention of C. acnes.
In this study, we examined the detection rate of C. acnes in patients who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability.
2. Methods
2.1. Study design and patients
This study was approved by our institutional review board, and all participants provided informed consent from April 2016 to May 2017. Thirty-six patients who underwent arthroscopic Bankart repair at our hospital for recurrent shoulder dislocation with a minimum 2-year follow-up were included in our study, excluding patients with a previous history of shoulder surgery, those with septic shoulder joint, and those with dermatological disease.
All procedures were performed by a single experienced shoulder surgeon. Patients were instructed not to shave their shoulders prior to surgery. Surgeries were performed under general anesthesia with an additional interscalene nerve block. Patients were positioned in the lateral decubitus position and received a routine antibiotic prophylaxis of 1 g cefazolin within 30 min prior to the procedure. The patients subsequently underwent antisepsis with 70% isopropyl alcohol to the skin of the exposed shoulder. Arthroscopic portals were created anteriorly, anterosuperiorly, and posteriorly. We used a 3 mm, 30-degree arthroscope through a cannula. Bankart lesions with glenoid involvement were debrided using a rasp, and a Bankart repair was subsequently performed using a suture anchor (1.4-mm Jugger-Knot anchor, Biomet, Warsaw, USA). Four to 6 suture anchors were inserted according to the size and damage of the lesion. The anterior capsule and anteroinferior glenohumeral ligament were sutured using a suture lasso (QuickPass Suture Lasso, Arthrex, Naples, USA) that acted as a suture relay. Each suture was passed through the anterior capsule and anteroinferior glenohumeral ligament and tied using a sliding knot technique. In addition, in cases with superior labral tear from anterior to posterior (SLAP lesion), repair for the injury was performed simultaneously with 1 or 2 additional suture anchors.
2.2. Sample collection
The site of sample collection included swabs of the anterior, lateral, and posterior incision sites for arthroscopic portals prior to surgical skin antisepsis (Fig. 1A, B, C, respectively), intraarticular synovial swabs of the glenohumeral joint immediately after surgical incision and prior to wound closure (Fig. 2A and B), and a section approximately 5 cm from the end of the suture that was cut from the suture anchor used in rotator cuff repair (Fig. 2C). A culture test was performed with at least >3 weeks of incubation.
Fig. 1.
Sites of skin sample collection. A) Anterior portal of the shoulder: 1 cm lateral to the coracoid. B) Antero-superior portal of the shoulder: 1 cm anterior to the anterolateral acromion. C) Posterior portal of the shoulder: 3 cm distal to the posterolateral acromion.
Fig. 2.
A) Intraarticular synovial swab of the glenohumeral joint immediately after surgical incision. B) Intraarticular synovial swab of the glenohumeral joint prior to wound closure. C) Suture from the suture anchor used during cuff repair; the section was cut approximately 5 cm from the end of the suture.
The items of evaluation were as follows: re-dislocation rate, postoperative clinical outcome using Rowe score,19 operative time, presence or absence of deep-seated infection, and detection rate of C. acnes from skin swab culture, synovial swab culture, and suture culture. The minimum follow-up time for a clinical review to exclude infection was 24 months. We determined that there was no deep-seated infection if there were no clear postoperative signs of infection, including joint swelling, localized sensation of heat, and redness.
3. Results
The mean age was 29.5 ± 13.5 years (26 male and 10 female), and 1 patient exhibited coexisting diabetes mellitus. The detection rate of C. acnes is shown in Table 1. Postoperative re-dislocation was found in 1 patient (2.8%), and no C. acnes was detected from the patient. The re-dislocation was a result of a fall during a baseball game at 3 months postoperatively. Because the patient opted not to undergo reoperation, we are currently following up the patient without reoperation. The Rowe score was significantly improved from a mean of 31.8 ± 11.5 points preoperatively to a mean of 92.9 ± 15.9 points at final observation. The mean operative time was 103.8 ± 27.0 min. There were no cases of deep-seated infections.
Table 1.
Results of age, sex, presence of diabetes mellitus, operation time, and culture test for each case.
| Case Number |
Gender | Age (years) | DM | Operation Time (min) | 1 (Skin: Anterior) | 2 (Skin: Lateral) | 3 (Skin: Posterior) | 4 (Intraarticular: immediately after incision) | 5 (Intraarticular: immediately after closure) | Suture |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | M | 17 | – | 104 | + | + | + | – | + | – |
| 2 | F | 41 | – | 127 | + | + | – | – | – | – |
| 3 | M | 44 | – | 168 | – | – | – | – | – | – |
| 4 | F | 16 | – | 152 | + | + | + | – | – | – |
| 5 | M | 33 | – | 119 | + | + | + | – | – | – |
| 6 | M | 19 | – | 130 | + | – | + | – | – | – |
| 7 | M | 30 | – | 80 | + | + | + | – | – | – |
| 8 | M | 29 | – | 140 | + | + | + | – | – | – |
| 9 | M | 31 | – | 105 | + | + | + | – | – | – |
| 10 | M | 44 | – | 144 | + | + | – | – | – | – |
| 11 | M | 21 | – | 100 | – | – | – | – | – | – |
| 12 | F | 17 | – | 84 | + | + | + | – | – | – |
| 13 | M | 19 | – | 87 | – | – | – | – | – | – |
| 14 | M | 52 | + | 85 | + | – | + | – | – | – |
| 15 | M | 26 | – | 75 | – | – | – | – | – | – |
| 16 | F | 60 | – | 70 | – | – | + | – | – | – |
| 17 | M | 38 | – | 90 | – | – | – | – | – | – |
| 18 | M | 15 | – | 82 | – | + | – | – | – | – |
| 19 | F | 23 | – | 110 | – | – | – | – | – | – |
| 20 | M | 17 | – | 127 | – | – | – | – | – | – |
| 21 | M | 24 | – | 105 | + | + | + | – | – | – |
| 22 | F | 21 | – | 85 | – | – | – | – | – | – |
| 23 | M | 48 | – | 95 | + | + | + | – | – | – |
| 24 | F | 60 | – | 120 | – | – | – | – | – | – |
| 25 | M | 28 | – | 91 | – | + | – | – | – | – |
| 26 | M | 28 | – | 91 | – | – | – | – | – | – |
| 27 | M | 16 | – | 120 | + | – | – | – | – | – |
| 28 | M | 48 | – | 47 | + | + | + | – | + | + |
| 29 | F | 50 | – | 51 | + | + | + | – | + | – |
| 30 | F | 16 | – | 95 | + | + | + | + | – | – |
| 31 | M | 18 | + | 122 | – | – | + | – | – | – |
| 32 | M | 17 | + | 95 | + | + | + | – | + | – |
| 33 | M | 19 | – | 135 | – | + | + | – | – | – |
| 34 | M | 23 | – | 84 | + | + | + | + | – | – |
| 35 | M | 26 | – | 127 | + | + | + | – | – | – |
| 36 | M | 27 | – | 93 | + | + | + | – | – | – |
C. acnes was detected in 63 of 108 samples (58.3%) from the skin swab culture. In the synovial swab culture of the glenohumeral joint, C. acnes was detected in 2 of 36 samples (5.5%) immediately after surgical incision and 4 of 36 samples (11.1%) immediately before wound closure. In suture culture of the suture used for arthroscopic Bankart repair, the bacterium was detected in 1 of 36 samples (2.8%).
4. Discussion
There have been few reports on the relationship between arthroscopic Bankart repair and C acnes. In this study, we found several cases wherein C. acnes was detected from skin swabs and intraarticular synovial swabs in arthroscopic Bankart repairs.
The bacterium is part of the normal resident skin flora, which inhibits bacterial pathogens such as Staphylococcal aureus and Staphylococcal pyogenes by breaking down neutral fats in the sebaceous gland and producing fatty acids to acidify the skin. Because these bacterial pathogens favor a neutral pH environment, the acidity from the production of fatty acids by C. acnes plays a role in maintaining healthy skin. C. acnes is known to inhabit areas with a dense distribution of sebaceous glands, and a study its bacterial distribution in skin surrounding the buttocks, shoulder, and knee have found that it is most prevalent around the shoulder.8,13,16
In recent years, there have been reports on the relationship between C. acnes and diseases of the shoulder joint.3,8,11, 12, 13,18,20,21 Bunker et al.4 reported that when culturing samples from 10 patients who underwent arthroscopic capsular release for frozen shoulders, 8 patients exhibited positive cultures, and suggested that C. acnes may because of frozen shoulders. Furthermore, Levy et al.11 collected intraoperative joint fluid and tissue samples from shoulder replacement surgeries for patients with arthritic shoulders and detected C. acnes in 41.8% of patients, suggesting that the bacterium may be a risk factor for osteoarthritis. Both reports indicate its relationship to painful shoulder joint diseases and degenerative diseases; however, to our knowledge, there are no reports in the literature that describe its relationship to the instability of the shoulder joint, such as recurrent dislocation of the shoulder. Although postoperative re-dislocation was observed in one patient, no C. acnes was detected; therefore, we believe that there is no relationship between the detection of C. acnes and re-dislocation.
In this study, C. acnes was detected in 58.3% of the skin swab culture, 5.5% of the synovial swab culture immediately after surgical incision, and 11.1% of the wound prior to closure. Kajita et al.9 previously reported a similar study in cases that underwent arthroscopic rotator cuff repair. The detection rates of C. acnes in cases that underwent arthroscopic rotator cuff repair were comparable to that of this study, with a 65.5% detection rate from the skin swab culture and 13.6% from the synovial swab culture.
In this study, C. acnes was detected in 5.5% of samples derived from the synovial swab culture immediately after surgical incision. This suggests the presence of bacteria in the synovium prior to surgery is more probable than intraoperative contamination. Levy et al.11 reported that C. acnes was detected in the synovial fluid and synovial tissues prior to implantation in total shoulder arthroplasty, and the authors suggested the possibility that the bacteria was already present prior to surgery. We believe that preoperative intraarticular injection may be involved in the possible presence of C. acnes prior to surgery. We performed an arthroscopic Bankart repair, and all patients underwent arthrography with saline injection into the glenohumeral joint. In addition, for patients experiencing strong pain during reduction for dislocation, a local anesthetic was injected into the glenohumeral joint to carry out the reduction. Mook et al.14 examined the detection rate of C. acnes in pericapsular soft-tissue specimens from open surgery of the shoulder joint (tendon repair, artificial joint replacement, and trauma surgery). They reported that the detection rate of C acnes increases significantly when 2 or more preoperative corticosteroid injections are performed, and suggested the higher likelihood of contamination by preoperative injection into the shoulder joint. In addition, Sethi et al.21 reported that C. acnes was detected in 15.8% of skin swab cultures after skin antisepsis. They suggested that it is difficult to eliminate the presence of the bacteria with antisepsis, because the bacteria reside subcutaneously in the sebaceous glands rather than in the surface layer of the skin. Falconer et al.6 reported that C. acnes was detected in the swab culture of gloves and implants that were used during surgery, and Yamakado et al.23 reported that the bacteria was detected from sutures of suture anchors used in their arthroscopic rotator cuff repair. Both Falconer and Yamakado reported the possibility of intraoperative contamination.
In the present study, C. acnes was detected from the synovium immediately after incision in 2 patients, and the bacteria was not detected from their synovial swab culture prior to wound closure. In 4 patients, C. acnes was detected from the synovium prior to wound closure, and the bacteria was not detected from their synovium immediately after incision. In all patients, preoperative MRI imaging was performed after arthrography. Although we believe that both preoperative and intraoperative contamination is conceivable, we do not know the exact timing of contamination at this time.
In this study, there were no clear deep-seated infections in patients with positive results for C. acnes from synovial swab culture. There are several subtypes of C. acnes, but only a few of these types exhibit virulence and cause deep-seated infections.8 There is a possibility that the particular C. acnes detected in this present study were types with low virulence. In addition, deep-seated infections that are caused by C. acnes, also known as stealth type bacterial infections, do not present with commonly observed clinical findings such as swelling, sensation of heat, and pain.8 There are reports that C. acnes is associated with prolonged pain, shoulder joint contractures, and implant loosening of shoulder arthroplasty.1,5,7,21,22 Furthermore, there is also the possibility that stealth type infections may be associated with hydrarthrosis and subacromial bursitis after cuff repair. The present study is a short-term postoperative observational study, and long-term follow-up on deep-seated infections may be necessary for future research in patients detected with C. acnes. If the presence of C. acnes is suspected, surgeons should consider the administration of antibiotics that are highly effective against C. acnes.
There were several limitations in this study. First, the sample size was small, and the follow-up period was short. Secondly, this study was not a case-control study. Thirdly, several different subtypes of C. acnes have been identified that may explain the diversity of the bacterium and its clinical manifestation; however, these variations were not considered in this study.
5. Conclusion
C acnes was detected in patients who underwent surgery for shoulder instability. The relationship between C. acnes and the condition of the shoulder instability remains unknown.
Funding/support
The authors of this article did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
none.
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