Septic conditions of the shoulder--an up-dating of treatment strategies.

We report the cases of 28 patients with bacterial infections of the shoulder treated between 1979 and 1991. There were ten cases of septic arthritis, ten cases of simple osteomyelitis of the proximal humerus, four cases of septic arthritis and concomitant osteomyelitis of the proximal humerus and four cases of periarticular soft-tissue infection. The infections, except for the cases of osteomyelitis, were staged by a "Classification of Exogenic Bacterial Infections" (CEBI). In septic arthritis and in periarticular soft-tissue infection, the time between the initial symptoms of infection and diagnosis was about 20 days. In the cases with osteomyelitis, there was an average delay of 9 months, which was partly due to the slow evolution of plasmacellular osteomyelitis. Treatment was based on operative debridement and arthrotomy, the insertion of drains, the implantation of gentamicin-polymethylmethacrylate beads and the application of high-dose parenteral antibiotics. In the postoperative period physiotherapy with early active and/or passive range-of-motion exercises favoured the draining of secretions and therefore gave better results than complete immobilisation. Treatment was evaluated using a modification of the shoulder score of Wülker et al. [17]. This study demonstrated that favourable results could only be obtained if the diagnosis was made early. This is particularly true for infections with Staphylococcus aureus (found in 19 patients). The overall result of the treatment of osteomyelitis and periarticular soft-tissue infection was good or satisfactory, while unsatisfactory results were noted for the patients with septic arthritis, particularly those with both septic arthritis and osteomyelitis.