Thursday, April 23, 2026

Reducing periprosthetic infection risk in shoulder arthroplasty: what the current evidence supports




A shoulder periprosthetic joint infection (PJI) is among the most significant complications a patient, a surgeon, or a health system can face. It is difficult to diagnose, difficult to eradicate, and disproportionately likely to be caused by Cutibacterium— an organism that lives in the pilosebaceous units of the normal dermis, beyond the reach of any antiseptic applied to the skin surface and that the host's immune system may not recognize as "foreign". 







Cutibacterium can be isolated from healthy shoulders. So we need to consider an "infction" as "bacteria doing harm".  Whether Cutibacterium are doing harm in a shoulder arthroplasty - a periprosthetic infection -  depends primarily on the interaction between it and the host in the environment of the prosthetic joint.

Shoulder periprothetic infections can present in different ways. 

An "obvious" presentation is one in which there is pain, swelling, erythema, draining sinus, intraarticular pus, elevated serum inflammatory markers, and cultures than rapidly turn positive. While obvious infections can be caused by Cutibacterium, methicillin resistant staphylococcus and methicillin sensitive staphylococcus are common offenders. 

A "stealth" presentation is one in which the patient's expected post-arthroplasty course becomes complicated by otherwise unexplained pain and stiffness after a "honeymoon" recovery. Stealth infections are commonly associated with Cutibacterium.


Given the stakes, it is not surprising that a great deal of time, money, and effort is being spent on interventions that claim to reduce PJI risk. What is worth asking is what the supporting evidence actually shows.

It helps to distinguish two questions about any proposed intervention: (1) Does it reduce a surrogate for PJI — skin-surface colony counts, dermal culture positivity, intraoperative field culture positivity, or bacterial load on instruments? (2) Does it address the clinical outcome the patient cares about — periprosthetic infection, revision for infection, or poorer comfort and function? 

The surrogate-to-outcome link is biologically plausible but unproven; there is direct evidence that intraoperative culture positivity at primary TSA does not predict clinical PJI or inferior patient-reported outcomes[reference 1]. 

Another confounding finding is that the Cutibacterium positive culture rate for a sterile swab or sponge exposed to the air in a shoulder OR is 5 to 15% [32],[34]. Thus a positive culture for a shoulder tissue specimen may be due to contamination of the specimen on its path from the patient to the OR environment to the lab. Surgeons should consider periodically testing the culture results for sterile samples in their ORs to guide the interpretation of their surgical specimen culture results.

Approaches to lowering infection risk

The one intervention with robust shoulder-specific outcome data: weight-based IV cefazolin
A single-institution review of 7,713 primary shoulder arthroplasties over two decades reported that cefazolin, compared with non-cefazolin alternatives (vancomycin, clindamycin), was associated with a 69% reduction in all-cause PJI and a 78% reduction in Cutibacterium PJI over 15-year follow-up [reference17]. The findings of this observational, retrospective analysis were congruent with a separate analysis of 139,032 primary shoulder arthroplasties[18] providing the strongest shoulder-specific outcome evidence in the entire infection-prevention literature. The mechanism is consistent with Cutibacterium's susceptibility to beta-lactams and with the tissue concentrations cefazolin achieves when given inside the guideline window.

When vancomycin is used (usually for self-reported penicillin allergy), the protective effect depends on complete infusion before incision: a fourfold increase in PJI risk has been reported when vancomycin infusion-to-incision was less than 30 minutes[19]. A large randomized trial in total joint arthroplasty found no benefit to adding IV vancomycin to cefazolin, and in the knee subgroup vancomycin addition was associated with a higher surgical site infection (SSI) rate; the shoulder subgroup (n = 30) was too small to support inference[30].

IV cefazolin reduces but does not eliminate deep-tissue inoculation. Cutibacterium is still recoverable from deep tissues at primary arthroplasty despite prophylaxis and standard skin preparation[5]. A 2024 prospective genomic study of 90 primary reverse shoulder arthroplasties showed that the Cutibacterium recovered from deep tissues after cefazolin and chlorhexidine gluconate (CHG) skin preparation was genotypically identical to the organism present on the skin, consistent with skin-to-deep-tissue inoculation[20]. Falconer and colleagues similarly documented surgical field contamination despite prophylaxis[21]. Adding doxycycline to cefazolin did not further reduce culture positivity in a randomized trial[22].


Patient-side risk factors with shoulder-specific supporting data


Glycemic control in patients with diabetes
A shoulder-specific analysis of patients with diabetes mellitus identified a perioperative HbA1c threshold of 8.0 as an inflection point above which wound-complication and deep-infection rates rise significantly[49]. The absolute infection rate remains low even above this threshold, and HbA1c alone has limited discrimination as a predictive test — but the data support preoperative HbA1c screening in patients with diabetes and consideration of glycemic optimization before elective surgery.

Timing of corticosteroid injection
Shoulder injection within 3 months of arthroplasty is associated with increased postoperative infection risk in a Medicare analysis[50]; a subsequent national-database study of reverse shoulder arthroplasty found the increased PJI risk concentrated in patients injected within 4 weeks of surgery[51]. Scheduling arthroplasty ≥4 weeks — and ideally ≥3 months — after any ipsilateral glenohumeral corticosteroid injection is a reasonable risk-reduction step.

Operative time
A 33,987-case NSQIP analysis showed an increasing odds of SSI as operative time lengthened, with an inflection above 180 minutes[52]. Operative time is a modifiable factor to the extent that surgical volume, implant selection, team familiarity, and case complexity permit.

Other items often cited without shoulder-specific PJI-outcome data
Smoking cessation, preoperative anemia correction, nutritional optimization, OR personnel traffic reduction, intraoperative normothermia, appropriate hair removal, glove changes at key moments, and excellent wound closure are all reasonable, low-harm elements of a perioperative protocol. They are supported to varying degrees by extrapolated evidence from other surgical fields and by surrogate-endpoint orthopaedic data. None has a shoulder-specific randomized controlled trial showing a reduction in PJI. Recommending them is sensible; describing them as 'evidence-based for shoulder PJI reduction' overstates the case.

Preoperative decolonization

Chlorhexidine gluconate (CHG) applied on the skin surface
Home CHG showers are widely used. Their shoulder-specific support is weaker than often assumed. Standard surgical preparation does not eradicate Cutibacterium from the dermis[3], home CHG washes lower skin loads of most bacteria but are specifically less effective against Cutibacterium[4], and the organism can still be isolated from deep cultures at primary shoulder arthroplasty despite prophylaxis[5]. A randomized trial in male shoulder arthroplasty patients comparing home 4% CHG washes to 10% benzoyl peroxide soap found neither agent eliminated Cutibacterium from the skin surface or the incised dermal edge[6]. Cutibacterium repopulates the shoulder skin surface from the sebaceous-gland reservoir within 60 minutes[2].

Benzoyl peroxide (BPO) applied on the skin surface
The BPO shoulder literature now comprises multiple randomized trials. Sabetta and colleagues first reported in 2015 that adding topical 5% BPO cream to standard skin preparation reduced Cutibacterium recovered during shoulder surgery[53]. The 2018 Neer Award trial randomized 80 shoulder-surgery patients to 5% BPO or 4% CHG for three consecutive days; the BPO-treated shoulder had fewer positive cultures than the contralateral untreated control (P = 0.0003), while the CHG-treated shoulder did not differ from its control[7]. A separate small volunteer trial showed a similar BPO surface effect[8]. Scheer and colleagues later reported in a 100-patient randomized trial that BPO reduced Cutibacterium positivity across all phases of open shoulder surgery, from skin incision through wound closure[9].

The picture is not uniformly positive. Heckmann and colleagues showed that topical clindamycin, BPO, and the combination each failed to eliminate Cutibacterium from the dermis in randomized treatment quadrants on the upper back[54]. The Hsu trial on the shoulder was also negative[6]. Taken together, BPO has the most consistent surrogate-endpoint signal of any topical agent in this space, but it reduces rather than eliminates surface colonization and has no shoulder-arthroplasty trial demonstrating reduction in clinical PJI.

Hydrogen peroxide (H2O2)
3% hydrogen peroxide is bactericidal against Cutibacterium at clinically achievable contact times[10]. A nonrandomized controlled trial of 61 primary shoulder arthroplasties reported reduced triple-site (skin + dermis + joint) culture positivity with the addition of an H2O2 wipe to standard preparation[11], and a two-year follow-up of that cohort noted a non-significant trend toward fewer revisions and fewer Cutibacterium infections[12]. Against these: a randomized controlled trial applying H2O2 to the dermis after skin incision showed no difference in culture positivity (20% vs. 16%, p > 0.99)[13], and a 2024 randomized volunteer study found no additional benefit to H2O2-followed-by-CHG over CHG alone, with 78% of shoulders in both arms repopulating from the sebaceous reservoir within 60 minutes[14]. The collective evidence for H2O2 is split, with two studies suggesting a surrogate-endpoint benefit and two showing none; no shoulder-arthroplasty trial has demonstrated a clinical PJI benefit.

Nasal Staphylococcus aureus screening and decolonization
S. aureus is not the dominant shoulder arthroplasty pathogen. Meta-analytic data from hip and knee arthroplasty cohorts suggest screen-and-decolonize protocols lower SSI rates[15]. The largest randomized trial enrolled 613 arthroplasty patients — only 14 (2%) of whom had shoulder arthroplasty — and found zero PJIs in either arm at 2 years, rendering the trial inconclusive[16].

Intraoperative antimicrobial measures
Dilute povidone-iodine joint irrigation
In hip and knee arthroplasty, an early report noted a reduction in acute deep PJI from 0.97% with saline lavage to 0.15% with 0.35% dilute povidone-iodine lavage[23]; a randomized trial in aseptic revision TJA showed a reduction in PJI from 3.4% (saline) to 0.4% (dilute povidone-iodine) (p = 0.038)[24]. Larger cohorts have not replicated this, and a 2025 multicenter randomized trial in high-risk primary THA and TKA found no significant reduction in 3-month PJI or wound-complication rates for dilute povidone-iodine, topical vancomycin powder, or their combination compared with saline[25].

Shoulder-specific data are sparser and focus on microbial surrogates. An observational study of 187 isolates recovered during reverse shoulder arthroplasty reported substantial reduction in recoverable Cutibacterium and coagulase-negative staphylococci after 3 minutes of 0.35% povidone-iodine irrigation[26]. No shoulder-arthroplasty RCT has demonstrated a reduction in clinical PJI attributable to dilute povidone-iodine irrigation. The practice is nonetheless endorsed by WHO, CDC, and ICM guidelines based predominantly on hip, knee, and spine data.

Subcutaneous povidone-iodine lavage
A distinct approach — povidone-iodine applied to the subcutaneous layer after skin incision, rather than joint-space lavage before closure — was tested in a 120-patient randomized, single-blinded trial. Subcutaneous povidone-iodine applied after deltoid fascia exposure significantly reduced Cutibacterium surgical-field culture positivity compared with no-additional-preparation control[35].

Subcutaneous chlorhexidine gluconate lavage
Two randomized trials published in 2025 tested 0.05% chlorhexidine gluconate as an intraoperative adjunct to reduce Cutibacterium contamination in primary shoulder arthroplasty. The results were mixed. One reported a pooled deep-culture odds ratio of 2.21 favoring CHG over saline (n = 126, single surgeon)[31]. The other reported no difference (n = 56, single surgeon); the CHG arm was numerically (but not statistically significantly) worse (10.08% vs. 5.77%)[32].  In a dermal biopsy subgroup, the CHG arm was 13% positive and the control arm was 0% (p = 0.115)[32].

It would be of interest to know how subcutaneous CHG compares head-to-head with subcutaneous povidone-iodine.

Topical (intrawound) vancomycin powder
Meta-analyses of predominantly retrospective hip and knee arthroplasty studies have reported reductions in PJI with intrawound vancomycin powder[27][28]. In a prospective multicenter RCT in high-risk primary THA and TKA, topical vancomycin powder (alone or with dilute povidone-iodine) produced no statistically significant reduction in 3-month PJI compared with saline[25]. Shoulder-specific data consist of a single retrospective cohort: 422 shoulder arthroplasties that received intrawound vancomycin powder embedded in a collagen sponge compared with 405 historical controls. The study reported a reduction in PJI without an increase in aseptic wound complications[29]. The comparison is to historical rather than concurrent controls. No prospective, randomized trial in shoulder arthroplasty has tested intrawound vancomycin powder for the outcome of PJI.

Operating room environment
No widely used OR environment measure for shoulder PJI prevention has high-quality, shoulder-specific outcome evidence demonstrating a reduction in clinical PJI. Most data extrapolate from hip and knee arthroplasty or rely on surrogate endpoints.

Surgical drapes
Adhesive drapes — iodine-impregnated or not — reduce wound contamination in a meta-analysis (OR 0.49; 95% CI 0.34–0.72), but the two studies reporting SSI found zero infections in both arms, leaving the clinical infection benefit indeterminate[36]. WHO conditionally recommends against plastic adhesive incise drapes — with or without antimicrobial properties — for SSI prevention[37]. No shoulder-specific draping study has demonstrated PJI reduction.

Surgical hoods and helmet systems
The distinction between older Charnley-type body exhaust suits and modern positive-pressure surgical helmet systems matters. Older systems showed reduced air and wound contamination in most studies; modern helmet systems have not[38]. A 2025 systematic review found that helmet systems frequently harbor microbes and that their exhaust fans can contaminate the sterile field — some systems exhaust air laterally at the level of the surgical wound[39][40]. Simulated studies have shown surgical helmets can actually increase particle and microbial emission rates compared with standard surgical clothing[41]. The CDC 2017 guidelines classified space suits as an 'unresolved issue'[42]. The most directly relevant shoulder-specific evidence is a 2024 New Zealand Joint Registry analysis of 16,000 primary shoulder arthroplasties, which found no difference in all-cause revision or revision for deep infection between surgical helmet systems and conventional gowns[43].

Laminar airflow and closed-incision NPWT
Major guidelines recommend against laminar airflow for arthroplasty SSI prevention[37][44]. A single shoulder-arthroplasty RCT of a localized laminar flow device (n = 43) demonstrated reduced airborne CFUs near the wound but no infections occurred in either group[45]. Closed-incision negative pressure wound therapy has broad SSI-reduction evidence across surgical specialties[46][47][48], but no trial has specifically evaluated it for shoulder arthroplasty PJI.


Putting all this together
Weight-based IV cefazolin, administered within the guideline window, is the one intervention with robust shoulder-specific outcome data for PJI reduction[17,18]. When vancomycin is required, complete infusion before incision matters[19]. Beyond that, the evidence base consists almost entirely of either extrapolation from hip and knee arthroplasty or surrogate endpoints that have a known and unresolved dissociation from clinical PJI[1][32][34].

Several patient-side measures are supported by shoulder-specific data on associated infection risk: perioperative HbA1c screening and optimization in patients with diabetes[49], deferring elective arthroplasty ≥4 weeks (ideally ≥3 months) after any ipsilateral corticosteroid injection[50,51], and minimizing operative time[52]. Smoking cessation, nutritional optimization, anemia correction, normothermia, traffic reduction, and careful wound closure are reasonable — but are not 'evidence-based for shoulder PJI reduction' in the strong sense of that phrase.

Multiple inexpensive, low-harm adjuncts — BPO, H2O2, subcutaneous povidone-iodine, dilute povidone-iodine joint lavage, intrawound vancomycin, subcutaneous CHG — reduce surrogate endpoints with varying consistency. 

Nevertheless, because shoulder PJI is serious and difficult to treat, prevention is the preferred strategy. Surgeons should consider adding such low-harm, low cost adjuncts on biological-plausibility grounds, even though robust evidence supporting their efficacy in reducing PJI is lacking. 


References
1. Zmistowski B, Nicholson TA, Wang WL, Abboud JA, Namdari S. What is the clinical impact of positive cultures at the time of primary total shoulder arthroplasty? J Shoulder Elbow Surg. 2021;30(6):1324–1328. PMID 32920106.
2. Hsu JE, Whitson AJ, Van Dyke R, Wu JC, Matsen FA III. Dynamics of Cutibacterium repopulation onto the skin surface of the shoulder after chlorhexidine application. Int Orthop. 2023;47(6):1511–1515.
3. Lee MJ, Pottinger PS, Butler-Wu S, Bumgarner RE, Russ SM, Matsen FA III. Propionibacterium persists in the skin despite standard surgical preparation. J Bone Joint Surg Am. 2014;96(17):1447–1450.
4. Matsen FA III, Whitson AJ, Hsu JE. While home chlorhexidine washes prior to shoulder surgery lower skin loads of most bacteria, they are not effective against Cutibacterium (Propionibacterium). Int Orthop. 2020;44(3):531–534.
5. Matsen FA III, Russ SM, Bertelsen A, Butler-Wu S, Pottinger PS. Propionibacterium can be isolated from deep cultures obtained at primary arthroplasty despite intravenous antimicrobial prophylaxis. J Shoulder Elbow Surg. 2015;24(6):844–847.
6. Hsu JE, Whitson AJ, Woodhead BM, Napierala MA, Gong D, Matsen FA III. Randomized controlled trial of chlorhexidine wash versus benzoyl peroxide soap for home surgical preparation: neither is effective in removing Cutibacterium from the skin of shoulder arthroplasty patients. Int Orthop. 2020;44(7):1325–1329.
7. Kolakowski L, Lai JK, Duvall GT, Jauregui JJ, Dubina AG, Jones DL, Williams KM, Hasan SA, Henn RF 3rd, Gilotra MN. Neer Award 2018: Benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2018;27(9):1539–1544. PMID 30054245.
8. Scheer VM, Bergman Jungeström M, Lerm M, Serrander L, Kalén A. Topical benzoyl peroxide application on the shoulder reduces Propionibacterium acnes: a randomized study. J Shoulder Elbow Surg. 2018;27(6):957–961.
9. Scheer VM, Bergman Jungeström M, Serrander L, Scheer JH, Kalén A. Benzoyl peroxide treatment decreases Cutibacterium acnes in shoulder surgery, from skin incision until wound closure. J Shoulder Elbow Surg. 2021;30(7):1572–1578.
10. Hernandez P, Sager B, Fa A, Liang T, Lozano C, Khazzam M. Bactericidal efficacy of hydrogen peroxide on Cutibacterium acnes. Bone Joint Res. 2019;8(1):3–10.
11. Chalmers PN, Beck L, Stertz I, Tashjian RZ. Hydrogen peroxide skin preparation reduces Cutibacterium acnes in shoulder arthroplasty: a prospective, blinded, controlled trial. J Shoulder Elbow Surg. 2019;28(8):1554–1561.
12. Mizels J, Lewis DC, Tashjian RZ, Chalmers PN. Hydrogen peroxide may reduce the risk for revision surgery and infection in primary shoulder arthroplasty: two-year follow-up from a prospective, blinded, controlled trial. J Am Acad Orthop Surg. 2024;32(15):e769–e776. PMID 38759230.
13. Grewal G, Polisetty T, Boltuch A, Colley R, Tapia R, Levy JC. Does application of hydrogen peroxide to the dermis reduce incidence of Cutibacterium acnes during shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2021;30(8):1827–1833.
14. Crutcher WL, Acidera JC, Whitson AJ, Matsen FA III, Hsu JE. Does adding hydrogen peroxide to chlorhexidine gluconate increase the effectiveness of skin preparation in reducing cutaneous Cutibacterium levels? A randomized controlled trial. J Shoulder Elbow Surg. 2024;33(9):1905–1908. PMID 38815731.
15. Ribau AI, Collins JE, Chen AF, Sousa RJ. Is preoperative Staphylococcus aureus screening and decolonization effective at reducing surgical site infection in patients undergoing orthopedic surgery? A systematic review and meta-analysis with a special focus on elective total joint arthroplasty. J Arthroplasty. 2021;36(2):752–766.e6.
16. Rohrer F, Nötzli H, Risch L, et al. Preoperative decolonization and periprosthetic joint infections—a randomized controlled trial with 2-year follow-up. J Orthop Res. 2021;39(2):320–325.
17. Marigi EM, Bartels DW, Yoon JH, Sperling JW, Sanchez-Sotelo J. Antibiotic prophylaxis with cefazolin is associated with lower shoulder periprosthetic joint infection rates than non-cefazolin alternatives. J Bone Joint Surg Am. 2022;104(10):872–880.
18. Freshman RD, Fathi A, Orringer M, Kotlier JL, Mayfield CK, Lin EH, Feingold CL, Petrigliano FA, Liu JN. Non-cefazolin antibiotic prophylaxis is associated with increased rates of acute infectious, medical, and surgical complications following primary total shoulder arthroplasty: a database study. JSES Int. 2025;9(4):1286–1292.
19. Marigi EM, Marigi IM, Shah HN, Schoch BS, Sperling JW, Sanchez-Sotelo J. When intravenous vancomycin prophylaxis is needed in shoulder arthroplasty, incomplete administration is associated with increased infectious complications. J Shoulder Elbow Surg. 2023;32(4):803–812.
20. Torrens C, Bellosillo B, Gibert J, Suárez-López A, Santana F, Alier A. Are Cutibacterium acnes delivered from skin to deep tissues in primary reverse shoulder arthroplasty? A prospective study. Arch Orthop Trauma Surg. 2024;144(2):635–640.
21. Falconer TM, Baba M, Kruse LM, et al. Contamination of the surgical field with Propionibacterium acnes in primary shoulder arthroplasty. J Bone Joint Surg Am. 2016;98(20):1722–1728.
22. Rao AJ, Chalmers PN, Cvetanovich GL, et al. Preoperative doxycycline does not reduce Propionibacterium acnes in shoulder arthroplasty. J Bone Joint Surg Am. 2018;100(11):958–964.
23. Brown NM, Cipriano CA, Moric M, Sporer SM, Della Valle CJ. Dilute betadine lavage before closure for the prevention of acute postoperative deep periprosthetic joint infection. J Arthroplasty. 2012;27(1):27–30.
24. Calkins TE, Culvern C, Nam D, et al. Dilute betadine lavage reduces the risk of acute postoperative periprosthetic joint infection in aseptic revision total knee and hip arthroplasty: a randomized controlled trial. J Arthroplasty. 2020;35(2):538–543.e1.
25. Saba BV, VPIP Study Group; Higuera-Rueda CA, Dundon J, Cooper HJ, Dennis DA, Long WJ, Chen AF, Schwarzkopf R, et al. The three-month wound complication and infection rates after vancomycin powder and dilute povidone-iodine lavage for infection prophylaxis in high-risk total joint arthroplasty: a multicenter randomized controlled trial. J Arthroplasty. 2025;40(9S1):S487–S494. PMID 40349869.
26. Bellato E, Longo F, Menotti F, Mariani R, Massobrio L, Bartolotti V, Villavicencio H, Mandras N, Bondi A, Curtoni A, et al. Pathogen profiling in reverse total shoulder arthroplasty: virulence traits of clinical isolates before and after intraoperative povidone-iodine irrigation. Antibiotics (Basel). 2026;15(2):129.
27. Peng Z, Lin X, Kuang X, Teng Z, Lu S. The application of topical vancomycin powder for the prevention of surgical site infections in primary total hip and knee arthroplasty: a meta-analysis. Orthop Traumatol Surg Res. 2021;107(4):102741.
28. Zhu Z, Tung TH, Su Y, Li Y, Luo H. Intrawound vancomycin powder for prevention of surgical site infections in primary joint arthroplasty: an umbrella review of systematic reviews and meta-analyses. Int J Surg. 2025;111(5):3508–3524. PMID 40035719.
29. Garofalo R, Fontanarosa A, De Giorgi S, Lassandro N, De Crescenzo A. Vancomycin powder embedded in collagen sponge decreases the rate of prosthetic shoulder infection. J Shoulder Elbow Surg. 2023;32(8):1638–1644. PMID 36967057.
30. Peel TN, Astbury S, Cheng AC, et al. (ASAP Trial Investigators). Trial of vancomycin and cefazolin as surgical prophylaxis in arthroplasty. N Engl J Med. 2023;389(16):1488–1498.
31. Kassam HF, Mathur A, Saunders P, Smith K, Montes B, Quilligan E, Gardner V. Subcutaneous lavage with a 0.05% chlorhexidine gluconate solution leads to decreased Cutibacterium acnes deep culture rate in primary total shoulder arthroplasty: a prospective, randomized controlled trial. J Shoulder Elbow Surg. 2025 Apr 2 [online ahead of print]. doi:10.1016/j.jse.2025.02.043. PMID 40185389.
32. Bilden TT, Winkel LA, Lenters TR. Effect of antiseptic irrigation with 0.05% chlorhexidine gluconate (Irrisept) on the incidence of Cutibacterium acnes in primary shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34(6):1583–1588. PMID 39557112.
33. Matsen FA III, Butler-Wu S, Carofino BC, Jette JL, Bertelsen A, Bumgarner R. Origin of propionibacterium in surgical wounds and evidence-based approach for culturing propionibacterium from surgical sites. J Bone Joint Surg Am. 2013;95(23):e181. PMID 24306704.
34. Namdari S, Nicholson T, Parvizi J. Cutibacterium acnes is isolated from air swabs: time to doubt the value of traditional cultures in shoulder surgery? Arch Bone Jt Surg. 2020;8(4):506–510. PMID 32884971.
35. Moor BK, Léger B, Steffen V, Troillet N, Emonet S, Gallusser N. Subcutaneous tissue disinfection significantly reduces Cutibacterium acnes burden in primary open shoulder surgery. J Shoulder Elbow Surg. 2021;30(7):1537–1543. PMID 33421560.
36. Mundi R, Nucci N, Ekhtiari S, Wolfstadt J, Ravi B, Chaudhry H. Do adhesive drapes have an effect on infection rates in orthopaedic surgery? A systematic review and meta-analysis. Clin Orthop Relat Res. 2022;480(3):551–559. PMID 34491975.
37. Allegranzi B, Zayed B, Bischoff P, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16(12):e288–e303.
38. Young SW, Zhu M, Shirley OC, Wu Q, Spangehl MJ. Do 'surgical helmet systems' or 'body exhaust suits' affect contamination and deep infection rates in arthroplasty? A systematic review. J Arthroplasty. 2016;31(1):225–233. PMID 26321627.
39. Porto JR, Lavu MS, Hecht CJ 2nd, Kamath AF. Is your surgical helmet system compromising the sterile field? A systematic review of contamination risks and preventive measures in total joint arthroplasty. Clin Orthop Relat Res. 2025;483(6):972–990. PMID 39915114.
40. Ling F, Halabi S, Jones C. Comparison of air exhausts for surgical body suits (space suits) and the potential for periprosthetic joint infection. J Hosp Infect. 2018;99(3):279–283.
41. Vijaysegaran P, Knibbs LD, Morawska L, Crawford RW. Surgical space suits increase particle and microbiological emission rates in a simulated surgical environment. J Arthroplasty. 2018;33(5):1524–1529. PMID 29317156.
42. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784–791.
43. Stoneham A, Poon P, Hirner M, Frampton C, Gao R. Intraoperative 'space suits' do not reduce periprosthetic joint infections in shoulder arthroplasty. Bone Jt Open. 2024;5(10):894–897. PMID 39410846.
44. Bischoff P, Kubilay NZ, Allegranzi B, Egger M, Gastmeier P. Effect of laminar airflow ventilation on surgical site infections: a systematic review and meta-analysis. Lancet Infect Dis. 2017;17(5):553–561.
45. Morris BJ, Kiser CJ, Laughlin MS, Sheth MM, Dunn WR, Elkousy HA, Edwards TB. A localized laminar flow device decreases airborne particulates during shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2021;30(3):580–586. PMID 32949760.
46. Shiroky J, Lillie E, Muaddi H, Sevigny M, Choi WJ, Karanicolas PJ. The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: a systematic review and meta-analysis. Surgery. 2020;167(6):1001–1009. PMID 32143842.
47. Seidelman JL, Mantyh CR, Anderson DJ. Surgical site infection prevention: a review. JAMA. 2023;329(3):244–252. PMID 36648463.
48. James K, Glasswell A, Costa B. Single-use negative pressure wound therapy versus conventional dressings for the reduction of surgical site infections in closed surgical incisions: systematic literature review and meta-analysis. Am J Surg. 2024;228:70–77. PMID 37903665.
49. Cancienne JM, Brockmeier SF, Werner BC. Association of perioperative glycemic control with deep postoperative infection after shoulder arthroplasty in patients with diabetes. J Am Acad Orthop Surg. 2018;26(11):e238–e245. PMID 29688958.
50. Werner BC, Cancienne JM, Burrus MT, Griffin JW, Gwathmey FW, Brockmeier SF. The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients. J Shoulder Elbow Surg. 2016;25(3):390–397.
51. Baksh N, Gu A, Pollard TG, et al. Does preoperative corticosteroid injection increase the risk of periprosthetic joint infection after reverse shoulder arthroplasty? J Shoulder Elbow Surg. 2023;32(7):1459–1467. PMID 36737032.
52. Schmitt MW, Chenault PK, Samuel LT, Apel PJ, Bravo CJ, Tuttle JR. The effect of operative time on surgical-site infection following total shoulder arthroplasty. J Shoulder Elbow Surg. 2023;32(11):2371–2375. PMID 37327990.
53. Sabetta JR, Rana VP, Vadasdi KB, Greene RT, Cunningham JG, Miller SR, Sethi PM. Efficacy of topical benzoyl peroxide on the reduction of Propionibacterium acnes during shoulder surgery. J Shoulder Elbow Surg. 2015;24(7):995–1004. PMID 26067191.
54. Heckmann N, Heidari KS, Jalali O, Weber AE, She R, Omid R, Vangsness CT, Hatch GFR 3rd. Cutibacterium acnes persists despite topical clindamycin and benzoyl peroxide. J Shoulder Elbow Surg. 2019;28(12):2279–2283. PMID 31471244.


Lots to consider!





Follow on twitter/X: 
https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

Follow on LinkedIn: https://www.linkedin.com/in/rickmatsenmd




Sunday, April 19, 2026

Component malposition and clinical outcomes in shoulder arthroplasty - are they related?

It seems intuitive that substantial malposition of shoulder arthroplasty components can lead to poor clinical outcomes.  


The assumption that malposition drives poor outcomes has become the rationale for investment in three-dimensional planning, patient-specific instrumentation, navigation, augmented reality, and robotics. However, examination of published evidence indicates that the relationship between measured component position and patient-reported outcomes is weaker than this narrative implies. For example Negligible Correlation between Radiographic Measurements and Clinical Outcomes in Patients Following Primary Reverse Total Shoulder Arthroplasty concluded that the relationship between measured component position and clinical outcomes is limited. Does postoperative glenoid component retroversion following anatomic total shoulder arthroplasty affect clinical outcomes? A systematic review and meta-analysis found no clinically significant difference in patient-reported outcome scores, range of motion, or complications for anatomic total shoulder arthroplasty glenoid components implanted with <15° versus ≥15° of postoperative retroversion across 15 studies and 1,190 shoulders. 

Humeral and glenoid component malposition in patients requiring revision shoulder arthroplasty: a retrospective, cross-sectional study measured component positions for TSA and RSA on pre-revision radiographs of patients having revision arthroplasty and compared these measures to "ideal" values for glenoid inclination, critical shoulder angle, glenosphere overhang, change in center of rotation, humeral head height, acromio-humeral interval, and humeral stem alignment. These measurements were not made on radiographs obtained immediately after the index arthroplasty, so the extent of postoperative component shift is not known.

The article found that the majority of glenoid components in these revision cases were malpositioned in relation to the "ideal" values for both TSA (51%) and RSA (93%) when all of the measures were considered. Similarly, there was humeral component malposition in 57% of TSA cases and 62% of RSA cases when all of the measures were considered.  

The prevalence of malpositioning in unrevised arthroplasties was not presented in this study.

Data such as that shown in graph A  (showing hypothetical values for unrevised shoulders) would suggest that malposition was not an important driver of revision.



On the other hand, data such as that shown in graph B would suggest that malposition was an important driver of revision.

This article did not provide data on the relationship of the degree of malposition to the rate of revision.

Data such as that shown in hypothetical graph C would suggest that the degree of malposition was tightly related to the revision rate.

Data such as that shown in hypothetical graph D would suggest that smaller degrees of malposition did not affect revision rate, whereas substantial degrees of malposition were clinically important.

What the literature does provide is evidence against a meaningful dose-response relationship. 

Below is a Forest plot of some key published studies relating glenoid component version to patient-reported clinical outcomes for aTSA and RSA. The effect sizes near zero with confidence intervals crossing the null line suggest the lack of a clinically meaningful dose-response relationship between glenoid component version and clinical outcome.



Below is a scatterplot showing the lack of a relationship between SANE and ASES scores and glenoid component version (data from Glenoid retroversion does not impact clinical outcomes or implant survivorship after total shoulder arthroplasty with minimal, noncorrective reaming).





Conclusion: A search of the currently available literature did not show a relationship between immediate postoperative radiographic measures of component position on one hand and clinically meaningful measures (such as patient-reported outcomes and revision rates) on the other. Such data will be important in demonstrating the potential clinical value of preoperative plan transfer technologies such as robotics, patient-specific instrumentation, navigation, and virtual/augmented reality. The thought that "continued improvements in component positioning technologies for both the glenoid and humeral implants are needed" will need to be supported by these analyses.

References
1. Checketts JX, Sanchez B, Norris G, Williamson TK, Hachadorian ME, Hsu JE, Schiffman CJ, Matsen FA III. Does postoperative glenoid component retroversion following anatomic total shoulder arthroplasty affect clinical outcomes? A systematic review and meta-analysis. J Shoulder Elbow Surg. 2026;35(5):1103–1116.
2. Sperling JW, Anderson MB, Jobin CM, Verborgt O, Duquin TR. Humeral and glenoid component malposition in patients requiring revision shoulder arthroplasty: a retrospective, cross-sectional study. J Shoulder Elbow Surg. 2025;34(8):1886–1896.
3. Service BC, Hsu JE, Somerson JS, Russ SM, Matsen FA III. Does postoperative glenoid retroversion affect the 2-year clinical and radiographic outcomes for total shoulder arthroplasty? Clin Orthop Relat Res. 2017;475(11):2726–2739.
4. Sheth MM, Mills ZD, Dasari SP, Whitson AJ, Matsen FA III, Hsu JE. Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at a minimum 5-year follow-up. J Shoulder Elbow Surg. 2025;34(2):473–483.
5. Matsen FA III, Whitson AJ, Somerson JS, Hsu JE. Anatomic total shoulder arthroplasty with all-polyethylene glenoid component for primary osteoarthritis with glenoid deficiencies. JB JS Open Access. 2020;5(4):e20.00002.
6. Grantham WJ, Dekker TJ, Lacheta L, Horan MP, Goldenberg BT, Elrick BP, et al. Total shoulder arthroplasty outcomes after noncorrective, concentric reaming of B2 glenoids. JSES Int. 2020;4(3):644–648.
7. Ma CB, Xiao W, Salesky M, Cheung E, Zhang AL, Feeley BT, et al. Do glenoid retroversion and humeral subluxation affect outcomes following total shoulder arthroplasty? JSES Int. 2020;4(3):649–656.
8. Rutledge JC, Dey Hazra RO, Geissbuhler AR, Yamaura K, Dey Hazra ME, Hanson JA, et al. Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review. J Shoulder Elbow Surg. 2024;33(7):e384–e399.
9. Chalmers PN, Granger EK, Orvets ND, Patterson BM, Chamberlain AM, Keener JD, et al. Does prosthetic humeral articular surface positioning associate with outcome after total shoulder arthroplasty? J Shoulder Elbow Surg. 2018;27(5):863–870.
10. Werner BC, Creighton RA, Denard PJ, Lederman E, Romeo A, Griffin JW. Prosthetic humeral head center of rotation shift from ideal is associated with inferior clinical outcomes after anatomic total shoulder arthroplasty. Semin Arthroplasty JSES. 2021;31(4):668–676.
11. Varady NH, Bram JT, Chow J, Taylor SA, Dines JS, Fu MC, et al. Inconsistencies in measuring glenoid version in shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2025;34(2):639–649.
12. Terrier A, Ramondetti S, Merlini F, Pioletti DD, Farron A. Biomechanical consequences of humeral component malpositioning after anatomical total shoulder arthroplasty. J Shoulder Elbow Surg. 2010;19(8):1184–1190.
13. Franta AK, Lenters TR, Mounce D, Neradilek B, Matsen FA III. The complex characteristics of 282 unsatisfactory shoulder arthroplasties. J Shoulder Elbow Surg. 2007;16(5):555–562.
14. Sanchez-Sotelo J, Sperling JW, Rowland CM, Cofield RH. Instability after shoulder arthroplasty: results of surgical treatment. J Bone Joint Surg Am. 2003;85(4):622–631.
15. Burns DM, Frank T, Whyne CM, Henry PDG. Glenoid component positioning and guidance techniques in anatomic and reverse total shoulder arthroplasty: a systematic review and meta-analysis. Shoulder Elbow. 2019;11(2 Suppl):16–28.
16. Navarro RA, Chan PH, Prentice HA, Pearl M, Matsen FA III, McElvany MD. Use of preoperative CT scans and patient-specific instrumentation may not improve short-term adverse events after shoulder arthroplasty: results from a large integrated health-care system. JB JS Open Access. 2023;8(3):e22.00139.
17. Hsu JE, Hackett DJ Jr, Vo KV, Matsen FA III. What can be learned from an analysis of 215 glenoid component failures? J Shoulder Elbow Surg. 2018;27(3):478–486.
18. Walch G, Young AA, Boileau P, Loew M, Gazielly D, Molé D. Patterns of loosening of polyethylene keeled glenoid components after shoulder arthroplasty for primary osteoarthritis: results of a multicenter study with more than five years of follow-up. J Bone Joint Surg Am. 2012;94(2):145–150.
19. Harold RE, Sweeney PT, Torchia MT, Chamberlain AM, Keener JD. Total shoulder arthroplasty in patients with a B2 glenoid addressed with corrective reaming: mean 8-year follow-up. J Shoulder Elbow Surg. 2023;32(6 Suppl):S8–S16.



Sunday, March 29, 2026

Glenoid component version in anatomic total shoulder arthroplasty- does it matter?

 


Almost 30 years ago Gilles Walch called our attention to arthritic glenoid retroversion. Morphologic study of the glenoid in primary glenohumeral osteoarthritis

From that point on, there has been great interest in the version of the arthritic glenoid: what is it?, how should it be measured?. 

And in the execution of an anatomic total shoulder (aTSA),  should the version of the glenoid component be "corrected" to some particular value?, if so what value?, how should this correction be achieved? and does changing the preoperative version affect the clinical outcome of aTSA?

It goes without saying that a lot of time and money can go into the evaluation and management of arthritic glenoid retroversion. Perhaps it's time to see how much glenoid component matters to the patient.

About 15 years ago, Patterns of loosening of polyethylene keeled glenoid components after shoulder arthroplasty for primary osteoarthritis: results of a multicenter study with more than five years of follow-up pointed out that posterior tilting of the glenoid component was associated with preoperative posterior decentering and with excessive reaming. The authors suggested that preserving subchondral bone may be important for long-term longevity of the glenoid component.

Glenoid component retroversion is associated with osteolysis found that osteolysis around the center peg of a glenoid component was correlated with component retroversion of ≥15°, the paper clearly stated that "the presence of osteolysis around the center peg was not correlated with a worse clinical outcome defined by shoulder scores or a reoperation due to glenoid loosening". 

Nevertheless, achieving component retroversion of <15° has become a goal for many surgeons and an opportunity for orthopaedic companies who have made substantial investments in three-dimensional planning platforms, patient specific instrumentation, navigation, augmented / virtual reality and robotic assisted glenoid preparation.

A recent paper,  Does postoperative glenoid component retroversion following anatomic total shoulder arthroplasty affect clinical outcomes? A systematic review and meta-analysis assessed the clinical importance of implanting the glenoid component in <15° of retroversion. After screening 2,457 articles, 15 studies comprising 1,190 shoulders met inclusion criteria. Patients were stratified by whether postoperative glenoid component retroversion was <15° or ≥15°The principal finding was that no clinically significant differences were observed between the two groups in patient-reported outcome scores, range of motion, or complications. 

An unexpected and important finding in this meta-analysis was that shoulders with ≥15° of postoperative retroversion were actually more likely to have no radiolucency (a Lazarus grade 0 radiographic score) than those with <15° retroversion (76.9% vs. 55.6%; P = .00021). This finding argues against the presumption that retroversion promotes loosening. 

Does Postoperative Glenoid Retroversion Affect the 2-Year Clinical and Radiographic Outcomes for Total Shoulder Arthroplasty? directly addressed the question in a case-control study. At 2-year follow-up, patients with glenoid components implanted in ≥15° retroversion had similar improvement in Simple Shoulder Test (SST) scores, similar final outcome scores, and similar radiographic findings compared to those with <15° retroversion. Notably, none of the patients with retroverted glenoid components underwent revision surgery, compared to 3 of 50 patients in the non-retroverted group.

Anatomic Total Shoulder Arthroplasty with All-Polyethylene Glenoid Component for Primary Osteoarthritis with Glenoid Deficiencies reported outcomes of aTSA with conservative, noncorrective reaming in shoulders with glenoid deficiencies, including those with significant retroversion. Mean postoperative retroversion in this series was 16°, yet mean postoperative SST was 9 out of 12, consistent with the excellent results achieved in shoulders without glenoid deformity. The revision rate was zero in 143 shoulders at mean follow-up of 34 months.

Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at a minimum 5-year follow-up compared outcomes of aTSA for posteriorly eccentric (Walch B) versus concentric osteoarthritis at minimum 5-year follow-up, finding no significant difference in ASES scores, revision rates, or radiographic loosening between groups. These durable results were achieved without attempting retroversion correction.

Does glenoid version and its correction affect outcomes in anatomic shoulder arthroplasty? A systematic review analyzed 16 studies and 1,211 shoulders finding that 8 of 11 reports found no significant association between pre- or postoperative glenoid retroversion and clinical results, including patient-reported outcomes, range of motion, and revision rates.

Total shoulder arthroplasty outcomes after noncorrective, concentric reaming of B2 glenoids reported a 95% implant survivorship at a mean of 4.9 years in a series treated with noncorrective reaming with a mean postoperative retroversion of 19°.

The Effect of Version Correction Techniques

If clinical outcomes are equivalent regardless of postoperative retroversion, the question becomes whether correction efforts add value without adding risk.  Does postoperative glenoid component retroversion following anatomic total shoulder arthroplasty affect clinical outcomes? A systematic review and meta-analysis compared three correction strategies: posteriorly augmented glenoids, eccentric (“high-side”) reaming, and conservative noncorrective reaming. Eccentric reaming was associated with a significantly higher complication rate than noncorrective reaming (9.3% vs. 3.1%; P = .043, OR 3.22) and a significantly higher revision rate (7.4% vs. 1.2%; P = .015, OR 6.18). 

Loss of the dense subchondral bone layer from corrective reaming may result in reduced glenoid component support, increased micromotion, and greater loosening risk over time. 


Implications for 3D CT Planning and Technology Transfer

CT-based three-dimensional preoperative planning, patient specific instrumentation, intraoperative navigation, augmented/virtual reality, and robotic glenoid preparation are all predicated on the same clinical logic: that achieving a glenoid component position closer to neutral version will improve patient outcomes. As reviewed above, the available evidence indicates that differences in postoperative glenoid component retroversion do not produce clinically detectable differences in pain relief, function, or implant survival at the follow-up intervals studied.

Use of Preoperative CT Scans and Patient-Specific Instrumentation May Not Improve Short-Term Adverse Events After Shoulder Arthroplasty: Results from a Large Integrated Health-Care System compared aTSA with and without preoperative CT scanning and PSI. These technologies expose patients to additional radiation from CT scanning and incur substantially greater costs of care. Use of CT scans and PSI did not reduce the rate of short-term adverse events following shoulder arthroplasty. Patients receiving PSI may be at greater risk of deep vein thrombosis or deep infection, possibly reflecting the additional operative time this technology requires. 

Three-dimensional computed tomography analysis of pathologic correction in total shoulder arthroplasty based on severity of preoperative pathology analyzed 152 shoulders with 3D CT postoperatively and found that while glenoid component shift occurred in 51% of patients, neither component shift nor central peg osteolysis was associated with worse clinical outcomes at minimum 2-year follow-up. 

What the Evidence Does Suggest About Optimizing aTSA outcomes?

The available evidence points to factors other than retroversion that drive aTSA results. 

See: Below left-poor glenoid seating with cement interposed between the glenoid component and the bone. 

Below right-posterior decentering due to poor glenoid preparation and ill-advised use of a posteriorly eccentric humeral head component.


Surgeons may wish to consider 6 aspects of aTSA that are relevant to the glenoid side of the arthroplasty.

(1) conservative reaming to retain the maximal amount of quality host bone

(2) rather than "correcting" glenoid retroversion (A, below), consider "accepting" it (B, below)




(3) component seating — good carpentry with complete backside contact of the glenoid implant against prepared bone; no cement between the component and the bone.


(4) humeral head centering on the glenoid achieved through soft tissue balancing and the possible us of an anteriorly eccentric humeral component.


(5) awareness that technologies can lead surgeons to prioritize postoperative glenoid component retroversion <15° retroversion (without acknowledging the potential risks)




(6) recognition that specialized (e.g. augmented) glenoid components may have downstream risks (see chart below from the 2025 AOANJRR)


Here is a thought provoking case in which substantial glenoid retroversion was accepted


Function at 14 years




Conclusion:
Glenoid component version may not be as critical to the outcome of aTSA as secure seating of the glenoid component on quality host bone and centering of the humeral head on the prosthetic glenoid. 

Rather than improving outcomes, there is evidence that "corrective reaming" can be associated with a significantly higher complication rate than noncorrective reaming (9.3% vs. 3.1% ) and a significantly higher revision rate (7.4% vs. 1.2%).

Seating and balance


Yellow-headed blackbird
Malheur
2024



Follow on twitter/X: https://x.com/RickMatsen

Follow on facebook: https://www.facebook.com/shoulder.arthritis

Follow on LinkedIn: https://www.linkedin.com/in/rickmatsenmd