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Editorial Commentary: An Alternative to Opioids? Adhesive Drapes and Chlorhexidine Skin Preparation May Reduce Propionibacterium acnes–Related Pain After Shoulder Surgery

      Abstract

      Propionibacterium acnes has long been known to play a detrimental role in shoulder surgery. This thoughtful and revealing study found significant evidence of lower rates of P. acnes cultured during arthroscopic rotator cuff repair with the use of an adhesive drape and chlorhexidine skin preparation.
      Propionibacterium acnes has long been known to play a detrimental role in shoulder surgery. In Dr. Yamakado's thoughtful and revealing study “Propionibacterium acnes Suture Contamination in Arthroscopic Rotator Cuff Repair: A Prospective Randomized Study,”
      • Yamakado K.
      Propionibacterium acnes suture contamination in arthroscopic rotator cuff repair: A prospective randomized study.
      there is significant evidence of lower rates of P. acnes cultured during arthroscopic rotator cuff repair with the use of an adhesive drape and chlorhexidine skin preparation. The study is a randomized controlled study of povidone-iodine versus chlorhexidine skin preparation with and without the use of an adhesive drape; P. acnes was cultured from the sutures used in rotator cuff repairs. The chlorhexidine preparation with an adhesive drape yielded a significant decrease in the rate of culture of P. acnes compared with the other groups.
      P. acnes has also shown up in other unexpected places. It has been cultured from native shoulders during primary total shoulder arthroplasty in patients without prior surgery or injections.
      • Levy O.
      • Iyer S.
      • Atoun E.
      • et al.
      Propionibacterium acnes: An underestimated etiology in the pathogenesis of osteoarthritis?.
      In addition, P. acnes has been cultured in revision rotator cuff surgery performed for pain and stiffness,
      • Horneff R.
      • Hsu J.
      • Voleti P.
      • O’Donnell J.
      • Huffman R.
      Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain.
      which makes me think that indolent infection may be what I am seeing in some of my patients with unexpected postoperative pain. In patients with herniated nucleus pulposis, P. acnes has been cultured from the disc material removed from surgically naive backs.
      • Albert H.
      • Lambert P.
      • Rollason J.
      • et al.
      Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae?.
      Our spine colleagues went one step further,
      • Albert H.
      • Sorensen J.
      • Christensen B.
      • Manniche C.
      Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): A double-blind randomized controlled trial of efficacy.
      and in a double-blind randomized controlled study administered antibiotics versus placebo, reducing chronic back pain from herniated discs; the antibiotic group improved in measures both objective and subjective, beyond the shadow of statistical doubt, for more than 1 year after initiating therapy.
      In viewing the current study by Dr. Yamakado, we should look at the use of an adhesive drape and chlorhexidine skin preparation not just as a way to prevent the introduction of a commensal low-virulence organism,
      • Hudek R.
      • Sommer F.
      • Kerwat M.
      • Abdelkawi A.
      • Loos F.
      • Gohlke F.
      Propionibacterium acnes in shoulder surgery: True infection, contamination or commensal of the deep tissue?.
      but more importantly as a way to keep patients safe from a bacterium capable of inflicting chronic pain and disability. I often wonder why some of my patients require minimal narcotics for their shoulder surgeries while others request opioids for a suspiciously long time. I have always attributed this difference in opioid use to ranges of pain tolerance, but now I consider indolent infection as a potential culprit. In shoulder arthroplasty, the focus on P. acnes is keen, but now we have to have similar vigilance in our rotator cuff repairs. The trick will be ferreting out who would benefit from antibiotics to treat an underlying P. acnes infection rather than managing chronic pain with opioids.

      Supplementary Data

      References

        • Yamakado K.
        Propionibacterium acnes suture contamination in arthroscopic rotator cuff repair: A prospective randomized study.
        Arthroscopy. 2018; 34: 1151-1155
        • Levy O.
        • Iyer S.
        • Atoun E.
        • et al.
        Propionibacterium acnes: An underestimated etiology in the pathogenesis of osteoarthritis?.
        J Shoulder Elbow Surg. 2013; 22: 505-511
        • Horneff R.
        • Hsu J.
        • Voleti P.
        • O’Donnell J.
        • Huffman R.
        Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain.
        J Shoulder Elbow Surg. 2015; 24: 838-843
        • Albert H.
        • Lambert P.
        • Rollason J.
        • et al.
        Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae?.
        Eur Spine J. 2013; 22: 690-696
        • Albert H.
        • Sorensen J.
        • Christensen B.
        • Manniche C.
        Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): A double-blind randomized controlled trial of efficacy.
        Eur Spine J. 2013; 22: 697-707
        • Hudek R.
        • Sommer F.
        • Kerwat M.
        • Abdelkawi A.
        • Loos F.
        • Gohlke F.
        Propionibacterium acnes in shoulder surgery: True infection, contamination or commensal of the deep tissue?.
        J Shoulder Elbow Surg. 2014; 23: 1763-1771

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