It is generally recognized that Cutibacterium originating from the patient's skin is the commonest organism associated with shoulder periprosthetic infections. While these organisms normally populate the skin's epidermal surface, they reside in the pilosebaceous units of the dermis - especially in the areas over the shoulder, back and face and especially in male patients. The surgical incision for shoulder arthroplasty must transect many of these structures, allowing the Cutibacterium to fall into the wound, potentially contaminating the arthroplasty.
Surgeons routinely "prep the skin" with various solutions, however the effectiveness of a skin surface prep has been shown to be suboptimal given the subsurface location this bacterial reservoir.
Some authors have indicated that the addition of hydrogen peroxide (H2O2) may increase the effectiveness of a chlorhexidine gluconate (CHG) prep (which is the most common solution applied before shoulder arthroplasty).
Skin swabs were taken from each shoulder prior to skin preparation and again at 60 minutes after preparation. Swabs were cultured for Cutibacterium and observed for 14 days. Cutibacterium skin load was reported using a semiquantitative system based on the number of quadrants growing on the culture plate, thus the range for the Specimen Cutibacterium Value (SpCuV) is 0 to 4. This is an example of a 4, all four quadrants have growth.
Prior to skin preparation, 100% of the CHG-only shoulders and 100% of the H2O2!CHG shoulders had positive skin surface cultures for Cutibacterium.
The mean SpCuV for the CHG-only shoulders prior to preparation was 2.1 +/- 0.8.
The mean baseline SpCuV for the H2O2!CHG shoulders prior to preparation was 2.2 +/- 0.7.
The mean SpCuV for the CHG-only shoulders 60 minutes after preparation was 1.3 +/- 0.9.
The mean SpCuV for the H2O2!CHG shoulders 60 minutes after preparation was 1.4 +/- 0.9
There was a reduction of Cutibacterium load at 60 minutes in 10 (56%) of the CHG-only shoulders.
There was a reduction of Cutibacterium load at 60 minutes in 11 (61%) of the H2O2!CHG shoulders.
The mean reduction in SpCuV at 60 minutes was 0.8 for the CHG-only group
The mean reduction in SpCuV at 60 minutes was 0.8 for the H2O2!CHG group.
After 60 minutes, Cutibacterium had repopulated the skin surface on 14 (78%) of the CHG-only shoulders.
After 60 minutes, Cutibacterium had repopulated the skin surface on 14 (78%) of the H2O2!CHG shoulders.
Comment: These data corroborate other studies indicating that Cutibacterium cannot be removed from the skin by skin preparation of the shoulder.
While skin surface preparations may be of some value in temporarily reducing the load of these organisms, a combination of host defenses along with intraoperative and postoperative prophylactic measures must be relied on to defend the shoulder against periprosthetic infection.
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