Single Dose Antibiotic Regimens in Total Shoulder Arthroplasty are Safe in the Outpatient Surgery Setting

Charles Fryberger, MD1 Thomas W. Throckmorton, MD1 SaeRam Oh, BS2 Jim Wan, PhD3 Frederick M. Azar, MD1 Tyler J. Brolin, MD1

1 University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering Memphis, Tennessee 2 University of Tennessee

Health Science Center

College of Medicine

Memphis, Tennessee 3 University of Tennessee

Health Science Center

Department of Biostatistics and

Epidemiology Research Department

Memphis, Tennessee

Corresponding Author

Tyler J. Brolin, MD

1458 W. Poplar Avenue, Suite 100 Collierville, TN 38017 P: 901-759-5522 F: 901-759-3195 tbrolin@campbellclinic.com

Background

As the healthcare environment continues to evolve, government and regulatory organizations continue to place increasing emphasis on the delivery of safe, high-quality, cost-e ective, and e cient healthcare. This has led to a shift toward shorter hospital stays and increased utilization of the outpatient setting for total joint arthroplasty. Shoulder arthroplasty is a valuable procedure in the treatment of end-stage shoulder condition, and the demand for total shoulder arthroplasty (TSA) continues to increase. Recent literature supports outpatient shoulder arthroplasty as a safe alternative to the traditional inpatient setting in appropriately selected patients. One potential drawback to outpatient TSA is the inability to administer 24 hours of intravenous (IV) prophylactic antibiotics to prevent prosthetic joint injection (PJI) as generally, patients are sent home on the same day of surgery.

Methods

An institutional database query was used to identify patients who underwent either primary anatomic (aTSA) or reverse total shoulder arthroplasty (rTSA) between the years of 2009 to 2019. Patient candidacy for outpatient TSA was based on each patient’s overall health status, adequacy of social support, and patient preference. A multidisciplinary team comprised of physical therapy, anesthesiology and orthopaedic surgery evaluated the patient preoperatively for candidacy of outpatient TSA. Of the total 1,022 patients identifi ed, 896 received 24hr of perioperative IV antibiotics while in the traditional inpatient setting and 126 patients received a single dose of preoperative IV antibiotics (single) prior to undergoing an outpatient TSA at an ambulatory surgery center. Outcomes measured include overall infection and revision rates. Infection rate was further subcategorized into superfi cial versus deep infection. Additionally, the timing of infection was subcategorized as early, with the diagnosis made within fi rst three months after the procedure, or late, with the diagnosis made after three months.

Results

The 896 patients who received 24hr of IV antibiotics had an average age of 67.6±9.9 years (age range of 22-90). The average age of the 129 patients who received a single dose of antibiotics was 57.3±7.7 years (range of 33 to 79). The 24hr groups was on average 10.3 years older (p<0.001) than the single dose cohort. The patients in the 24hr group were more likely to undergo rTSA (61.5% vs 29.4%; p=<0.0001), more likely to have diabetes (23.0% vs 10.3%; p=0.001), and hypertension (69.3% vs 47.6%, p=<0.0001). The patients in the single dose group were more likely to have undergone previous non-arthroplasty shoulder surgery on the operative side (23.8% vs 16.5%; p=0.04). Employment status (p=<0.0001) and indication for procedure (p=0.001) varied signifi cantly between the two groups. The patients in single dose group were more likely to be employed and patients in the 24hr group were more likely to be retired (employed single: 73.8% vs 24hr: 24.4%, retired single: 14.3% vs 24hr: 57.1%, unemployed single: 11.9% vs 24hr: 18.5%).

Average length of follow-up was 23.0±21.0 months for the 24hr group and 17.8±15.6 months for the single dose group. There was no signifi cant di erence in overall infection rate (24hr: 1.5% vs single: 1.6%, p=0.71) or revision rate (24hr: 4.6% vs single: 3.2%, p=0.47). Rate of superfi cial (24hr: 0.2% vs single: 0%) or deep infection (24hr: 1.2%, single: 1.6%, p=0.73), timing of infection (24hr: <3months=0.6%, >3months=0.9% vs single dose: <3months=0%, >3months=1.6%, p=0.53), and revision for infection (24hr: 1.1% vs single: 0.8%) versus non-infectious indications (24hr: 4.6% vs single: 3.2%, p=0.92) were not statistically signifi cant.

Discussion

The goal of this study was to compare infection rates of single dose antibiotic prophylaxis in an ambulatory setting versus 24hr IV antibiotic prophylaxis in an inpatient setting in patients undergoing TSA. To our knowledge, this is the fi rst study to report such antibiotic regimens in TSA. This study is the largest to date comparing single dose and 24hr antibiotic regimens in TSA. Our data revealed no signifi cant di erence in infection rates between 24hr IV inpatient antibiotic regimens and single dose ambulatory antibiotic regimens, most notably within the fi rst 3 post-operative months. There were no statistically signifi cant di erences in post-operative infection or revision rate seen between the two groups. Ultimately, this study suggests that a single dose of IV antibiotic prophylaxis protocols can be safely used in patients undergoing TSA in an ambulatory center.

CHARLES T. FRYBERGER, III, MD

Hometown: Huntsville, Alabama Undergraduate Institution: Auburn University Medical School: University of Alabama School of Medicine Dr. Fryberger is the oldest of three children and is the fi rst in his family to pursue a medical career. Dr. Fryberger met his wife Emily in college, and they were married in 2013. Emily is a full-time mom to their two children - two-year-old Colton, and four-month-old Landon. When asked why he chose medicine as a career: There is no better way to combine science, critical thinking and helping people. And why he chose orthopaedics as a specialty: I love that the majority of patients get better and want to get better. I love the mechanical nature of many of the surgeries and the immediate gratifi cation they provide. I can’t imagine doing anything else. Plans After Campbell: Dr. Fryberger will complete a Sports Medicine Fellowship at American Sports Medicine Institute in Birmingham, AL. Dr. Fryberger adds: Thank you to Drs. Azar, Throckmorton, Brolin, Bernholt, Miller, and Phillips for allowing me to learn from you and your patients. Thank you for mentoring me throughout residency.