Infection following primary rotator cuff repair — Prophylaxis, diagnosis, and management — an international expert Delphi consensus statement

Background: The purpose of this study was to establish consensus statements on the diagnosis, prophylaxis, and treatment of infections following primary rotator cuff repair (RCR). Methods: A Delphi consensus process on the diagnosis, prophylaxis, and treatment of infections following primary RCR was conducted with 56 shoulder/sports surgeons from North America and Europe with at least 10 years of experience in RCR. Consensus was defined as achieving 80-89% agreement, whereas strong consensus was defined as 90-99% agreement, and unanimous consensus was indicated by 100% agreement with a proposed statement. Results: A total of 32 statements were evaluated. Regarding diagnosis, consensus outcomes included 1 unanimous, 4 strong consensus, 2 consensus, and 3 statements without consensus. For prophylaxis, 2 statements reached strong consensus, 1 reached consensus, and 2 did not achieve consensus. In acute infection management, 5 statements reached strong consensus, 1 reached consensus, and 2 did not reach consensus. For chronic infection management, 4 statements achieved strong consensus, 2 reached consensus, and 1 did not achieve consensus. Regarding negative versus positive cultures, 3 statements reached strong consensus and 1 reached consensus. For staged revision procedures, 2 statements reached consensus. Conclusion: This international Delphi study achieved strong consensus or consensus on most aspects of infection management following primary RCR, including diagnostic signs, laboratory tests, imaging, preferred prophylaxis with a single pre-operative IV dose of cefazolin, and surgical approach for acute and chronic infections. Strong consensus supported empiric treatment of culture-negative pathogens, withholding antibiotics until cultures are obtained when feasible and delaying revision 6-12 weeks after antibiotic treatment completion. Areas without consensus included surgical management in acute infection with high virulence organisms using a staged procedure, attempting hardware retention in chronic infections even with low virulence organisms, the routine use of vancomycin powder in RCR, and pre-operative oral antibiotics as a method of prophylaxis.