Thursday, April 23, 2026

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





Summary

Shoulder periprosthetic infections (PJI) are serious for the patient, the surgeon and the health care system. It is, therefore, understandable that much time, money and effort are being directed at lowering the risk of PJI. Many risk reduction strategies are supported by robust clinical evidence, such as optimizing nutrition, smoking cessation, management of diabetes, treating anemia, distancing arthroplasty from corticosteroid injection, shortening surgical time, reducing personnel traffic in the operating room, glove changes, normothermia, hair removal and excellent wound closure.

The only infection-prevention intervention for which there is reasonably robust shoulder-PJI specific outcome data is weight-based IV cefazolin administered preoperatively. When vancomycin is used it needs to be completely infused before incision [references 17–19 below]. 

In addition to the established risk reduction strategies noted above, there is current interest in approaches to reducing the shoulder's bacterial load in the hope that this "decolonization" would reduce PJI risk. Two questions should be asked in this regard: (1) does the intervention reduce a "surrogate", such as skin-surface colony counts, dermal culture positivity, intraoperative field culture positivity, or bacterial load on instruments; and (2) does the intervention affect the clinical outcome realized by the patient, such as reduced periprosthetic infection or revision for infection?

While the surrogate-to-outcome link is biologically plausible, it remains uncertain. There is evidence that intraoperative culture positivity at primary TSA does not predict clinical PJI or inferior patient reported outcomes [1]. 

Another shoulder-specific issue is that Cutibacterium is the most commonly isolated organism in shoulder PJI. 


The reservoir for this organism is in the pilosebaceous units of the dermis, where it is beyond the effective reach of topical antiseptics applied to the skin surface. 






While topical chlorhexidine can reduce the surface load of Cutibacterium, the surface is repopulated from the sebaceous-gland reservoir in less than an hour [2]. 

Multiple inexpensive, low-harm adjuncts (benzoyl peroxide (BPO), hydrogen peroxide (H2O2), and chlorhexidine gluconate (CHG) skin preparations, as well as subcutaneous povidone-iodine, dilute povidone-iodine joint lavage, intrawound vancomycin) seem reasonable but cannot be viewed as "evidence-based for PJI reduction" in shoulder arthroplasty. 

Some details on the published evidence


Intravenous prophylaxis

IV cefazolin is the preventive intervention with the strongest shoulder-specific outcome data. A recent report reviewed 7,713 primary shoulder arthroplasties from a single institution (2000–2019) and reported that cefazolin administration, compared with non-cefazolin alternatives (vancomycin, clindamycin), was associated with a 69% reduction in all-cause PJI and a 78% reduction in C. acnes PJI (p < 0.001) over 15-year follow-up [17]. An analysis of 139,032 primary shoulder arthroplasties (2016–2020) reached a congruent conclusion: cefazolin monotherapy was associated with lower rates of 90-day PJI than vancomycin or clindamycin monotherapy [18].
The mechanism of benefit is consistent with known pharmacology: Cutibacterium is generally susceptible to beta-lactams, and cefazolin achieves adequate tissue concentrations at the time of incision when administered within the guideline-recommended window. When vancomycin is used in place of cefazolin (typically for self-reported penicillin allergy), the protective effect is contingent on complete infusion prior to incision: a fourfold increase in PJI risk is reported when vancomycin infusion-to-incision was less than 30 minutes (HR 4.22; 95% CI 1.12–15.90) [19].
Despite cefazolin's effect, Cutibacterium is still recoverable from deep tissues at primary arthroplasty in a substantial minority of patients despite IV 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 prophylaxis and CHG skin preparation was genotypically the same as the C. acnes present on the skin, suggesting possible intraoperative skin-to-deep-tissue inoculation [20]. Falconer et al. similarly documented field contamination despite prophylaxis [21]. IV antibiotics therefore reduce but do not eliminate deep-tissue inoculation. A randomized trial showed that adding doxycycline to cefazolin did not further reduce Cutibacterium culture positivity [22].

A large randomized trial tested whether adding IV vancomycin to cefazolin prophylaxis reduced SSI across arthroplasty. The trial enrolled 4,113 patients, of whom only 30 underwent shoulder arthroplasty. The addition of IV vancomycin was not superior to placebo (4.5% vs 3.5% SSI; RR 1.28; 95% CI 0.94–1.73; p = 0.11) and, in the knee subgroup, was associated with a higher rate of SSI (RR 1.52; 95% CI 1.04–2.23) [30]. The shoulder subgroup was too small (n = 30) to support any inference and the overall trial-level result, if anything, favored placebo.

Preoperative skin decolonization

Chlorhexidine (CHG) applied to skin surface
Home CHG showers are a widely considered preoperative decolonization strategy, but shoulder-specific data do not support their effectiveness [3]. It has been subsequently shown that home CHG washes lower skin loads of most bacteria but are less effective against Cutibacterium [4], and that the organism can 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 that 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 to skin surface
BPO is a skin agent often used in shoulder surgery. Multiple randomized trials demonstrate that topical 5% BPO applied for 2–5 days preoperatively reduces skin-surface Cutibacterium counts compared with CHG or soap controls. A recent trial randomized 80 shoulder-surgery patients to 5% BPO or 4% CHG for three consecutive days and found a significantly greater reduction in positive skin cultures on the BPO-treated side [7]. A similar BPO-vs-placebo surface effect was shown in a small randomized trial [8], and later a 100-patient randomized trial showed that BPO reduces Cutibacterium culture positivity across all phases of open shoulder surgery, from skin incision through wound closure, particularly in male patients [9].

Hydrogen peroxide (H2O2)
Interest in adjunctive 3% hydrogen peroxide stems from its bactericidal activity against Cutibacterium at clinically achievable contact times [10]. A recent article reported that a brief H2O2 wipe added to standard preparation reduced triple-site (skin + dermis + joint) culture positivity in 61 primary shoulder arthroplasties in a nonrandomized controlled trial [11]. Two-year follow-up of that cohort suggested a non significant trend toward fewer revisions and fewer Cutibacterium infections in the H2O2 arm [12]. A randomized controlled trial applied H2O2 to the dermis after skin incision and found no difference in culture positivity (20% vs 16%, p > 0.99) [13]. A 2024 study randomized 18 male volunteers to CHG alone versus H2O2 followed by CHG and found no additional benefit of H2O2 in reducing skin-surface Cutibacterium; repopulation from the sebaceous reservoir occurred in 78% of shoulders in both groups within 60 minutes [14].

Systemic measures

Nasal Staphylococcus aureus screening and decolonization
For S. aureus — not the dominant shoulder pathogen — meta-analytic data from hip and knee arthroplasty cohorts suggest screen-and-decolonize protocols lower surgical site infection rates, but the signal is dominated by retrospective before/after and quality-improvement designs [15]. The largest randomized trial enrolled 613 arthroplasty patients (of whom only 14, or 2%, underwent shoulder arthroplasty) and found zero PJIs in either arm at 2 years, rendering the trial inconclusive [16].


Intraoperative antimicrobial measures

Joint irrigation
In hip and knee arthroplasty, a reduction was noted in acute deep PJI from 0.97% (18/1,862) with saline lavage to 0.15% (1/688) with 0.35% dilute povidone-iodine lavage [23]. A randomized controlled trial in aseptic revision TJA (457 patients) showed a reduction in PJI from 3.4% in the saline arm to 0.4% in the dilute povidone-iodine arm (p = 0.038) [24]. Larger cohorts, however, did not replicate this benefit, and a 2025 multicenter randomized trial of 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 the combination relative to saline [25].
Shoulder-specific data are sparser and largely focus on microbial surrogates. An observational study of 187 isolates recovered during reverse shoulder arthroplasty reported a substantial reduction in recoverable C. acnes and coagulase-negative staphylococci after 3 minutes of 0.35% povidone-iodine irrigation, with no selection for more virulent or biofilm-forming phenotypes [26]. No shoulder-arthroplasty RCT has demonstrated a reduction in clinical PJI attributable to dilute povidone-iodine irrigation. Nevertheless, the practice is endorsed by the WHO, CDC, and International Consensus Meeting on Musculoskeletal Infection guidelines based predominantly on hip, knee, and spine data.


Subcutaneous lavage

Subcutaneous Betadine lavage
A separate, shoulder-specific approach to the subcutaneous layer after skin incision — rather than joint-space lavage before closure — was tested in a 2-arm randomized single-blinded trial (n = 120). Povidone-iodine applied to the subcutaneous layer after deltoid fascia exposure significantly reduced C. acnes surgical-field culture positivity compared with the no-additional-preparation arm [35].

Subcutaneous chlorhexidine gluconate lavage
Two randomized trials published in 2025 tested the same commercial irrigant — 0.05% chlorhexidine gluconate — as an intraoperative adjunct to reduce Cutibacterium contamination in primary shoulder arthroplasty. One study [31] reported a pooled deep-culture odds ratio of 2.21 favoring CHG over saline (n = 126, single surgeon). Another study [32] reported no difference (n = 56, single surgeon); the CHG arm was numerically worse (10.08% vs. 5.77%). Neither trial measured periprosthetic joint infection. [33]. These trials do not yet establish whether 0.05% CHG subcutaneous lavage reduces clinical infection after shoulder arthroplasty.

It would be of great interest to know how CHG subcutaneous lavage compares to Betadine subcutaneous lavage.

The issue of positive cultures for sterile samples.
Interestingly, in one of the studies, a sterile kidney-basin control was positive in 5.4% of cases, essentially identical to the 5.5% positive rate at the inferior glenohumeral recess [32]. If the open-air basin and the deep joint have the same positive rate, culture positivity at the deep site may be tracking ambient operating-room Cutibacterium load at least as much as any true surgical-field contamination. Another study independently reported Cutibacterium recovered from OR air swabs in 15% of samples [34], a finding that compounds the interpretive problem for any culture-based surrogate in this setting.  It seem important that surgeons periodically submit sterile specimens exposed to the air of their operating room for Cutibacterium culture to determine the background culture positivity rate.

In a dermal biopsy subgroup, the CHG arm was 13% positive and the control arm was 0% (p = 0.115, underpowered) [32]. If real, this finding would be in the wrong direction for a bactericidal irrigant applied directly to that layer. This may be an example of small-sample noise or it may suggest that high-flow lavage of the open wound mechanically translocates organisms from pilosebaceous reservoirs into the tissue being sampled. 

Topical (intrawound) vancomycin powder
For hip and knee arthroplasty, meta-analyses of predominantly retrospective studies have reported substantial reductions in PJI with intrawound vancomycin powder [27, 28]. When tested prospectively in a large multicenter RCT in high-risk primary THA and TKA, topical vancomycin powder (alone or combined 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 study. A comparison study of 422 shoulder arthroplasties that received intrawound vancomycin powder (embedded in a collagen sponge) with 405 historical controls reported a significant reduction in periprosthetic shoulder infection with no increase in aseptic wound complications at minimum 12-month follow-up [29]. No prospective, randomized trial in shoulder arthroplasty has tested intrawound vancomycin powder against a placebo or saline control for the outcome of PJI.

Operating room environment
None of the widely used OR environment measures for reducing shoulder PJI has high-quality, shoulder-specific outcome evidence demonstrating a reduction in clinical PJI. Most data are extrapolated from hip and knee arthroplasty literature or rely on surrogate endpoints — airborne colony-forming units, wound contamination cultures — rather than infection outcomes.

Surgical drapes
Adhesive drapes, including iodine-impregnated variants, are widely used but have conflicting evidence regarding infection reduction. A meta-analysis of orthopaedic RCTs found that adhesive drapes reduced wound contamination (OR 0.49; 95% CI 0.34–0.72), but the two studies in that analysis that reported SSI found zero infections in both arms, leaving the clinical infection benefit indeterminate [36]. The WHO conditionally recommends against plastic adhesive incise drapes — with or without antimicrobial properties — for SSI prevention, as meta-analyses showed no difference in SSI risk compared with no drapes [37]. No shoulder-specific draping study has demonstrated PJI reduction.

Surgical hoods and helmet systems
The evidence here is nuanced, and the distinction between Charnley-type body exhaust suits (BES) and modern positive-pressure surgical helmet systems (SHS) matters. A systematic review found that 71% of studies of BES showed less air contamination and 50% showed less wound contamination. In contrast, modern SHS designs were not shown to reduce contamination or deep infection during arthroplasty [38]. A 2025 systematic review found that SHS 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]. An earlier study of air-exhaust patterns reached the same conclusion [40]. Simulated studies have shown SHS actually increase particle and microbiological emission rates compared with standard surgical clothing [41]. The CDC 2017 guidelines classified space suits as an "unresolved issue" with uncertain trade-offs between benefits and harms [42].
Shoulder-specific data: a 2024 New Zealand Joint Registry analysis of 16,000 primary shoulder arthroplasties (hemiarthroplasty, anatomic, and reverse) found no difference in all-cause revision or revision for deep infection between SHS and conventional gowns [43]. This is the first large shoulder-arthroplasty dataset addressing the question, and the result mirrors the hip/knee registry signal.

Laminar airflow (LAF)
The evidence for LAF in arthroplasty is conflicting, and major guidelines recommend against its use for SSI prevention. The WHO conditionally recommends that LAF should not be used to reduce SSI risk in total arthroplasty (low to very low quality evidence) [37]. A Lancet Infectious Diseases systematic review found no benefit for hip (OR 1.29; 95% CI 0.98–1.71) or knee arthroplasty (OR 1.08; 95% CI 0.77–1.52), and some registry data suggested increased infection rates; the authors concluded LAF should not be used as a preventive measure given the higher costs [44].
Shoulder-specific data: a single RCT of a localized laminar flow device during shoulder arthroplasty (n = 43) demonstrated significantly reduced airborne CFUs near the wound (p < 0.001), but infection was not a primary outcome and no infections occurred in either group [45]; airborne CFU reduction is a surrogate with unknown clinical correlate in shoulder arthroplasty. Clinical PJI reduction with LAF in shoulder arthroplasty has not been demonstrated.

Closed-incision negative pressure wound therapy (ciNPWT)
ciNPWT has the broadest evidence base across surgical specialties, though shoulder-specific data are absent. A meta-analysis of 44 RCTs (n = 5,693) found a ~40% reduction in SSI risk with ciNPWT (pooled RR 0.61; 95% CI 0.49–0.74) [46]. A separate review reached the same pooled estimate [47]. When stratified by surgical discipline, however, the benefit in orthopaedic/trauma surgery was not statistically significant (RR 0.68; 95% CI 0.43–1.08), likely reflecting underpowering at the low baseline orthopaedic infection rate [47]. The WHO conditionally recommends ciNPWT for high-risk wounds (low quality evidence), noting benefit in clean and clean-contaminated surgery but not specifically in orthopaedic surgery [37]. A meta-analysis of single-use NPWT devices found significant reductions in both superficial SSI (OR 0.30) and deep SSI (OR 0.67) across all specialties pooled [48]. No RCT has specifically evaluated ciNPWT for shoulder arthroplasty PJI.

In summary, adhesive drapes, surgical helmet systems, electrocautery in making the skin incision, laminar airflow, closed-incision negative pressure wound therapy have no or minimal evidence to support their use in PJI prevention [36, 37, 42, 43, 44]. 


End Note
Because of the seriousness of shoulder periprosthetic infections and the difficulty in treating them, optimizing prevention is the preferred strategy. Patients and their surgeons will benefit by optimizing nutrition, smoking cessation, management of diabetes, treating anemia, distancing arthroplasty from corticosteroid injection, shortening surgical time, reducing personnel traffic in the operating room, and using preoperative weight-based IV cefazolin administered preoperatively. 

Multiple inexpensive, low-harm adjuncts (BPO, H2O2, subcutaneous povidone-iodine, dilute povidone-iodine joint lavage, intrawound vancomycin) are reasonable considerations, but they are not at this point "evidence-based for PJI reduction" in shoulder arthroplasty. 

Lots to consider!





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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



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