JSES International 8 (2024) 167e175

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JSES International
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Can Pyrocarbon be used as a functional spacer for the treatment of

recalcitrant shoulder infections?
Hugo Barret, MD, Pascal Boileau, MD, PhD*
ICR-Institut de Chirurgie R
eparatrice, Groupe Kantys, Nice, France

a r t i c l e i n f o Background: The most common treatment approach in periprosthetic joint infection (PJI) and chronic
shoulder joint infection (SJI) is a two-stage revision involving interval placement of an antibiotic cement
Keywords: spacer or a resection arthroplasty. Knowing that Pyrocarbon has a smooth surface that prevents pathogen
Periprosthetic joint infection adhesion, the question arises whether it could be used as a temporary or permanent functional spacer?
Shoulder joint infection Purpose: The primary objective of the present study was to assess the rate of infection eradication after
Pyrocarbon interposition shoulder
temporary or definitive implantation of Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in
arthroplasty
patients with recalcitrant PJI or SJI. Our secondary objective was to assess mid-term clinical and radio-
Cement spacer
Resection arthroplasty graphic outcomes.
Arthrolysis Methods: Fifteen patients (mean age: 52 ± 19 years) with chronic shoulder infection underwent, after
bridement, implantation of PISA (InSpyre; Tornier-Stryker, Kalamazoo, MI, USA) with tailored
joint de
Level of evidence: Level IV; Case Series; perioperative antibiotics. In 7 cases, PJI occurred after hemiarthroplasty (n ¼ 2), reverse shoulder arthro-
Treatment Study plasty (n ¼ 2), hemireverse (n ¼ 2), and resurfacing arthroplasty (n ¼ 1). In 8 cases, SJI occurred in the
context of failed surgery after fracture sequelae (n ¼ 4), instability (n ¼ 2), and cuff arthropathy (n ¼ 2).
Preoperatively, patients had a mean of 3 previous failed surgeries before PISA implantation. Patients were
evaluated with clinical, laboratory, and radiographic assessment at a minimum of 2 years after surgery.
Results: At a mean follow-up of 55 ± 18 months, no patient experienced reinfection after temporary
(3 cases) or definitive (12 cases) PISA implantation. The adjusted Constant score increased from 33% ± 20
preoperatively to 65% ± 28 at last follow-up and SSV from 22% ± 19 to 63% ± 23 (P < .001). Active forward
elevation increased from 27 ± 19 to 113 ± 30, external rotation from 7 ± 21 to 25 ± 25, and internal
rotation level 3 ± 2 to level 5 ± 2 points (P < . 001). On final radiographs of definitive PISA, complete
humeral densification, or a neocortex, formed around the implant in 64% (7/11).
Conclusion: Our data suggest that, after washout, de bridement and tailored antibiotics, PISA can be used
as a temporary or definitive functional spacer for the treatment of recalcitrant shoulder infections and
presents the following advantages: (1) PISA does not seem to be a risk for recurrent infection thanks to
the antibacterial property of Pyrocarbon; (2) PISA can be used as a temporary or a definitive spacer
without causing bone erosion, thanks to the low modulus of elasticity of Pyrocarbon; (3) PISA can be
used as a salvage procedure in case of complete glenoid or humeral destruction, thanks to the sphericity
of the implant needing no implant anchorage.
© 2023 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Surgical management for the treatment of periprosthetic joint possible and depend on the patient's comorbidities,3,7,19 a possible
infection (PJI) and shoulder joint infection (SJI) after multiple failed fistula,7 whether the bacteria has been identified,4,30 and the
surgeries is challenging and controversial.7 Several strategies are resultant bone and cartilage destruction.21 Currently, no consensus
management algorithm has emerged. The most common treatment
approach is a two-stage revision involving interval placement of an
This study was performed according to the medical ethical guidelines of the
antibiotic cement spacer (ACS) or a resection arthroplasty (RA) in
authors' institution (approval reference: ICR-2021-SR-10-01). All patients were cases of recalcitrant infection or in the elderly and frail patients and
informed of the characteristics of this new implant and provided their consent to in those who refuse further surgery.23
participate in the study. In 2010, we started to treat select patients who had undergone
*Corresponding author: Pascal Boileau, MD, PhD, ICR-Institut de Chirurgie
paratrice (Institute for Sports & Reconstructive Surgery), Groupe Kantys, 7,
multiple surgical procedures and failed medical treatment utilizing
Re
Avenue Durante, Nice 06000, France. a Pyrocarbon Interposition Shoulder Arthroplasty (PISA) as an
E-mail address: [email protected] (P. Boileau). alternative to ACS or RA for temporary or definitive treatment of

https://doi.org/10.1016/j.jseint.2023.09.005
2666-6383/© 2023 The Author(s). Published by Elsevier Inc. on behalf of American Shoulder and Elbow Surgeons. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
H. Barret and P. Boileau JSES International 8 (2024) 167e175

chronic PJIs or SJIs. The theoretical benefits of Pyrocarbon (PYC) 3 patients two pathogens were identified. The epidemiology data
material, besides its biocompatibility and elasticity,15,18 is it is are summarized in Table I.
resistance to wear, fatigue, and prevention of bacterial adhesion.17
Furthermore, the spherical shape of PISA makes implantation Surgical technique
easy to perform as there is no need for prosthetic stem fixation in
the bone.2 Obviating the need for fixation is beneficial in patients All patients were operated in the beach chair position under
with infected fracture sequelae as PISA allows for easy adaptation to general anesthesia and an interscalene block. A deltopectoral
the distorted anatomy of the proximal humerus.6 As well, PISA approach was performed with elevation of the subscapularis by a
represents a potential salvage option in patients that do not desire a peel-off technique. In cases of PJI, the previous prosthesis and
RA and in those where glenoid reconstruction is not feasible due to cement were removed. In cases of infection after proximal humerus
significant bone loss and erosion. fracture fixation, the previous metallic (plate, nail, wires) material
The questions we attempted to answer in the present study was removed. In cases of infection after failed cuff repair or
were the following: (1) since Pyrocarbon material is resistant to shoulder stabilization, all anchors and sutures were removed.
bacterial adherence, could it be used as a temporary or permanent Complete synovectomy and joint de bridement were performed. A
spacer for treatment of chronic SJI and PJI? and (2) if PISA is used as minimum of five tissue samples12,32 was taken for each patient and
a definitive treatment, could it provide acceptable pain relief and sent for early14 and late cultures before intraoperative antibiotic
shoulder function? therapy was initiated. Each shoulder was copiously irrigated with a
The primary objective of the present study was to assess the 9-liter (6 liters of normal saline after using 3 liters of betadine)
infection cure rate after temporary and definitive PISA implantation wash. After changing gowns, gloves, and surgical drapes, a PISA was
in the treatment of recalcitrant SJI and PJI. Our secondary objective implanted. Using specific reamers of increasing sizes, we per-
was to assess mid-term clinical and radiographic outcomes. We formed concentric reaming of the humeral epiphysis to accept the
hypothesized that our strategy, including implantation of PISA with spherical implant of the correct size. A glenoid defect was present
bridement and perioperative antibiotics, would effectively
joint de in 8 patients, graded as cavitary (n ¼ 5), mural (n ¼ 2), and complex
treat shoulder infection and improve shoulder pain and motion (n ¼ 1).5 After synovectomy and de bridement, glenoid bone
such that it can be employed as a definitive procedure in select grafting was performed in 6 cases using allograft (Osteopure; OST,
complex patients. Paris, France) to fill the bone defect. A greater tuberosity fracture
occurred in 2 patients: one occurred at the time of humeral implant
Methods extraction and the other after surgery when putting on the brace;
no internal fixation material other than suture was used for fracture
Study design fixation. The glenohumeral joint was closed using the remnant
subscapularis tendon and capsule when present. A drain was put in
We performed a single-center retrospective study with pro- place for 24-48 hours.
spective inclusion of data. We included patients with PJI or SJI who
underwent implantation of PISA (InSpyre; Tornier-Stryker, Kala- Medical treatment
mazoo, MI, USA) with joint debridement and tailored perioperative
antibiotics. Infection was confirmed with positive intraoperative A multidisciplinary approach with an infectious disease
cultures. We excluded patients who underwent PISA for reasons specialist was performed. After PISA implantation, patients were
other than infection sequelae and patients with substantial treated with antibiotics for at least 6 weeks based on culture-
neurologic dysfunction. All patients provided written consent for specific sensitivities. The patients were seen by the infectious dis-
study inclusion and follow-up. ease specialist at 3 weeks postoperatively to modify the antibiotic
treatment based on the culture results and then at the end of the
Patient population antibiotic therapy. In patients where the pathogen(s) had been
preoperatively identified, appropriate antibiotic therapy was
Between 2010 and 2020, 15 patients (mean age of 52 ± 19 years) administered directly after sampling for a total period of 6-12
who underwent PISA implantation for PJI or SJI (5 women and 10 weeks.16,22 If the pathogen was unknown prior to surgery, a mini-
men) were included and reviewed for clinical, laboratory, and mum of 3 weeks of antibiotic therapy was administrated with
radiological assessment (Table I). No patients were lost to follow- Clindamycin. After these 3 weeks, modified antibiotics according to
up. Ten patients had their dominant side affected and 8 were the culture results were administered for a period of 6-12 weeks.
manual workers. In 8 cases, SJI occurred in the context of previous Patient education and systemic monitoring was implemented
surgery for fracture sequelae (n ¼ 4), instability (n ¼ 2), and rotator (hepatic and renal monitoring, etc.) at the discretion of the treating
cuff disease (n ¼ 2). In 7 cases, a PJI occurred after hemiarthroplasty infectious disease specialist.
(n ¼ 2), reverse shoulder arthroplasty (n ¼ 2), hemireverse (n ¼ 2),
and resurfacing arthroplasty (n ¼ 1). The most frequent medical Clinical and radiological assessment
comorbidities included smoking (6 cases), obesity (3 cases), and
diabetes (3 cases). All patients were operated on by the senior author (P.B.), and
Concerning the etiology of the infection, 12 patients had been prospectively followed and reviewed by the junior author (H.B.).
contaminated during one or more shoulder surgeries, 1 patient had The analysis of the clinical and radiographic results was performed
a hematogenous infection, 1 patient had an infected pacemaker, for PISA used as the definitive treatment strategy at final follow-up
and 1 patient had an infected knee replacement with resultant (n ¼ 11).
contamination of the shoulder prostheses. Prior to PISA implanta- Clinical assessment was performed using pre and postoperative
tion, all patients had prolonged antibiotic treatment and a mean of mobility, pain (Visual Analog Scale [VAS]), subjective shoulder
3 previous failed surgeries. Four patients had a persistent fistula value (SSV) score17 and Constant score.9 Laboratory analysis was
involving their shoulders and 1 patient had an abscess in the performed with a complete blood count, erythrocyte sedimenta-
axillary fold. The most common identified pathogens were tion rate (ESR), and C-reactive Protein. Confirmation of infection
Cutibacterium acnes (n ¼ 14) and Staphylococcus aureus (n ¼ 3); in eradication was based on the clinical aspect of the shoulder
168
 Table I

H. Barret and P. Boileau

Epidemiologic data.

Nb Age M/F Sport/activity Occupation Medical Number & type Etiology of PJI or Pathogens Fistula Antibiotics Definitive
co-morbidities of prior shoulder SJI present treatment with
surgeries infection PISA

1 73 M None Retired Diabetes, heart 1) Resurfacing Septic pacemaker PJI Cutibacteium yes Ciprofloxacin þ bactrim 14 yes
rhythm arthroplasty Acnes þ serratia d then amox þ acid clav.
disorder marcescens 1 mo
2 50 M Rugby Truck Obesity 1) Biceps tenodesis Septic knee SJI Staphyloccocus aureus yes Levofloxacin þ rifampicin 6 yes
driver 2) Open cuff repair arthroplasty MultiR weeks
3) Antibiotic cement spacer
3 39 F Wind surf Athletic 0 1) Open Bankart Shoulder surgery SJI Cutibacterium Acnes No Dalacin 6 weeks yes
trainer 2) Arthroscopic Bankart
bridement
3) Arthroscopic de
4 69 F None Shopkeeper 0 1) Open Bankart Shoulder surgery PJI Cutibacterium Acnes No Dalacin 6 weeks Yes
2) Open bone block (ICBG x2)
3) HA
4) RSA
5) HA
5 69 F None Retired Obesity, 1) RSA (Type-1 fracture Shoulder surgery PJI Cutibacterium No Rifampicin þ fluorquinolone yes
diabetes sequelae) Acnes þ Strepto (tendon and digestive
Parasangunis intolerance) then
amoxicilin þ dalacin 8 weeks
6 45 M No None No 1) Arthroscopic Cuff repair Shoulder surgery PJI Staphyloccocus No Dalacin 6 weeks No conversion
2) HA Epidermidis to hemireverse
3) RSA Cutibacterium Acnes
4) Cement spacer Staphyloccocus aureus
5) RSA MultiR
6) RSA removal
169

7 33 F Gymnastics, Nurse Epilepsy 1) steosynthesis (screws) Shoulder PJI Cutibacterium Acnes No Dalacin yes
hiking 2) Screw removal surgery 6 weeks
3) Stemless HA
4) Cuff repair
8 62 M None Truck No 1) Plate osteosynthesis Shoulder surgery SJI Cutibacterium Acnes No Dalacin 6 weeks yes
driver 2) Plate removal
9 25 M Rugby Athlete No 1) Open Latarjet Shoulder surgery PJI Cutibacterium Acnes No Dalacin 6 weeks Yes
2) Acromioplasty
3) Anterior Bankart
4) Posterior Bankart
5) Anchor/screw removal
6) HA
10 50 M Cycling Business No 1) Plate osteosynthesis Shoulder surgery SJI Cutibacterium Acnes No Dalacin 6 weeks yes
11 44 M None Policeman No 1) Pinning Prox. Hum. Shoulder surgery SJI Staphylococcus Yes Vancomycin-Genta Peni No conversion
Fracture Coagulase Negative M then ofloxacin & rifadin 6 to RSA
2) Plateosteosynthesis multi-Resistant weeks
3) Antibiotic cement spacer Streptococcus Mitis
Cutibacterium Acnes
12 41 F Skiing Lawyer No 1) Hook plateosteosynthesis Shoulder surgery SJI Staphylococcus Aureus Yes Peni M then ofloxacin & yes

JSES International 8 (2024) 167e175

with suprapinatus tear Streptococcus rifadin 6 weeks
2) MUGA
3) Plate removal
4) Supraspinatus repair
(continued on next page)
 H. Barret and P. Boileau JSES International 8 (2024) 167e175

(absence of redness, absence of pain during shoulder motion) and

treatment with

normalization of serum inflammatory markers (normalized ESR

No conversion
and C-reactive Protein).
Definitive

On final radiographs, glenoid erosion was assessed according to

to RSA
the classification by Sperling31 and humeral erosion according to
PISA

yes

yes

Barret.2 We also analyzed the evolution of humeral bone loss by

rifanpicin þ triflucan 21 d then
levofloxacin rifampicin and assessing the radiographic densification around the spherical PYC
linezolid and rifampicin 21

implant by stratifying patients into 2 groups: without or with bone

PJI, periprosthetic joint infection; SJI, shoulder joint infection; HA, hemiarthroplasty; RSA, reverse shoulder arthroplasty; ICBG, iliac crest bone graft; MUGA, maniipulation under general anesthesia.
densification at final follow-up.2
triflucan 6 weeks
Dalacin 6 weeks

Dalacin 6 weeks

Statistical analysis
clindamicin þ
Antibiotics

Quantitative variables were analyzed by the Mann Whitney and

d then

Wilcoxon tests. The Chi-square and Fisher tests were used for
analysis of qualitative variables. The value of P < .05 was consid-
ered statistically significant. Statistical analysis was performed
present
Fistula

using R studio.
Yes
No

No

Results
Cutibacterium Acnes

Cutibacterium Acnes
Negative þ Candida

As shown in Table I, our study population was composed of

Staphylococcus

relatively young patients (mean age 52 years old), mainly men

(11/15), with PJI (7 cases) or recalcitrant SJI (8 cases). These chronic
Pathogens

Coagulase

Albicans

infections occurred in patients who present medical comorbidities

(diabetes, smoking, or obesity) and underwent multiple surgical
treatments (a mean of 3 surgeries per patient before PISA
implantation) and failed prolonged antibiotic treatment.
PJI or

PJI
SJI

SJI

SJI

Complications and reinterventions

Shoulder surgery

Shoulder surgery

Shoulder surgery

As mentioned above, PISA was used as permanent spacer in 12

Etiology of

cases and as temporary spacer in 3 cases where PISA was

infection
shoulder

converted to RSA to improve shoulder function.

Two patients were reoperated for a shoulder arthroscopy. The
first patient, a 30-year-old male, underwent an arthroscopic
1) Osteosynthesis with pins

Antibiotic cement spacer

arthrolysis for release of adherences between the deltoid and the

2) RSA þ Latissimus Dorsi

cuff 6 months after PISA; this arthroscopic arthrolysis improved

bridement

shoulder motion and decreased shoulder pain, and SSV at last

Anchor removal

follow-up was 80%. The second patient, a 42-year-old female,

Bankart repair
Number & type

underwent an acromioplasty under arthroscopy 12 years after

Cuff repair

1) Cuff repair
Joint de

PISA; this arthroscopy improved shoulder function with a SSV of

surgeries

transfer
of prior

70% at last follow-up.

The two GT fractures were treated with a neutral rotation brace
1)
2)
3)
4)
5)

for 4 weeks and healed without additional revision surgery. No

co-morbidities

revision surgery was performed for painful glenoid erosion or

symptomatic GT fracture. A permanent dislocation of PISA was
Real estate Diabetes

Diabetes
Occupation Medical

Obesity

found following a severe glenoid bone defect and destruction of

the anterior soft tissues without the need for revision due to an
acceptable clinical outcome for the patient.
Retired
agent
None

Infection recurrence

At a mean follow-up of 55 ± 18 months, no recurrence of

Sport/activity

infection was observed in the 15 patients. All patients at final

Horseback

follow-up demonstrated no clinical or laboratory evidence of

riding
None

None

persistent infection (normalized ESR and CPR).

Functional outcomes
M/F

The functional results of the 12 patients where PISA was

M

employed as the definitive treatment strategy are summarized in

Table I (continued )

Table II. The mean Constant score increased significantly from 33%
Age

60

30

74

preoperatively to 65% and, based on SSV, patients considered their

shoulder to be, on average, 63% of a normal shoulder. Significant
improvements in shoulder mobility were observed with active
Nb

13

14

15

forward elevation increasing from 75 þ/ 11 to 113 þ/ 30 and

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H. Barret and P. Boileau JSES International 8 (2024) 167e175

Table II
Clinical results.

Preoperative mean ± SD Last follow up mean ± SD P

Active forward elevation ( ) 75 ± 11 113 ± 30 <.001

Active external rotation ( ) 7 ± 12 25 ± 25 <.001
Active external rotation (points) 3 ± 12 5 ± 2 <.001
Visual Analog Scale 6 ± 1.8 2.1 ± 1.3 <.001
Absolute Constant score (points) 27 ± 18 57 ± 25 <.001
Adjusted Constant score (%) 33 ± 20 65 ± 28 <.001
Subjective shoulder value (%) 22 ± 19 63 ± 23 <.001

SD, standard deviation.

acceptable active rotations allowing most activities of daily living. The use of ACS, in 130 or two stages,4,10,13,20,23,26,28,29,33,34 is the
Seven patients went back to work, and 1 patient went back to most common treatment option in patients with recalcitrant PJI or
competitive windsurf. SJI.7 Definitive spacer retention may be proposed to patients who
refuse or are at a high medical risk to undergo two-stage revision
arthroplasty. However, ACS can rarely be used as a definitive or per-
Radiological outcomes
manent spacer because the rough surface of cement can subject the
Radiological results are summarized in Table III. On final radio-
glenoid to painful erosion.11,22,24,35 Other known complications of
graphs of definitive PISA, complete humeral densification, or a
antibiotic spacers retention include implant instability or dislocation,
neocortex, formed around the implant in 64% (8/12); no or mild
rotation or fracture of the spacer, and fracture of the humerus or
bone erosion was observed in 73% on the glenoid side and 55% on
greater tuberosity at the time of implantation or explantation.24,25
the humeral side (Figs. 1 and 2).
Furthermore, the results of permanent ACS are not always better
than those of RA.11,22,35 Our data suggest that PISA, used as a tem-
Discussion porary or permanent spacer, can potentially offer an alternative to
ACS with improved pain relief and shoulder function.
The data of the present study confirm our hypothesis: after RA is sometimes indicated in elderly, fragile, and low-demand
eradication of shoulder joint infection with washout, de bridement patients with chronic shoulder infections, in those who refuse
and antibiotics, PISA can be used in select patients, as a temporary or further surgery or in the case where prothesis reimplantation is
permanent functional spacer, in the treatment of shoulder infections technically unfeasible.8,25 Although this surgical procedure has high
to improve pain, and restore shoulder motion. In our series of 15 rates of infection resolution, up to 50% of patients experience residual
patients operated for chronic PJI and SJI, no recurrence of infection pain after RA and functional shoulder outcomes are often poor.7,27
was observed after temporary (3 cases) or definitive (12 cases) Furthermore, revision surgery after RA posed many technical chal-
pyrocarbon spacer implantation. The benefit of PISA is threefold: (1) lenges and may be associated with poor functional outcomes because
the PYC material prevents adhesion of bacterial pathogens and does of capsular contraction, intra-articular scar tissue, and limited soft-
not seem to be a risk for recurrent infection like implanting a metal tissue mobilization. In this patient population, our preference is to
would be, (2) the PYC implant acts as a “functional spacer” that use PISA as a permanent spacer (instead of performing a RA) as our data
mitigates some of the pain associated with cement spacers and re- show that it is effective in curing shoulder infection and provides
stores acceptable shoulder function for activities of daily living, and adequate pain relief and function. Furthermore, in cases of severe
(3) in case where prothesis reimplantation is technically infeasible glenoid destruction where bone reconstruction and/or RSA reim-
because of significant bone loss and in patients who refuse a RA, PISA plantation is technically impossible, PISA can be employed as a
represents a potential salvage option. The sphericity of the implant definitive salvage procedure that allows for resolution of the infection
prevents the need of implant anchorage and provides acceptable and provides acceptable shoulder function (Fig. 3).
shoulder motion for ADLs. Our results suggest that PISA may be an The advantages of using PISA in select patients with recalcitrant
alternative to ACS (avoiding painful glenoid erosion) or RA (avoiding shoulder infections include reduced surgical time (no prosthetic
a flail shoulder with limited motion). stem fixation in the bone is needed) and easy adaptation to the
deformed anatomy of the proximal humerus in case of infected
fracture sequelae compared to ACS.7 The other advantages are, (1)
Table III maintenance of soft-tissue pliability and joint space (avoiding “dead
Radiological results.
space” and postoperative hematoma) with different sizes of im-
Nb % plants, (2) easy explantation in the case of two-stage revision sur-
Glenoid erosion (Sperling classification)31 gery, and (3) less destruction of the articular surface of the glenoid
Grade 1 (No glenoid erosion) 1 9 before revision surgery than the ones observed after ACS retention.
Grade 2 (Mild erosion into sub-chondral 7 64 Of note, an important surgical requirement for the use of PISA is to
bone)
close the glenohumeral joint anteriorly with the remaining soft tis-
Grade 3 (Moderate erosion hemispheric 3 27
deformation with medialization) sues (remnant of capsule and subscapularis tendon) to prevent
Grade 4 (Spherical deformation until/beyond 0 0 implant instability or dislocation. One anterior dislocation occurred
the base of the coracoid) in our series secondary to the patient’s severe deficiency of anterior
Humeral Erosion (Barret classification)2 soft tissues which did not allow for adequate repair.
Grade 1 (GT densification) 2 18
Grade 2 (GT erosion without humeral 4 37
A potential disadvantage of PISA is the absence of elution of
densification) antibiotics inside the shoulder joint, which has been shown to be
Grade 3 (GT thinning) 3 27 helpful curing infection.1 This is the main advantage of ACS,
Grade 4 (Spherical deformation reaching the 2 18 although the amount of antibiotic elution is unknown and remains
lateral cortex)
limited in time and concentration.25 An important benefit of PYC
GT, greater tuberosity. material is its resistance to bacterial adhesion at the smooth surface
171
H. Barret and P. Boileau JSES International 8 (2024) 167e175

Figure 1 Example of a permanent Pyrocarbon spacer in the context of shoulder joint infection in a 49-year-old patient with glenohumeral joint osteoarthritis and previous cuff
repair. He developed shoulder joint infection (multiresistant Staphylococcus) after an infected knee replacement; (A) Preoperative AP radiograph shows glenohumeral joint
bridement and fistula excision, an antibiotic cement spacer was first implanted; however, this implant was too painful for the patient and was
osteoarthritis; (B) After joint de
subsequently revised to a PISA 1 month later; (C) AP radiograph taken 8 years after PISA implantation shows mild stable glenoid erosion but no humeral erosion with bone
densification; (D) At 8 years, the functional result is good with 150 of active forward elevation, little pain (VAS ¼ 2/10), adjusted Constant score of 78%, SSV increased from 20%
preoperatively to 95% at final follow-up. PISA, Pyrocarbon Interposition Shoulder Arthroplasty; SSV, Subjective Shoulder Value; AP, anteroposterior.

of the implant.17 Our data show that PISA can be used in chronic shoulder pain (average VAS: 2.1 points) at final follow-up. This is
infections without increasing the recurrence of infections (despite likely attributable to the range of motion facilitated by such a
multiple previous failed medical and surgical treatments) and smooth implant and the high modulus of elasticity of pyrocarbon
provides acceptable shoulder function. We observed no recurrence (like that of bone and cartilage), making it a “bone and cartilage-
of infection in the 15 patients of our series who underwent PISA friendly material.” Previous in-vitro studies17 have shown that
implantation after surgical de bridement and perioperative anti- PYC coating promotes cartilage-like cell membranes through me-
biotic treatment. In patients with clinical concern for infection with chanical stress which is responsible for reduced friction and
a virulent and drug-resistant bacteria (like methicillin-resistant facilitates bone remodeling.
Staphylococcus aureus), a two-stage approach may be preferred One could argue that handmade stemless spacers created by
with implantation of ACS first followed by implantation of defini- forming a ball of cement, placed into the glenohumeral joint space,
tive PISA 6-8 weeks after (Fig. 2). could play the same role than PISA with the additional advantage of
Another potential disadvantage of PISA is that, like any cement intra-articular elution of antibiotics. Our experience with such kind
spacer, it could lead to painful bone wear or erosion.2 However, on of spherical ACS has been disappointing and we have completely
final radiographs, we observed little or no glenoid erosion and no stopped their use because of significant glenoid and humeral bone
humeral complications even after 8 or 10 years of follow-up (Figs. 1 erosion. In our experience, the glenoid and humeral erosion with
and 2). Our clinical data demonstrate that patients have little or no such “balls of cement” prevent patients to move their shoulder and

Figure 2 Example of permanent Pyrocarbon spacer in the context of periprosthetic joint infection in a 33-year-old lady with a painful and stiff shoulder after failed proximal
humeral fracture fixation and failed stemless hemiarthroplasty. (A) Preoperative AP radiograph shows proud stemless hemiarthroplasty and joint overstuffing; (B) Postoperative AP
radiograph shows PISA in place; infection is confirmed (Cutibacterium Acnes) and perioperative antibiotic treatment is administered; (C) AP radiograph taken 10 years after PISA
implantation demonstrates minimal glenoid and humeral erosion with bone densification; (D) Ten years after Pyrocarbon spacer implantation the functional result is still good with
140 of active forward elevation, no pain (VAS ¼ 1/10), adjusted Constant score of 80%, and SSV of 80%. PISA, Pyrocarbon Interposition Shoulder Arthroplasty; SSV, Subjective
Shoulder Value; VAS, Visual Analog Scale; AP, anteroposterior.

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H. Barret and P. Boileau JSES International 8 (2024) 167e175

Figure 3 Example of salvage Pyrocarbon spacer in the context of periprosthetic joint infection with severe glenoid bone loss and permanent dislocation of hemiarthroplasty. This
69-year old patient was referred to us for a resection-arthroplasty after 4 previous failed surgeries (open Latarjet, hemiarthroplasty, Grammont RSA, and finally conversion of RSA into
HA). She had a persistent infection and complete glenoid destruction despite 2 attempts at reconstruction with iliac crest bone grafts with a stiff and painful shoulder (VAS ¼ 8/10).
(A and B) Preoperative anteroposterior and axillary radiographs show permanent anterior dislocation of the HA with glenoid destruction; (C) Postoperative radiograph demonstrates
PISA implantation after HA removal, joint de bridement, and repair of the remaining soft tissues (subscapularis and capsule); biopsies confirm Cutibacterium acnes infection (5/7
specimens positive) and perioperative antibiotics are tailored and administered; (D-F) 2D and 3D CT-scan, performed 3 years after surgery, demonstrates PISA articulating with the
remaining glenoid and ribs; (G-J); At 3 years, the patient is very satisfied and demonstrates acceptable range of motion with no or little pain (VAS ¼ 1/10); laboratory analysis and bone
scan with marked leukocytes confirm cured infection, and SSV increased from 20% to 65%. PISA, Pyrocarbon Interposition Shoulder Arthroplasty; RSA, reverse shoulder arthroplasty; HA,
hemiarthroplasty; SSV, Subjective Shoulder Value; VAS, Visual Analog Scale; CT, computed tomography.

makes glenoid and humeral reconstruction more difficult and should be balanced by the absence of need for second stage surgery
challenging. and additional hospitalization.
Although the functional results after PISA used as a permanent Our study has several limitations. It is a retrospective single-
spacer are good, they are inferior to those seen after RSA in a two- center case series with a small number of patients. Additionally,
stage strategy. The insufficiency (or absence) of cuff tendons and this is a very heterogeneous population with highly complex SJI and
muscles in these multi-operated and infected shoulders represents PJI, and with variable prior surgeries and antibiotic treatment
one of the limits of PISA. Therefore, in younger and healthy patients, strategies. Furthermore, we did not perform comparative analyses
our preference is to use PISA as a temporary spacer before staging a between PISA and other surgical options such as ACS or RA. Another
revision RSA when it is technically possible (3 cases in our series). weakness of our study is that we did not confirm infection eradi-
Finally, a last argument against the use of PISA for the treatment of cation with aspiration of joint fluid or biopsies. Our assessment was
chronic shoulder infections could be the cost of such implant. based on clinical aspect of the shoulder and on biology with
However, when used as a definitive spacer, the cost of such implant normalization of serum inflammatory markers markers.25 To the

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best of our knowledge, this is the first study to analyze the in- 6. Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C. Proximal humerus
fracture sequelae: impact of a new radiographic classification on arthro-
fectious and functional outcomes of PISA for complex shoulder
plasty. Clin Orthop Relat Res 2006;442:121-30. https://doi.org/10.1097/
infections with or without a history of prior arthroplasty. PJI is a 01.blo.0000195679.87258.6.
rare complication of shoulder arthroplasty and SJI is also infre- 7. Bonnevialle N, Dauze res F, Toulemonde J, Elia F, Laffosse JM, Mansat P. Peri-
quent. No patient was lost of follow-up and our follow-up is long prosthetic shoulder infection: an overview. EFORT Open Rev 2017;2:104-9.
https://doi.org/10.1302/2058-5241.2.160023.
(2-12 years). We made all efforts to trace and follow all patients 8. Braman JP, Sprague M, Bishop J, Lo IK, Lee EW, Flatow EL. The outcome
who underwent a PISA implanted in the context of shoulder of resection shoulder arthroplasty for recalcitrant shoulder infections.
infection We acknowledge that longer follow-up is required to J Shoulder Elbow Surg 2006;15:549-53. https://doi.org/10.1016/j.jse.20
05.11.001.
assess additional glenoid or humeral bone erosion and definitive 9. Conboy VB, Morris RW, Kiss J, Carr AJ. An evaluation of the Constant-Murley
cure of infection. shoulder assessment. J Bone Joint Surg Br 1996;78:229-32.
10. Coste JS, Reig S, Trojani C, Berg M, Walch G, Boileau P. The management
of infection in arthroplasty of the shoulder. J Bone Joint Surg Br 2004;86:
Conclusion 65-9.
11. Cronin KJ, Hayes CB, Sajadi KR. Antibiotic cement spacer retention for chronic
In the context of chronic shoulder joint infection or prosthetic shoulder infection after minimum 2-year follow-up. J Shoulder Elbow Surg
2020;29:e325-9. https://doi.org/10.1016/j.jse.2020.01.065.
joint infection, PISA may be an alternative to ACS (avoiding painful 12. Dilisio MF, Miller LR, Warner JJ, Higgins LD. Arthroscopic tissue culture for the
glenoid erosion) or RA (avoiding a flail shoulder with limited mo- evaluation of periprosthetic shoulder infection. J Bone Joint Surg Am 2014;96:
tion). Our data suggest that, after eradication of shoulder joint 1952-8. https://doi.org/10.2106/JBJS.M.01512.
bridement and antibiotics, the use of 13. Duncan SF, Sperling JW. Treatment of primary isolated shoulder sepsis in the
infection with washout, de
adult patient. Clin Orthop Relat Res 2008;466:1392-6. https://doi.org/10.1007/
PISA, as a spacer, is effective and presents the following advantages: s11999-008-0213-8.
(1) PISA does not seem to be a risk for recurrent infection, thanks to 14. Frangiamore SJ, Saleh A, Grosso MJ, Alolabi B, Bauer TW, Iannotti JP, et al. Early
the antibacterial property of pyrocarbon which prevents germ versus late culture growth of propionibacterium acnes in revision shoulder
arthroplasty. J Bone Joint Surg Am 2015;97:1149-58. https://doi.org/10.2106/
adhesion; (2) PISA can be used as a temporary or a definitive spacer JBJS.N.00881.
without causing glenoid or humeral bone erosion, thanks to the low 15. Garret J, Godeneche A, Boileau P, Mole  D, Etzner M, Favard L, et al. Pyrocarbon
modulus of elasticity of pyrocarbon; (3) PISA can be used as a interposition shoulder arthroplasty: preliminary results from a prospective
multicenter study at 2 years of follow-up. J Shoulder Elbow Surg 2017;26:
salvage procedure in case of complete glenoid or humeral 1143-51. https://doi.org/10.1016/j.jse.2017.01.002.
destruction without possibility of surgical reconstruction, thanks to 16. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the
the sphericity of the implant needing no implant anchorage. constant score. J Shoulder Elbow Surg 2007;16:717-21. https://doi.org/
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17. Hannoun A, Ouenzerfi G, Brizuela L, Mebarek S, Bougault C, Hassler M, et al.
Acknowledgment Pyrocarbon versus cobalt-chromium in the context of spherical interposition
implants: an in vitro study on cultured chondrocytes. Eur Cell Mater 2019;37:
1-15. https://doi.org/10.22203/eCM.v037a01.
The authors wish to thank Ethan Harlow, MD for his pertinent 18. Hudek R, Werner B, Abdelkawi AF, Gohlke F. Pyrocarbon interposition shoulder
questions and help to correct the manuscript. arthroplasty in advanced collapse of the humeral head. Orthopade 2017;46:
1034-44. https://doi.org/10.1007/s00132-017-3495-2.
19. Jacquot A, Sirveaux F, Roche O, Favard L, Clavert P, Mole  D. Surgical manage-
Disclaimers:
ment of the infected reversed shoulder arthroplasty: a French multicenter
study of reoperation in 32 patients. J Shoulder Elbow Surg 2015;24:1713-22.
Funding: No funding was disclosed by the authors. https://doi.org/10.1016/j.jse.2015.03.007.
Conflict of interest: Pascal Boileau declares Tornier-Stryker consul- 20. Klatte TO, Junghans K, Al-Khateeb H, Rueger JM, Gehrke T, Kendoff D, et al.
Single-stage revision for peri-prosthetic shoulder infection: outcomes and re-
tancy in relation to the subject of the present work. The other author, sults. Bone Joint J 2013;95-B:391-5. https://doi.org/10.1302/0301-
his immediate family, and any research foundations with which he is 620X.95B3.30134.
affiliated have not received any financial payments or other benefits 21. Lee DK, Rhee SM, Jeong HY, Ro K, Jeon YS, Rhee YG. Treatment of acute
shoulder infection: can osseous lesion be a rudder in guideline for determining
from any commercial entity related to the subject of this article. the method of debridement? J Shoulder Elbow Surg 2019;28:2317-25. https://
doi.org/10.1016/j.jse.2019.05.010.
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