Propionobacter acnes Infection as an Occult Cause of Postoperative Shoulder Pain

Authors:

Peter J. Millett, MD, MSc, Yi-Meng Yen, MD, PhD, Connie S. Price, MD, Marilee P. Horan, MPH, Olivier A. van der Meijden, MD, and Florian Elser, MD

Abstract:

Infection after shoulder surgery is a potentially devastating complication. The incidence of infection after rotator cuff repair ranges between 0.27% to 1.9%, whereas the incidence after shoulder arthroplasty ranges from 0% and 15.4%. Infections after proximal humerus fractures are less common.

P. acnes is being recognized as a causal agent in shoulder infections with increasing frequency. This nonspore-forming microaerophilic bacillus has a low level of virulence but has been established as a pathogen in endocarditis, meningitis, arthritis, osteomyelitis and spondylitis. It has been described as the infectious etiology in 16% of prosthetic shoulder infections and in 21% of revision shoulder arthroplasties. In another series, P. acnes was the major etiology of postoperative septic arthritis, comprising 56% of shoulder infections. Herrera in 2002 reported the incidence of deep infection after open rotator cuff repair to be 0.27% to 1.7%. Athwal found an incidence of 0.43% after different techniques of rotator cuff reconstructions. P. acnes was reported as the most common infecting organism in both studies.

In contrast, reports of P. acnes in lower-extremity infections, including prosthetic joint infections or after arthroscopy, are rare. This is likely because P. acnes is predominant in the pilosebaceous follicles that are most prevalent in the head, neck, and thorax. P. acnes is a dominant anaerobic bacteria isolated from the healthy skin in moist areas such as the axilla. This is another reason why the shoulder is thought to have a propensity for infections with this type of microorganism.

Because it is difficult to detect, the actual number of P. acnes shoulder infections probably has been underestimated. P. acnes is a fastidious organism, requiring prolonged growth duration and anaerobic conditions to grow in culture. When isolated, it often is disregarded as a contaminant owing to its presence as a commensal of upper-body skin sites. Furthermore, the clinical presentation of P. acnes is usually insidious and nonspecific.

Patients present without the typical signs of infection such as fever or local inflammatory reaction and invariably have normal leukocyte counts (WBCs).

To increase our awareness of the potential of P. acnes infection as an occult cause of postoperative shoulder pain, we investigated a series of patients diagnosed with post-surgical P. acnes shoulder infections to answer the following questions: (1) What characterizes a P. acnes infection of the shoulder, in clinical presentation and quantification of laboratory markers? (2) How are the microbiologic diagnosis and analysis best obtained? (3) How should this infection be treated and what clinical results of therapy can be expected?

For the complete study: Propionobacter acnes Infection as an Occult Cause of Postoperative Shoulder Pain

Peter Millett, MD

Average rating:

39 reviews

Alexandra Thompson

Mar 23, 2024

by Alexandra Thompson on Peter Millett, MD

110%

Dr. Millett and his team did a SLAP tear repair and bicep tenodesis on my left shoulder. I use my arms as an artist, and love to swim in the ocean, surf, paddle, and telemark ski. So regaining full use of my shoulder and keeping my bicep attached was very important to me. Now, over two years later, my shoulder has the equivalent range of motion as my other arm and as before the injury, and no pain. After the first three months it felt so good and was so strong that - to my horror - I completely forgot my six-month follow-up.

Not only did Dr. Millett and his team make my arm as good as new, but having had the experience of such kindness and expertise throughout the process of surgery and recovery is like an added shoulder superpower.

Thank you Rita, Brooke, Jason, Sarah, Camille, Olivia, Dr. Millett and everyone! And see you soon when my husband comes in for his knee...

Jeff Chandler

Jan 31, 2022

by Jeff Chandler on Peter Millett, MD

Flawless procedure, Easy recovery

Dr. Millet's repaired my knee and tibia, following a botched operation by a different surgeon. That procedure was virtually pain free and I was weight bearing within a few days. That was 18 years ago and the knee is still strong. A few years after the knee incident, Dr Millet repaired my shoulder. My insurance company approved me for 3 months of disability following that surgery. I was off pain medication in 2 days and had 90% range of motion within a week. I withdrew my disability claim and returned to work within two weeks of surgery. I’m not a famous athlete—just a regular guy. Nonetheless, I was treated like an NFL at the Steadman clinic. Most notable was the time for recovery. Other surgeons perform their hour-long task in the OR and don’t involve themselves in the other functions. Peter and his team manages the entire process from diagnosis, anesthesia, nursing care, and therapy. He takes a holistic approach to patient care and doesn’t skip any steps.

Jenn West

Jul 2, 2021

by Jenn West on Peter Millett, MD

Saved My Life

I went to Dr. Millett after 7 knee surgeries (6 on my right and 1 on my left) and had seen 11 different surgeons who all refused to remove femur metal from my right leg. I am highly allergic to metal and the chronic pain was leaving me bedridden for 3.5wks out of a month. He personally wrote me back on my inquiry, listened to my concerns, scheduled my surgery within a week (due to insurance issues) and personally followed up with my recovery. The level of patient care from Dr. Millett and his ENTIRE team is above any care I have ever received in my 20 years of dealing with orthopedic surgeons. There are not enough words to describe the level of care, dedication and professionalism you receive from Dr. Millett and his staff.
My only disappointment is that I did not find him sooner!!!

Submit your review
Name:
Email:
Website:
Review Title:
Rating:	1 2 3 4 5
Review:

Check this box to confirm you are human.
Submit Cancel

Propionobacter acnes Infection as an Occult Cause of Postoperative Shoulder Pain

Authors:

Abstract:

About the Author: Peter Millett, MD