Periprosthetic infection is one of the most frequent complications of reverse total shoulder arthroplasty - what is relationship of PJI to prior surgery?

Periprosthetic infection (PJI) is one of the most common and most serious reasons for failure of reverse total shoulder arthroplasty (RSA). When adjusted for age, sex, and indication, the risk of revision for  PJI after RSA (3.1%) is 2.4 times higher than after anatomic TSA. A possible contributing factor to this difference is the observation that patients having primary RSA are more likely to have had prior surgery than those having primary TSA.

Using the Danish Shoulder Arthroplasty Registry records of 2217 patients having RSA, the authors of Previous rotator cuff repair increases the risk of revision surgery for periprosthetic joint infection after reverse shoulder arthroplasty sought to determine the relationship between previous non-arthroplasty surgery and PJI after RSA performed for cuff tear arthropathy, massive irreparable rotator cuff tears, or osteoarthritis.

Patients were grouped as (1) having had a rotator cuff repair prior to their RSA, (2) having prior surgery other than cuff repair (such as subacromial decompression and/or AC joint resection), and (3) having no surgery prior to their RSA,

The fourteen-year cumulative rate of revision for different types of previous non-arthroplasty surgery are shown below. 

The cumulative RSA revision rate for shoulders with prior rotator cuff repair was 21.4% at 14 years. 

The cumulative rates for RSA after other types of prior non-arthroplasty surgery was 6.8% at 14 years. The cumulative rates for RSA with no prior surgery was 5.9% at 14 years.



PJI was defined as 3 of 5 tissue samples positive for the same bacteria or as definite or probable PJI evaluated based on criteria from the International Consensus Meeting.

Revision was performed in 88 shoulders (4.0%), of which almost half (40) had PJI.

There were 272 patients (12.3%) who had undergone previous rotator cuff repair, 11 (4.0%) of these had revision for PJI.

Fourteen-year cumulative rate of revision owing for periprosthetic joint infection (PJI)  for different types of previous non-arthroplasty surgery are shown below. 

The cumulative rate of revision for PJI for patients having prior rotator cuff repair was 14.1% at 14 years. 

The cumulative rate for others types of prior surgery was 2.1% at 14 years which was essentially the same as the cumulative rate for shoulders with no prior surgery was 2.7% at 14 years.

The bacteria identified at revision surgery were predominantly Cutibacterium - notably not only C. acnes.

Comment: It is of great interest and significance that the rate of revision for those shoulders with prior cuff repair continued to increase with time after RSA in contrast to the rates for shoulders having no prior surgery or prior surgery other than cuff repair. This finding points to the delayed onset of clinical manifestations of Cutibacterium infection noted by the authors of Substantial cultures of Propionibacterium can be found in apparently aseptic shoulders revised three years or more after the index arthroplasty

While the reasons for the increased risk of RSA PJI after cuff repair in comparison to procedures such as acromioclavicular arthroplasty and acromioplasty are not elucidated in this study, it is possible that the insertion of suture anchors and multiple non-dissolvable sutures may introduce bacteria into the shoulder - especially if the sutures have been in contact with the patient's skin.

Previous authors have noted the adverse effect of prior cuff repair on RSA outcomes. For example, in Failed Prior Rotator Cuff Repair Is Associated with Worse Clinical Outcomes After Reverse Total Shoulder Arthroplasty the authors sought to determine the comparative risk profile and clinical outcomes for patients undergoing reverse total shoulder arthroplasty (RSA) for cuff tear arthropathy (CTA) without failed prior rotator cuff repair (RCR) compared to RSA for CTA with prior RCR. The prior RCR group had a significantly higher complication rate (17.4%, n=15) than the primary RSA group (3.8%, n=4) (p=0.001).

At mean 36.3±26.1-month follow-up, the prior RCR group had statistically worse SST scores, ASES scores, and active forward elevation.




This study points out that prior cuff repair attempts can jeopardize the safety and outcome of reverse total shoulder. While not discussed in the manuscript, it seems likely that acromioplasty and section of the coracoacromial ligament - both often performed at the time of attempted cuff repair - may both contribute to instability and weaken the acromion, making it more susceptible to fracture. Prior surgery of any type may increase the risk of infection. Instability, fracture and infection can lead to revision of a failed reverse total shoulder.

Infection (including those that are not clinically obvious) is a cause of failure of cuff repair (see for example Mid- to Long-Term Outcomes After Deep Infections After Arthroscopic Rotator Cuff Repair and Postoperative deep shoulder infections following rotator cuff repair).

So, how might all of this change our practice? Here are some thoughts:

(1) a the time of cuff repair (and other surgical procedures) avoid contact of tagging and repair sutures with the patient's skin

(2) when evaluating a patient with a failed cuff repair, consider the possibility of an occult infection

(3) when performing a reverse total shoulder for a failed cuff repair consider

    (a) submitting deep specimens for culture for Cutibacterium

    (b) using extraordinary prophylactic measures, such as Betadine irrigation, topical antibiotics and post-operative antibiotics at least until the results of the intraoperative cultures are final at two weeks.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Does prior surgery affect the outcome of shoulder arthroplasty?

 Impact of previous non-arthroplasty surgery on clinical outcomes after primary anatomic shoulder arthroplasty

These authors asked two questions: 

(1) To what degree isprimary anatomic shoulder arthroplasty after prior non-arthroplasty surgery associated with inferior clinical outcomes and higher revision rates compared with arthroplasty without previous surgery? 

(2) Does type, approach, or timing of previous surgery affect outcomes after anatomic arthroplasty?

They analyzed  640 patients undergoing anatomic shoulder arthroplasty (345 TSAs and 295 ream-and-run arthroplasties). Of these patients, 183 (29%) underwent previous non-arthroplasty surgery. 

In patients undergoing TSA, previous non-arthroplasty surgery was associated with a significantly lower 2-year Simple ShoulderTest (SST) score, percentage maximum possible improvement  (MPI), and Single Assessment Numeric Evaluation (SANE) score and a higher rate of reoperation. 

The risk of reoperation was significantly higher (hazard ratio [HR], 20.79; 95% confidence interval [CI],

4.65-93.00; P < .001) in the previous surgery group.In the group with prior surgery, 2 patients underwent revision surgery for stiffness with downsizing of the humeral head component and 5 underwent revision for softtissue failure (rotator cuff or biceps). In the group without prior surgery, 1 patient underwent single-stage component exchange for suspected infection and 1 underwent revision because of rotator cuff failure.

In patients undergoing ream-and-run arthroplasty, these associations were present but were not statistically significant.In addition, the rates of MUA (7% vs. 7%, P . .911) and open revision (8% vs. 12%, P .340) were similar between groups. In the group with prior surgery, 3 patients underwent open release for stiffness, 5 underwent downsizing of the humeral head, 3 underwent single-stage exchange for suspected infection, and 1 underwent revision owing to rotator cuff failure. In the group without previous surgery, 1 patient underwent open release for stiffness, 8 underwent

downsizing of the humeral head, 2 underwent single-stage exchange for suspected infection, 1 underwent revision to TSA because of symptomatic glenoid wear, and 1 underwent revision surgery at an outside hospital for an unknown reason.

Among TSA and ream-and-run arthroplasty cases with prior non-arthroplasty surgery, prior fracture surgery carried the highest risk of revision (HR, 5.34; 95% CI, 0.96-29.61; P .055).

Comment: While this study does show a negative impact of prior non-arthroplasty surgery on the outcomes of TSA and RnR, it is reassuring that substantial gains in comfort and function can be realized in with these procedures for patients with previous surgery.

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What is the effect of prior surgery on shoulder arthroplasty outcomes?

Impact of previous non-arthroplasty surgery on clinical outcomes after primary anatomic shoulder arthroplasty

These authors sought to determine the effect of previous non-arthroplasty surgery prior to primary anatomic shoulder arthroplasty. They conducted a review 640 patients undergoing anatomic shoulder arthroplasty (345 total shoulders and 295 ream-and-run arthroplasties). Of these patients, 183 (29%) had previous non-arthroplasty surgery.

They found that among patients undergoing total shoulder arthroplasty, previous non-arthroplasty surgery was associated with a significantly lower 2-year Simple Shoulder Test (SST) scores, percentages of maximum possible improvement (MPI), and Single Assessment Numeric Evaluation (SANE) scores (P <.001) and higher rates of reoperation. 

In patients undergoing ream-and-run arthroplasty, previous non-arthroplasty surgery was associated with insignificantly lower 2-year SST scores, percentages of MPI, and SANE scores and higher reoperation rates.

Prior fracture surgery carried a higher risk of reoperation than other types of prior surgery (e.g. rotator cuff repair and instability surgery). 

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Comment: This study shows that good clinical outcomes can be achieved with the ream and run procedure and with total shoulder arthroplasty, even in shoulders that have had prior surgery.

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Shoulder arthroplasty after prior anterior stabilization procedures

Shoulder arthroplasty after prior anterior stabilization procedures: do reverses have better outcomes?

These authors compared the outcomes of 15 total shoulder arthroplasties (TSA) and 10 reverse total shoulder arthroplasties (RTSA)  after anterior stabilization surgical procedures. The TSA group’s mean age at surgery was 54.9 years, with an average follow-up period of 4.0 years. The RTSA group’s mean age was 65.4 years, with an average followup period of 3.3 years.

In the TSA group, 4 patients underwent prior bony procedures (27%), all of which were Bristow procedures. One underwent multiple other non-arthroplasty shoulder surgical procedures, and another underwent 4 previous arthroscopic surgical procedures. The remaining 11 patients underwent previous soft-tissue procedures that included the following: 7 with arthroscopic anterior labral repairs and 4 with open anterior capsular reconstructions.

In the RTSA group, 4 prior bony procedures (40%) were performed: 3 were Bristow procedures (1 patient also underwent a prior open rotator cuff repair) and 1 was a glenoid osteotomy. The remaining 6 patients underwent previous softtissue procedures that included the following: 3 with open anterior labral and capsular repairs (one of these with a total of 3 open reconstructive procedures), 2 with arthroscopic labral repairs, and 1 with a thermal capsulorrhaphy for instability with rotator cuff repair in the same setting. 

In the TSA group, all the subscapularis tendons were deemed of adequate quality in the operative reports.
In the RTSA group, 3 subscapularis tendons were intact, 3 were poor quality, 2 were scarred, and 1 was deficient; in 1 case, the tendon quality was not recorded in the operative report. The intact subscapularis tendons were repaired. One of the poor-quality tendons and one of the scarred tendons were repaired using suture. The remaining subscapularis tendons were left as tenotomies.

In the TSA group the rotator cuff tendons were documented as being of adequate quality in all patients.
In the RTSA group, the supraspinatus was intact in 2, partially torn or poor quality in 3, and absent (or with a full-thickness tear) in 4. The infraspinatus was intact in 5, poor quality in 1, and absent (or with a full-thickness tear) in 3. The teres minor was intact in 6, partially torn or poor quality in 2, and absent in 1. 

The Simple Shoulder Test scores improved from averages of 3.9 to 8.9 in the TSA group and from 3.4 to 11.2 in the RTSA group. 

There were no complications or re operations in the RTSA group. TSA patients had a 33% complication rate and a 20% reoperation rate. 2 TSA patients underwent revision to RTSA. One TSA was converted to RTSA after aseptic glenoid loosening, and one was converted to RTSA because of subsequent rotator cuff failure. One TSA patient had a dislocation, which was treated with closed reduction and did not require further surgery. 

Comment: Glenohumeral arthritis developing after prior surgery for anterior instability - "capsulorrhaphy arthropathy" - can be complicated by subscapularis, rotator cuff, glenoid bone deficiencies, and residual glenoid hardware. Each of these factors can complicate the surgeon's ability to achieve solid glenoid component fixation and a stable anatomic arthroplasty. It is of interest that the surgeons elected TSA in patients a decade younger than those having RTSA. The soft tissues were more compromised in the RTSA group.

Even though this is a small case series of patients that are dissimilar in some important ways, it does point out the challenges of attempting an anatomic TSA and the potential benefit of the RTSA in managing the complex pathology of arthritis after a prior instability repair.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

What is the effect of prior surgery on shoulder arthroplasty outcomes?

Shoulder Arthroplasty Outcomes After Prior Non-Arthroplasty Shoulder Surgery

These authors compared the outcomes and complications in patients with and without a history of non-arthroplasty surgery prior to total shoulder arthroplasty (TSA, n=263) or reverse total shoulder arthroplasty (RTSA, n=243). 

144 patients (28%) had an average of 1.9 ± 1.0 surgical procedures on the ipsilateral shoulder before arthroplasty. There were significant differences in age, BMI, smoking, and type of insurance between the two groups.

At an average follow-up of 42.8 ± 16.4 months, both groups had significant improvements in ASES, SST, VAS, and range-of-motion values. While both groups had preoperative SSTs of 3.5, the postoperative SST was 9.3 in the non-prior surgery group and 7.7 in the prior surgery group.

Postoperative complications were over four times as common in the prior surgery group.

Multivariate regression analysis revealed that prior surgery was a significant independent predictor of postoperative complications. 

Comment: This paper demonstrates that prior ipsilateral shoulder surgery is risk factor for a suboptimal outcome from shoulder arthroplasty. There may be several reasons for this finding: (1) the presence of prior surgery may indicate more complex shoulder pathology, (2) the prior procedure may have altered the surgical anatomy, making the arthroplasty more complex, (3) the failure of a prior procedure to resolve the patient's problem may indicate that the patient has diminished pain tolerance, motivation, or compliance (note, for example the 10 fold greater rate of workers' compensation and the 4 fold increase of smoking in the prior surgery group), and (4) even though it was not noted in this study, prior surgery can be expected to increase the risk of Propionibacterium contamination, which may present as pain and stiffness, rather than clinically apparent infection.

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Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Previous surgery increases the risk of shoulder replacement

Shoulder Arthroplasty Outcomes After Prior Non-Arthroplasty Shoulder Surgery

These authors compared the outcomes and complications in 506 patients with and patients without a history of non-arthroplasty surgery on the ipsilateral shoulder who later underwent total shoulder
arthroplasty (TSA 263) or reverse total shoulder arthroplasty (RTSA 243 ).

A total of 144 patients (28%) had an average of 1.9 ± 1.0 surgical procedures on the ipsilateral shoulder before arthroplasty. The average age in the prior surgery (PS) group was significantly younger at the time of arthroplasty compared with the non prior surgery (NPS) group (61.6 ± 10.2 years compared with 68.2 ± 8.6 years, p = 0.035).

At an average follow-up of 42.8 ± 16.4 months, both groups had significant improvements in ASES, SST, VAS, and range-of-motion values (p < 0.05 for all).

All outcome scores in the PS group were significantly lower than those in the NPS group (p < 0.001 for all). The PS group also had a significantly higher complication rate than the NPS group (19.4% compared with 4.4%, p < 0.001), and multivariate regression analysis revealed that prior surgery was a significant independent predictor of postoperative complications.

There were no differences between the PS and NPS groups in the number of postoperative infections (p = 0.679), reoperations (p = 0.553), or transfusions (p = 0.220).

Comment: So what might explain this finding? Here are several possibilities. (1) Prior surgery alters the anatomy, complicating both the pathology and the surgery. (2) Even though there was no apparent difference in infection rate, the revisions were not routinely cultured for the possibility of a stealth infection from Propionibacterium - prior surgery is known to increase the risk of such infections. (3) Patients and shoulders that fail one treatment are likely to have constitutional factors - such as poor compliance or low pain tolerance -  that contribute to the failure of a subsequent procedure.

We need to continue to learn all we can from each suboptimal result.

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Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

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The risk of shoulder joint replacement infection is doubled by prior surgery on the shoulder

Is previous nonarthroplasty surgery a risk factor for periprosthetic infection in primary shoulder arthroplasty?

These authors reviewed 4577 patients including 2890 with total shoulder arthroplasties, 1233 with hemiarthroplasties, and 454 with reverse total shoulders 813 (18%).

Medical records and the surgeon’s clinical notes and operative reports were reviewed to determine the type of prior surgery. These were categorized as rotator cuff repair (353), open reduction and internal fixation (185), débridement for nonseptic reasons (235), acromioplasty (111), capsular repair (131), hardware removal (35), and other surgeries (152).

Deep postoperative infection of the shoulder was diagnosed in 68 patients (1.49%). An infected arthroplasty was diagnosed by the presence of 1 or both of the following: (1) positive joint fluid culture from needle aspiration, arthroscopic procedure, fluid obtained at surgery, or fluid draining from a wound communicating  with the humerus or (2) positive synovial or bone tissue culture. In those patients without a positive joint fluid culture, the presence of a clinical infection was determined when the treating orthopedic surgeon believed an infection was present on the basis of clinical presentation (history and physical examination), documentation in the surgeon’s note, and one or both of the following: (1) operative findings including purulent joint fluid, thick serosanguineous joint fluid, or the presence of necrotic synovial tissue or (2) a positive blood culture. The criteria for diagnosing 'infection' obviously affect the rate with which it is diagnosed. On one hand the authors recognize the possibility of 'culture negative' infection. On the other hand, it is recognized that cultures of joint fluid aspirates may be negative in the presence of positive deep cultures of tissue and explants as is emphasized in this link. The authors do not provide the data on the type of organisms cultured.

Of the 813 patients who had undergone previous surgery, 20 (2.46%) developed a deep postoperative infection. 

Of the 3764 patients who did not have previous shoulder surgery, 48 patients (1.28%) sustained deep shoulder infection. This difference was significant in both the univariate (P = .0094) and multivariate analyses (P = .0390). A higher number of previous surgeries was significantly associated with an increased risk of deep postoperative infection (P = .0272).

Younger age and male gender were significantly associated with a higher risk of deep postoperative infection (P = .0150 and P = .0074, respectively).  Patients undergoing SA for cuff tear arthropathy (HR, 3.49; 95% CI, 1.60-7.27; P = .0020) or in the setting of acute trauma (HR, 4.49; 95% CI, 1.33- 10.61; P = .0117) had a significantly increased risk of deep postoperative infection in the multivariable analysis.

Comment: The messages are clear: (1) surgeons need to be aware that even 'minor' surgeries (such as joint debridement) can increase the risk of infection in a subsequent joint replacement and (2) surgeons and patients need to discuss the fact that a shoulder arthroplasty on a previously operated shoulder has almost twice the risk of becoming infected. Surgeons need to consider obtaining 'preemptive' cultures at the time of arthroplasty in such cases and to be aware that a deviation from the expected postoperative course may represent the stealth presentation of a periprosthetic infection.

These authors are not the first to point out the relationship between prior surgery and shoulder arthroplasty infection. Their findings are similar to those of a prior article, our post on which is reproduced here:
Infection after primary anatomic versus primary reverse total shoulder arthroplasty.

These authors reviewed 814 primary total shoulder arthroplasties and found deep periprosthetic infections in 16: 6 anatomic total shoulders (aTSA)  and 10 reverse total shoulders (rTSA).

The surgical technique included the use of surgical hoods, limitation of operating room traffic, 

antibiotic prophylaxis with intravenous cefazolin (or clindamycin in cases of b-lactam allergy) at

least 30 minutes before the incision, followed by 3 additional postoperative doses. Preparation of the surgical site was with chlorhexidine.

The infections were determined by retrospective chart review. An infection was diagnosed by joint fluid culture or tissue/bone culture. Infections occurred in 7 women (44%) and in 9 men (56%).

The isolated causative organisms were Staphylococcus  spp in 7 patients (43.8%), Propionibacterium

acnes  in 7 (43.8%), Escherichia coli  in 1 (6.3%), and both Staphylococcus  spp and P acnes  in 1 (6.3%). The prior surgeries included rotator cuff repair in 5, Bankart repair in 1, ORIF for fracture in 1, and arthroscopic debridement/biceps tenotomy in 1. The patient with the E coli infection had no prior surgery.

Shoulders with previous nonarthroplasty operations undergoing primary TSA exhibited a significantly higher (P = .016) infection rate compared with shoulders with no operative history. 

Both aTSA and rTSA performed in previously operated-on shoulders demonstrated higher infection rates compared with shoulders with no prior operative intervention. 

Comment: We prepared this chart to make the data from this study a bit easier to grasp.

These data indicate that patients with prior surgery have an increased risk of sustaining an infection after shoulder arthroplasty - information that should be shared with candidates for this procedure.

It is likely that these numbers underestimate the number of infections in that we recognize that Propionibacterium infections may present as pain, stiffness and component loosening many years after the index procedure as described in this post.

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Shoulder arthroplasty - the effect of prior surgery on outcome.

Does Prior Shoulder Surgery Negatively Impact Shoulder Arthroplasty Outcomes?  also presented as a poster presentation.

These authors sought to compare 71 patients undergoing total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (rTSA) withour prior surgery to 50 patients having prior open and arthroscopic procedures at an average of 24 months (minimum 12 months) after arthroplasty. 

Prior surgeries included a mix of both open and arthroscopic procedures, including open

and arthroscopic rotator cuff repair, open and arthroscopic stabilization (with and without bone

augmentation), arthroscopic capsular release, and arthroscopic debridement.

They found a significant difference in postoperative ASES scores in the no-surgery group compared to the prior-surgery group (84.49 versus 71.67, P=0.0003) as well as in the SST scores (8.97 versus 5.47, P<0.0001). They concluded that shoulder arthroplasty after undergoing prior shoulder surgery results in overall clinically improved outcomes, however these results are inferior compared to patients without a history of prior shoulder surgery. 

Comment: There is substantial evidence from other sources to support this conclusion. This study would have been more helpful if the authors had considered the change in the scores (the difference between the ingo and the outcome) rather than only the outcome. That would let us know if the patients with prior surgery had worse functioning shoulders before surgery and whether the change in scores was similar for the two groups. 

The possible reasons for inferior outcomes in patients with prior surgery needs further study. Is this finding because 

(1) these patients are less motivated or less healthy?

(2) these patients have more complex pathology or different expectations?

(3) these shoulders are more likely to be infected?

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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