Periprosthetic joint infections are serious complications of shoulder arthroplasty, occurring in about 1.1% of cases overall and as high as 10% in young men [1]. They are costly to the health care system and can be disastrous for the patient. As a result, surgeons adopt a range of prevention measures. Five act on the operating field: electrocautery skin incision, adhesive antimicrobial drapes, laminar flow, body-exhaust suits, and glove changes. Four act on the patient or the organism: optimizing modifiable patient risk, preparing the skin, timely administration of cefazolin, and applying antiseptics or antibiotics in the wound. The assumption is that if a measure lowers the number of bacteria in the air, on the skin, or at the wound, it should lower the rate of infections.
This post applies one test to all nine: has the measure been shown to reduce infection after shoulder arthroplasty, or only to change something on the way there? A trial powered to show a difference in infection itself would have to be very large, and none has been done in the shoulder for any of the nine. The published studies therefore report surrogate measures — colony-forming units in the air, cultures taken from the skin or the incised dermis, contamination of gloves and gowns — or associations observed in cohorts.
These measures are meant to prevent an infection, so it is worth asking what an infection costs. About 193,500 shoulder arthroplasties were performed in the United States in 2022 [12] with an infection rate of about 1.1% [1], that is at least 2,100 infections a year. National inpatient data put total hospital charges for shoulder periprosthetic joint infection at $190.3 million in 2018, up from $44.8 million in 2011, with a projection of about $460 million a year by 2030 [11]. Charges are what hospitals list, not what anyone pays, so the real figure may be below that.
These numbers count only hospital dollars, they do not include professional fees, revision surgeries, the months of antibiotics, the work days lost and the long term loss of the patient's shoulder comfort and function.
It is apparent that an ounce of prevention is worth a pound of cure. Inexpensive and safe measures merit consideration even in the absence of evidence that they lower infection rates. Absence of evidence is not evidence of absence.
Measures that act on the operating field
A 2026 review of infection prevention in primary shoulder arthroplasty describes the higher-level evidence for these intraoperative techniques as limited or conflicting [2].
Electrocautery skin incision
This has the most direct evidence of the five. In a prospective randomized trial in primary shoulder arthroplasty, incising the skin with electrocautery produced no positive C. acnes cultures at the incised dermis, compared with 25% (8 of 32) after scalpel incision (P < .001) [3]. Cultures of gloves and forceps were positive at similar rates in both groups, so a dermal source of organisms persisted whichever instrument was used. All positive cultures came from male patients.
Cautery is inexpensive and the rationale is apparent. Whether it reduces infection has not yet been shown. Reviews of total joint arthroplasty add a caution: extensive use of cautery produces necrotic tissue, which may itself contribute to infection [4].
Adhesive antimicrobial drapes
A Level I systematic review and meta-analysis of orthopaedic randomized trials found less wound contamination with adhesive drapes (OR 0.49, 95% CI 0.34–0.72) [5]. The trials that reported infection had no infections in either arm, so the effect on surgical site infection could not be determined. Where the drape peeled back at the wound edge, contamination increased. Neither the WHO nor the CDC endorses their routine use [4,5].
Laminar flow and localized air-barrier devices
A double-blinded randomized trial in shoulder arthroplasty showed fewer colony-forming units above the wound with a localized laminar-flow device [6]. No infections occurred in either group at a year or more of follow-up. In the wider arthroplasty literature, the reduction in airborne bacteria has not been accompanied by a reduction in infection; a large comparison of operating rooms with and without laminar flow found no difference in periprosthetic joint infection, and the WHO recommends against laminar airflow on the basis of low-quality evidence [4]. This is the most expensive item on the list, in capital and in maintenance, and its cost-effectiveness remains debated [4].
Space suits and body-exhaust suits
Their use is controversial and their efficacy is not universally supported [4]. There is no shoulder-specific evidence of a reduction in infection, and registry data from hip and knee arthroplasty have suggested no benefit and, in some analyses, possible harm [4].
Glove changes and double gloving
Gloves and gowns become contaminated as an operation proceeds, and both double gloving and periodic intraoperative glove changes are recommended in total joint arthroplasty to reduce that contamination [4]. The shoulder finding that gloves and forceps culture positive for C. acnes even after electrocautery incision supports changing gloves before the components are handled [3]. The effect on infection has not been measured in the shoulder. This measure costs very little.
Measures that act on the patient or the organism
These four are often described as having the strongest support in shoulder arthroplasty [2,7]. None of them requires a substantial expense. Again, evidence that they change infection rate is lacking.
Modifiable patient risk
Modifiable patient risk has consistent associations in shoulder patients. In a national database of shoulder arthroplasty, patients with diabetes had more deep infections requiring surgery than patients without diabetes (0.7% vs 0.4%), and the risk was higher with a perioperative hemoglobin A1c above about 8% [15]. A systematic review of seven studies and 87,820 patients found that a corticosteroid injection within three months before arthroplasty carried about twice the infection risk of no injection (risk ratio 2.30), while an injection three to twelve months before surgery was not associated with added risk (risk ratio 0.89) [16]. These are associations. No trial has shown that lowering a hemoglobin A1c, or waiting out an injection, lowers the infection rate.
Nutrition is the most often cited of these risks, and the association is real. In the NSQIP total shoulder arthroplasty cohort, patients with a preoperative albumin below 3.5 g/dL had more complications, longer hospital stays, and higher 30-day mortality than patients with normal albumin [8]. Malnutrition by that definition is not rare in the shoulder: 19.5% of primary and 36.6% of revision arthroplasty patients in a two-center series [9]. In hip and knee arthroplasty, pooled data put the odds of surgical site infection at 2.60 (95% CI 2.10–3.10) and of periprosthetic joint infection at 3.44 (95% CI 2.35–4.53) in malnourished patients [10].
However, no trial has shown that raising a low albumin lowers the infection rate, in the shoulder or elsewhere. Albumin falls in inflammation, renal loss, hepatic disease, and frailty as readily as in undernutrition, so it may be identifying the patient at risk rather than the mechanism of the risk. The screening costs a blood draw that is often already being sent. Acting on the result is inexpensive and reasonable even though we do not have robust data that this would lower infection risk.
Skin preparation
Skin preparation has randomized trials, but their endpoint is a culture. Benzoyl peroxide applied for three days before surgery reduced C. acnes on the skin of the shoulder more than chlorhexidine did [17]. In a randomized trial in shoulder arthroplasty patients, however, neither a chlorhexidine wash nor benzoyl peroxide soap removed Cutibacterium from the skin [18]. The organism lives in the sebaceous glands of the dermis, beneath the reach of an agent applied to the surface. The surrogate itself is in question as well: among 134 primary shoulder arthroplasties with cultures taken by a standard protocol, positive cultures did not appear to affect function or the need for further surgery in the short term [19]. On the evidence, skin preparation sits with electrocautery incision: it lowers a count, and its effect on infection has not been measured. Like glove changes, it is inexpensive.
Cefazolin at the correct time
Cefazolin is the only one of the nine with infection in shoulder patients as its endpoint. In 7,713 primary shoulder arthroplasties at one institution with at least two years of follow-up, cefazolin was associated with a 69% lower risk of infection and a 78% lower risk of C. acnes infection than the alternatives; compared with cefazolin, the hazard ratio for infection was 2.32 with vancomycin and 5.07 with clindamycin [20]. A second health-system cohort of 7,140 shoulder arthroplasties found the same for clindamycin (hazard ratio 3.45) but no difference for vancomycin (hazard ratio 1.17, 95% CI 0.42–3.30) [21]. When vancomycin is used, incomplete infusion by the time of incision has been associated with more infectious complications [22].
The correct time is within 60 minutes before incision, at a weight-based dose (2 g, or 3 g for patients weighing 120 kg or more), repeated if the operation runs past four hours; vancomycin, which must be infused slowly, is started within 120 minutes before incision [23]. The cefazolin cohorts are observational, and patients who receive an alternative, often because of a reported penicillin allergy, may differ from those who do not. Even so, the endpoint is infection and the patients had shoulder arthroplasties.
Dilute betadine lavage and vancomycin powder
These topical agents have infection as their endpoint, but mostly in the hip and knee. In a randomized trial of 457 aseptic hip and knee revisions, a three-minute 0.35% betadine lavage before closure was followed by fewer acute infections than saline (0.4% vs 3.4%), in a sample smaller than the authors’ own power calculation called for [24]. The largest trial since then randomized 2,053 high-risk primary hip and knee arthroplasties at 17 centers to vancomycin powder, dilute povidone-iodine, both, or saline, and found no significant difference in infection at three months or at one year [25]. In the shoulder, the evidence is one retrospective cohort: 422 arthroplasties with vancomycin powder in a collagen sponge had no infections, against 3.2% in 405 control patients [26]. However, a retrospective comparison cannot separate the powder from whatever else differed between the groups.
The nine measures side by side
Measure | Best evidence and endpoint | Effect on the surrogate | Effect on infection | Cost |
Electrocautery skin incision [3] | Shoulder RCT (n = 64), culture of the incised dermis | 0% vs 25% positive for C. acnes | Not shown; gloves and forceps positive in both groups | Low |
Adhesive antimicrobial drapes [5] | Level I meta-analysis, wound contamination | OR 0.49 (0.34–0.72) | Indeterminate — no infections in either arm | Moderate |
Laminar flow or air-barrier device [4,6] | Shoulder RCT, airborne colony-forming units | Significant reduction above the wound | Not shown; WHO recommends against laminar airflow | High capital and maintenance |
Space or body-exhaust suits [4] | Reviews of arthroplasty registry data | Uncertain | Not supported; some data suggest possible harm | High |
Glove changes, double gloving [3,4] | Arthroplasty reviews, glove and gown contamination | Reduces contamination | Not measured in the shoulder | Low |
Modifiable patient risk: glycemic control, injection timing, nutrition [8–10,15,16] | Shoulder database cohorts and systematic reviews, infection | Not applicable | Risk factors associated with infection; no trial of modifying them | Low |
Skin preparation: benzoyl peroxide, chlorhexidine [17–19] | Shoulder RCTs, skin culture | Benzoyl peroxide lowers surface C. acnes more than chlorhexidine; neither clears it from the skin | Not measured; positive cultures not shown to predict outcome | Low |
Cefazolin at the correct time [20–23] | Shoulder cohorts (7,713 and 7,140), infection | Not applicable | Associated with fewer infections than alternative antibiotics | Low |
Dilute betadine lavage, vancomycin powder [24–26] | Hip and knee RCTs; one retrospective shoulder cohort, infection | Not applicable | No difference in the largest hip and knee RCT; no prospective shoulder data | Low |
Of the nine measures, one — cefazolin given at the right time — has been associated with fewer infections in shoulder patients. The other eight rest on bacterial counts, on associations, or on data from other joints.
This review suggests that inexpensive, safe measures merit consideration for infection prophylaxis, even if they've not been proven to lower infection rate: cautery for incision, a change of gloves, and the four measures that act on the patient or the organism [2,3,4].
The two environmental controls (laminar flow and space suits) carry a high cost; the case for their use requires more robust data supporting their value [4,6].
My attempts to reduce the risk of periprosthetic infections include patient health optimization preoperatively (nutrition, glycemic control, avoiding injections within 3 months of surgery), timely intravenous administration of cephalosporin antibiotics, chlorhexidine skin preparation, adhesive drapes, electrocautery for the skin incision, double gloving with glove change when handling implants, Betadine and saline lavage, and topical vancomycin. I do not use laminar flow or space suits.
Looking for more evidence on infection prevention
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References
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