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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