title: Evaluation of autologous platelet rich plasma for cardiac surgery: outcome analysis of 2000 patients The role age plays in the outcomes and complications of shoulder arthroplasty. Outcomes after shoulder replacement: comparison between reverse and anatomic total shoulder arthroplasty. Efficacy of preoperative home use of 2% chlorhexidine gluconate cloth before shoulder surgery. Obesity is Not Associated with Increased Short-term Complications After Primary Total Shoulder Arthroplasty The Incidence of Propionibacterium acnes in Shoulder Arthroscopy. Diabetes as a risk factor for poorer early postoperative outcomes after shoulder arthroplasty. Early Experience With Continuous Cervical Paravertebral Block Using a Stimulating Catheter Periprosthetic infections after shoulder hemiarthroplasty. Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics. What Are the Instability and Infection Rates After Reverse Shoulder Arthroplasty? Closed wound drainage in shoulder surgery. Risk factors for periprosthetic infection after reverse shoulder arthroplasty. Evaluation of the Lateral Modified Approach for Continuous Interscalene Block after Shoulder Surgery Periprosthetic infections after total shoulder arthroplasty: a 33-year perspective. The effect of axillary hair on surgical antisepsis around the shoulder. Successful Continuous Interscalene Analgesia for Ambulatory Shoulder Surgery in a Private Practice Setting Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain. Association between Propionibacterium acnes and frozen shoulder: a pilot study Efficacy of surgical preparation solutions in shoulder surgery.
abstract: Background Deep and superficial sternal wound infections ( DSWI & SWI ) following cardiac surgery increase morbidity , mortality and cost . Autologous platelet rich plasma ( PRP ) derived from the patient ’s own blood has been used in other surgical setting s to promote successful wound healing . The goal of this study was to analyze the addition of PRP using a rapid point of care bedside system to st and ard wound care in all patients undergoing sternotomy for cardiac surgical procedures . Methods Over a 7 year period , 2000 patients undergoing open cardiac operations requiring sternotomy were enrolled . One thous and patients received st and ard of care sternal closure . The other 1000 patients received st and ard of care sternal closure plus PRP applied to the sternum at the time of closure . The outcomes related to wound healing , infection , readmissions , and costs were analyzed . Results In the 2000 patients , there were more ventricular assist device implants/heart transplants and emergency operations in the PRP group ; otherwise there were no significant differences . The use of PRP reduced the incidence of DSWI from 2.0 to 0.6 % , SWI from 8.0 to 2.0 % , and the readmission rate from 4.0 to 0.8 % . The use of PRP reduced the costs associated with the development of deep and superficial wound complications from $ 1,256,960 to $ 593,791 . Conclusions The use of PRP decreases the incidence and costs of sternal wound complications following cardiac surgery . The routine use of platelet rich plasma should be considered for all patients undergoing sternotomy for cardiac surgical procedures .Trial registration Clinical trials.gov ( NCT00130377 ) for the data registry BACKGROUND This investigation used age as a continuous variable to estimate implant survival and the risk of complications . METHODS Prospect ively collected data were used to analyze 5494 consecutive shoulder arthroplasties performed from 1970 to 2012 . Patients were a mean age of 67 years . The association between the age at the index procedure and the risk for each outcome was assessed using Cox regression and smoothing spline analysis . RESULTS Older age was associated with a decreased risk of revision surgery , revision for mechanical failure , and reoperation but with a higher risk for thromboembolic events . Reoperation rates also decreased in a linear fashion with older ages ( P < .001 ) . The risk of revision surgery decreased in a linear fashion between the ages of 40 and 85 , with a 3 % decreased risk of revision per 1-year increase in age ( P < .01 ) . This association held true in a multivariate model and when specific procedures were separated out . Compared with patients aged < 50 years , patients aged from 50 to 65 years ( P < .001 ) and those > 65 years ( P < .001 ) have decreased risks of revision surgery . The risk of a revision surgery in a patient aged > 50 years was significantly decreased ( ~13 % reduction in risk for each year ; P < .001 ) . There was a subtle association between older age and decreased rates of infection ( P = .01 ) . CONCLUSIONS There is a strong association between older age and decreased rates of revision surgery and reoperation after shoulder arthroplasty , with a striking association with decreased rates of mechanical failure . These are important considerations when counseling younger patients regarding their risks BACKGROUND Anatomic total shoulder arthroplasty ( TSA ) and reverse total shoulder arthroplasty ( RTSA ) are increasingly common procedures employed to treat arthritic conditions . Although TSA is a widely accepted procedure for glenohumeral arthritis with intact rotator cuff , concerns about RTSA persist because of variable complication rates and outcomes . METHODS This is a prospect i ve , case-control study comparing outcomes and complications after TSA and RTSA . The study included 47 patients undergoing TSA for glenohumeral arthritis and 53 patients undergoing RTSA for rotator cuff tear arthropathy . Average clinical follow-up was more than 2 years in both groups . Major complications included infection , periprosthetic fracture , instability , glenoid loosening , and need for revision surgery . Patient outcome measures included the American Shoulder and Elbow Surgeons score , pain visual analog scale score , and goniometer-measured range of motion . Plain radiographs were review ed to assess for degree of glenoid lucency in TSA and scapular notching in RTSA . RESULTS At 2 years , there were no differences in rate of major complications  ( TSA , 15 % ; RTSA , 13 % ; P = .808 ) or revision surgeries  ( TSA , 11 % ; RTSA , 9 % ) . Outcomes assessed by the American Shoulder and Elbow Surgeons score and visual analog scale were also similar between the 2 groups . TSA patients had greater external rotation than RTSA patients did ( 53 ° vs 38 ° ; P = .001 ) . Otherwise , forward flexion , abduction , and internal rotation were comparable in range of motion . CONCLUSIONS TSA and RTSA  have similar complication rates , need for revision , patient-reported outcomes , and range of motion at 2 years of follow-up . The use of side-by-side cohorts in this study allows st and ardized comparison between these 2 shoulder arthroplasty procedures HYPOTHESIS Deep infection after shoulder surgery is a rare but devastating problem . This study tested the hypothesis that the home application of a 2 % chlorhexidine gluconate cloth before shoulder surgery would be more efficacious than a st and ard shower of soap and water at decreasing the preoperative cutaneous levels of pathogenic bacteria on the shoulder . MATERIAL S AND METHODS This r and omized , prospect i ve study evaluated 100 consecutive patients undergoing shoulder surgery . Patients were r and omly assigned to use 2 % chlorhexidine gluconate-impregnated cloths ( treatment group ) or to shower with soap and water before surgery ( control group ) . Cutaneous cultures were taken from the patients ' shoulders in the preoperative holding area . Patients were monitored for 2 months postoperatively for clinical signs of infection . RESULTS In the treatment group vs the control group , the overall positive culture rate was 66 % vs 94 % ( P = .0008 ) , and the positive culture rate for coagulase-negative Staphylococcus was 30 % vs 70 % ( P = .0001 ) . The positive culture rate for Propionibacterium acnes was 46 % in the treatment group vs 58 % in the control group ( P = .32 ) . No infections occurred in any patients at a minimum of 2-months after surgery . DISCUSSION The use of the 2 % chlorhexidine cloth was effective at decreasing overall bacterial culture rates before shoulder surgery and was particularly effective at decreasing the quantity of coagulase-negative Staphylococcus , a known causative agent of postoperative shoulder infections . CONCLUSION Use of chlorhexidine impregnated cloths prior to shoulder surgery may be a useful adjunct to presently used infection prevention strategies Background Few studies have analyzed the association between elevated BMI and complications after total shoulder arthroplasty ( TSA ) . Previous studies have not consistently arrived at the same conclusion regarding whether obesity is associated with a greater number of postoperative complications . We used a national surgical data base to compare the 30-day complication profile and hospitalization outcomes after primary TSA among patients in different BMI categories . Questions / purpose sWe asked : ( 1 ) Is obesity associated with an increased risk of complications within 30 days of primary TSA ? ( 2 ) Is obesity associated with increased operative time ? Methods The American College of Surgeons National Surgical Quality Improvement Program ® data base for 2006 to 2012 was queried to identify all patients who underwent a primary TSA for osteoarthritis of the shoulder . The ACS-NSQIP ® data base was selected for this study as it is a nationally representative data base that provides prospect ively collected perioperative data and a comprehensive patient medical profile . Exclusion criteria included revision TSA , infection , tumor , or fracture . We analyzed 4796 patients who underwent a primary TSA for osteoarthritis of the shoulder . Patients who underwent a TSA  were divided in four BMI categories : normal ( 18.5–25 kg/m2 ) , overweight ( 25–30 kg/m2 ) , obesity Class 1 ( 30–35 kg/m2 ) , and obesity Class 2 or greater ( > 35 kg/m2 ) . Perioperative hospitalization data and 30-day postoperative complications were compared among different BMI classes . Differences in patient demographics , preoperative laboratory values , and preexisting patient comorbidities also were analyzed among different BMI groups , and multivariate analysis was used to adjust for any potential confounding variables . Results There was no association between BMI and 30-day complications after surgery ( normal as reference , overweight group relative risk : 0.57 [ 95 % CI , 0.30–1.06 ] , p = 0.076 ; obesity Class 1 relative risk : 0.52 [ 95 % CI , 0.26–1.03 ] , p = 0.061 ; obesity Class 2 or greater relative risk : 0.54 [ 95 % CI , 0.25–1.17 ] , p = 0.117 ) . However , greater BMI was associated with longer surgical times ( for normal BMI control group : 110 minutes , SD , 42 minutes ; overweight group : 115 minutes , SD , 46 minutes , mean difference to control : 5 minutes [ 95 % CI , −1 to 10 minutes ] , p = 0.096 ; obesity Class 1 : 120 minutes , SD , 43 minutes , mean difference : 10 minutes [ 95 % CI , 5–15 minutes ] , p < 0.001 ; obesity Class 2 or greater : 122 minutes , SD , 45 minutes , mean difference : 12 minutes [ 95 % CI , 6–18 minutes ] , p < 0.001 ) . Conclusions Although the surgical time increased for patients with greater BMI , the 30-day complications and perioperative hospitalization data after TSA were not different in patients with increased BMI levels . Obesity alone should not be a contraindication for TSA , and obese patients can expect similar incidences of postoperative complications . The preoperative medical optimization plan should be consistent with that of patients who are not obese who undergo TSA.Level of Evidence Level III , therapeutic study PURPOSE To document the skin colonization and deep tissue inoculation rates associated with  arthroscopic shoulder surgery  and how these rates differ with procedural and demographic factors . METHODS We prospect ively recruited outpatient shoulder arthroscopy patients who agreed to participate and met the inclusion criteria from February 2013 to May 2014 . All patients received routine antibiotic prophylaxis intravenously . Initial cultures were obtained before the skin preparation by swabbing the skin at the 3 st and ard portal sites : posterior , anterosuperior , and anterolateral . The skin preparation used 4 % chlorhexidine scrub and 2 % chlorhexidine gluconate/70 % isopropyl alcohol paint applied to the entire shoulder . After completion of the arthroscopic procedure , a second culture was obtained through a cannula at the surgical site . All cultures were plated for 21 days using Brucella medium . RESULTS We enrolled 51 patients over a 15-month period . Cultures showed a 72.5 % Propionibacterium acnes superficial colonization rate : 46.1 % of female and 81.6 % of male patients ( P = .027 ) . We identified a deep culture-positive inoculation rate of 19.6 % , all with positive P acnes skin colonization . No correlation could be made concerning diagnosis , procedure , suture anchor use , age , or sex . CONCLUSIONS The rate of skin colonization with P acnes is high at arthroscopic portals , especially in men . Despite st and ard skin preparation and prophylactic antibiotics , the rate of deep tissue inoculation with P acnes in shoulder arthroscopy is much higher than the rate of infection reported in the literature . CLINICAL RELEVANCE Shoulder arthroscopy introduces a significant amount of P acnes into the deep tissues BACKGROUND Although diabetes has been associated with increased perioperative morbidity and mortality after hip and knee arthroplasty , its impact on early postoperative outcomes after shoulder replacement remains relatively unexplored . The purpose of the study was to determine the association of diabetes with in-hospital death , complications , length of stay , non-homebound disposition , and cost in patients undergoing shoulder arthroplasty . METHODS By use of the Nationwide Inpatient Sample data base for the year 2011 , an estimated 66,485 patients having undergone shoulder arthroplasty were identified and separated into groups with ( 21 % ) and without ( 79 % ) diabetes mellitus . Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed by bivariate and multivariable analyses with logistic regression modeling . RESULTS Diabetes mellitus was independently associated with in-hospital death , a number of perioperative complications , prolonged hospital stay , and increased non-homebound disposition after shoulder arthroplasty . The presence of diabetes was not associated with increased hospital cost . CONCLUSION Patients with preexisting diabetes are at higher risk for perioperative morbidity and mortality after shoulder arthroplasty . Future prospect i ve research should explore in more detail the relationship between diabetes and shoulder arthroplasty outcomes Background and Objectives : This study reports our early experience with continuous  cervical paravertebral block ( CCPVB  ) using a stimulating catheter for the management of acute pain after shoulder surgery . Methods : This prospect i ve observational study presents 256 CCPVB for pain relief after 14 different shoulder operations . Surgery was performed under general anesthesia and blocks were placed prior to induction of general anesthesia ( n = 81 [ 32 % ] ) , after induction of general anesthesia ( n = 116 [ 45 % ] ) , or postoperatively in the recovery room ( n = 59 [ 23 % ] ) . A bolus dose of 30 mL of 0.5 % ropivacaine was followed by an infusion of 0.1 mL/kg/h of 0.2 % ropivacaine . Patient- or nurse-initiated bolus doses of 10 mL of the same drug were used for breakthrough pain and rescue analgesics were available . Postoperative pain , patient satisfaction , and motor function in different parts of the upper limb were evaluated immediately after surgery ( time 0 ) , and then 6 , 12 , 24 , 48 , 60 hours , and 14 days postoperatively . Results : An average of 2 ( range 1 - 7 ) attempts were needed to advance the catheter while still stimulating the nerve . Average postoperative pain ranged from 0.27 ± 1.04 cm to 0.78 ± 1.56 cm ( mean ± SD ) on a visual analog scale ( VAS ) ( 0 - 10 cm ) for the first 48 hours and 3.8 ± 2.1 cm and 3.5 ± 2.4 cm at 60 hours and 14 days , respectively . Patient satisfaction on a VAS of 0 to 5 was 4.19 ± 1.1 , 4.28 ± 1.01 , and 4.69 ± 1.05 at times 0 , 6 hours , and 14 days , respectively . Motor function returned to normal in the fingers within 24 hours and in the shoulder within 60 hours . Complications included Horner 's syndrome ( 40 % ) , dyspnea ( 8 % ) , superficial skin infection ( 5 % ) , posterior neck pain ( 22 % ) , subclavian artery puncture ( 1 % ) , contralateral epidural spread ( 4 % ) , and 8 % of the patients complained of an unpleasant “ dead feeling ” of the arm . Ninety-one percent of patients would request CCPVB again for future shoulder surgery . There was no evidence of nerve damage BACKGROUND To examine the rates and predictors of deep periprosthetic infections after  shoulder hemiarthroplasty .  METHODS We used prospect ively collected institutional registry data on all primary shoulder hemiarthroplasty patients from 1976 - 2008 . We estimated survival free of deep periprosthetic infections using Kaplan-Meier survival curves . Using univariate Cox regression analyses , we examined the association of patient-related factors ( age , sex , body mass index ) , comorbidity ( Deyo-Charlson index ) , American Society of Anesthesiologists grade , underlying diagnosis , and implant fixation with the risk of infection . RESULTS A total of 1,349 patients , with a mean age of 63 years ( SD , 16 years ) , 63 % of whom were women , underwent 1,431 primary shoulder hemiarthroplasties .  Mean follow-up was 8 years ( SD , 7 years ) . Fourteen deep periprosthetic infections occurred during the follow-up , confirmed by medical record review . The most common organisms were Staphylococcus aureus , coagulase-negative Staphylococcus , and Propionibacterium acnes , each accounting for 3 cases ( 21 % each ) . The 5- , 10- , and 20-year prosthetic infection-free rates were 98.9 % ( 95 % confidence interval [ CI ] , 98.3%-99.5 % ) , 98.7 % ( 95 % CI , 98.1%-99.4 % ) , and 98.7 % ( 95 % CI , 98.1%-99.4 % ) , respectively . None of the factors evaluated were significantly associated with risk of prosthetic infection after primary shoulder hemiarthroplasty , except that an underlying diagnosis of trauma was associated with a significantly higher hazard ratio of 3.18 ( 95 % CI , 1.06 - 9.56 ) for infection compared with all other diagnoses ( P = .04 ) . A higher body mass index showed a non-statistically significant trend toward an association with higher hazard ( P = .13 ) . CONCLUSION The periprosthetic infection rate after shoulder hemiarthroplasty was low , estimated at 1.3 % at 20-year follow-up . An underlying diagnosis of trauma was associated with a higher risk of periprosthetic infection . These patients should be observed closely for development of infection BACKGROUND In vitro , Propionibacterium acnes ( P acnes ) is highly susceptible to commonly used antibiotics and antiseptics , yet in vivo , it still causes postsurgical infections of the shoulder . We hypothesized that the local environment within the pilosebaceous gl and s protects P acnes and that incision of the skin transects these gl and s , exposing viable P acnes to the wound . METHODS Fifty consecutive patients undergoing open shoulder surgery were prospect ively studied .  Prophylactic antibiotics were administered to all patients . Microbiologic swabs of the skin surface were taken before and after skin preparation with 70 % alcoholic chlorhexidine . The skin was incised , and a further swab and dermal biopsy specimen were taken . RESULTS P acnes was cultured in 21 of 50 prepreparation skin surface swabs ( 42 % ) , 7 of 50 postpreparation skin surface swabs ( 14 % ) , 26 of 50 dermal swabs ( 52 % ) , and 20 of 50 dermal biopsy specimens ( 40 % ) . There was a significantly higher incidence of P acnes growth from the skin surface ( P = .009 ) and dermis ( P = .01 ) of patients aged ≤50 years old and in the dermal biopsy specimens of patients undergoing revision surgery ( P = .01 ) and a trend toward increased incidence of P acnes in men .  P acnes growth from a prepreparation skin surface swab had a sensitivity of 69 % , specificity of 88 % , positive predictive value of 86 % , and negative predictive value of 72 % at predicting subsequent P acnes growth from the dermal swab or biopsy specimen . CONCLUSIONS Viable P acnes persists within the skin dermis , despite st and ard antimicrobial pre caution s. These findings suggest that incising the skin is likely to lead to deep seeding of the surgical wound , which has implication s for the pathogenesis and prevention of postsurgical shoulder infections Background A concern regarding  reverse shoulder arthroplasty ( RSA )  is the possibly higher complication rate compared with conventional unconstrained shoulder arthroplasty . Questions / purpose sWe determined ( 1 ) the rate of instability and infection ; ( 2 ) whether diagnosis influenced instability and infection rates ; and ( 3 ) whether these complications affect ASES , Constant , and WOOS scores after RSA . Methods A prospect i ve data base , clinical charts , and radiographs of 284 patients who had undergone primary ( n = 212 patients ) or revision ( n = 72 patients ) RSA  were review ed to identify patients whose postoperative course was complicated by instability or infection . Results The rate of instability was similar in patients with primary ( eleven of 212 [ 5 % ) ] and revision ( six of 72 [ 8 % ] ) reverse arthroplasty . The rate of infection was higher in the revision ( five of 72 [ 7 % ] ) than in the primary ( three of 212 [ 1 % ] ) group . Patients with an irreparable subscapularis tendon had a higher rate of instability ( 14 of 123 [ 12 % ] ) compared with patients with a repairable subscapularis tendon ( one of 161 [ less than 1 % ] ) . The fracture sequelae group had the highest rate of instability ( seven of 25 [ 28 % ] ) among diagnoses within the primary group . The rates of infection were similar between the diagnoses within the primary group . The improvements in the ASES score , the Constant score , and the WOOS score from preoperatively to postoperatively were better in the no instability/infection group as compared with the instability/infection group . Conclusions This information confirms the available literature allowing surgeons to give patients realistic expectations regarding the infection and instability rates after RSA.Level of Evidence Level III , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence To evaluate the effectiveness of  closed wound drainage  in shoulder surgery , 300 patients were enrolled in a prospect i ve r and omized study . Three operations were studied : rotator cuff repair , anterior reconstruction for instability , and arthroplasty . One hundred patients were included in each group . All patients were evaluated for wound hematoma , infection , variation in postoperative rehabilitation caused by wound problems , and length of hospital stay . No statistical difference was found between the patients whose wounds were drained and those whose wounds were not drained . This finding existed within each category . Our data do not support the routine use of  closed wound drainage  in elective shoulder surgery BACKGROUND Management of periprosthetic infection after  reverse shoulder arthroplasty ( RSA )  remains a challenge . Whereas the infection rate after RSA has improved , more information would be helpful to identify patient risk factors for infection after RSA . The purpose of this study was to evaluate risk factors for infection after RSA . METHODS We identified 301 primary RSAs with a minimum of 1-year follow-up in a prospect ively collected shoulder arthroplasty registry . We performed bivariate and multivariable logistic regression analyses to assess the association between patient demographic and clinical characteristics ( age , sex , smoking , diabetes , rheumatoid arthritis , body mass index , and history of prior failed hemiarthroplasty or total shoulder arthroplasty ) and periprosthetic infection after RSA . RESULTS There were 15 periprosthetic infections after RSA ( 5.0 % ) . Patients with a history of RSA for failed arthroplasty ( odds ratio , 5.75 ; 95 % confidence interval , 2.01 - 16.43 ; P = .001 ) and patients younger than 65 years had an increased risk for development of an infection ( odds ratio , 4.0 ; 95 % confidence interval , 1.21 - 15.35 ; P = .021 ) . History of smoking , diabetes , rheumatoid arthritis , or obesity did not contribute to an increased risk of infection after RSA . CONCLUSIONS This is the first study evaluating risk factors for infection after RSA while controlling for confounding variables with multivariable analysis . The greatest risk factors for infection after RSA were history of a prior failed arthroplasty and age younger than 65 years . Patients with these clinical characteristics should be counseled preoperatively about the increased risk for development of infection after RSA Background Continuous interscalene block is the technique of choice for postoperative pain relief treatment after shoulder surgery . The authors prospect ively evaluated the modified lateral approach for the performance of the interscalene catheter block and monitored 700 patients for clinical efficacy and complications during the first 6 months after placement of the catheter . Methods A total of 700 adults scheduled to undergo elective shoulder surgery performed with an interscalene brachial plexus block through an interscalene catheter were included in this study . The interscalene brachial plexus block procedure was st and ardized for all patients . Difficulties in placement of the catheter , clinical efficacy of anesthesia and analgesia , patient satisfaction , and acute and chronic complications were recorded . Patients were observed daily for 5 days for any complications and were evaluated at 1 , 3 , and 6 months after surgery . Persistence of neurologic complication was investigated by electroneuromyography . Results A total of 700 adults completed the study . Easy placement of the catheter ( one attempt ) was achieved in 86 % of the patients . Resistance to thread the catheter was encountered in 6 % ; no major complications were observed during injection of the initial bolus . The success rate for anesthesia was 97 % . Postoperative analgesia was efficient in 99 % . The concentration and the rate of infusion of ropivacaine  had to be increased in 31 patients ( 6 % ) . In five patients ( 0.7 % ) , signs of local infection around the puncture point were noted ; in one patient ( 0.1 % ) , a collection of pus was surgically drained . Patient satisfaction was 9.6 on a scale of 0–10 . Minor neurologic complications ( paresthesias , dysesthesias , pain not related to surgery ) were observed in 2.4 % , 0.3 % , and 0 % at 1 , 3 , and 6 months , respectively . At 1 month , three sulcus ulnaris syndromes , one carpal tunnel syndrome , and one complex regional pain syndrome were diagnosed . Two patients ( 0.2 % ) had sensory-motor deficit , which necessitated 19 and 28 weeks to recover . Electromyography was suggestive of partial axonotmesis . Conclusion The lateral modified approach provides good conditions for placement of the interscalene catheter . Anesthesia and analgesia performed through the catheter are efficient . The rates of infection and neurologic complications are low , and patient satisfaction is high BACKGROUND To examine the rates and predictors of deep periprosthetic infections after  primary total shoulder arthroplasty ( TSA ) . METHODS We used prospect ively collected data on all primary TSA patients from 1976 - 2008 at Mayo Clinic Medical Center . We estimated survival free of deep periprosthetic infections after primary TSA using Kaplan-Meier survival . Univariate and multivariable Cox regression was used to assess the association of patient-related factors ( age , gender , body mass index ) , comorbidity ( Deyo-Charlson index ) , American Society of Anesthesiologists class , implant fixation , and underlying diagnosis with risk of infection . RESULTS A total of 2,207 patients , with a mean age of 65 years ( SD , 12 years ) , 53 % of whom were women , underwent 2,588 primary TSAs . Mean follow-up was 7 years ( SD , 6 years ) , and the mean body mass index was 30 kg/m(2 ) ( SD , 6 kg/m(2 ) ) . The American Society of Anesthesiologists class was 1 or 2 in 61 % of cases . Thirty-two confirmed deep periprosthetic infections occurred during follow-up . In earlier years , Staphylococcus predominated ; in recent years , Propionibacterium acnes was almost as common . The 5- , 10- , and 20-year prosthetic infection-free rates were 99.3 % ( 95 % confidence interval [ CI ] , 98.9 - 99.6 ) , 98.5 % ( 95 % CI , 97.8 - 99.1 ) , and 97.2 % ( 95 % CI , 96.0 - 98.4 ) , respectively . On multivariable analysis , a male patient had a significantly higher risk of deep periprosthetic infection ( hazard ratio , 2.67 [ 95 % CI , 1.22 - 5.87 ] ; P = .01 ) and older age was associated with lower risk ( hazard ratio , 0.97 [ 95 % CI , 0.95 - 1.00 ] per year ; P = .05 ) . CONCLUSIONS The periprosthetic infection rate was low at 20-year follow-up . Male gender and younger age were significant risk factors for deep periprosthetic infections after TSA . Future studies should investigate whether differences in bone morphology , medical comorbidity , or other factors are underlying these associations BACKGROUND Infection after shoulder surgery can have devastating consequences . Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections . Axillary hair removal has been suggested as a method for infection prevention , although data quantifying its effect on the bacterial load around the shoulder are lacking . METHODS We clipped  one r and omly selected axilla in 85 healthy male volunteers with commercially available surgical clippers . Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae . Each shoulder was then prepared with 2 % chlorhexidine gluconate and 70 % isopropyl alcohol . Repeated culture specimens were then taken from both axillae . Cultures were held for 14 days and recorded with a semiquantitative system ( 0 - 4 points ) . Results were compared by the Wilcoxon signed rank test . RESULTS There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation ( P = .109 , P = .344 , respectively ) . There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation ( P < .001 ) but not after preparation ( P = .285 ) . There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation ( P < .001 for all ) . CONCLUSIONS Removal of axillary hair has no effect on the burden of P. acnes in the axilla . Clipped axillae had a higher total bacterial burden . A 2 % chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla Background and Objectives : Large prospect i ve studies evaluating continuous interscalene block for shoulder surgery have thus far been limited to inpatient and university teaching practice s. Shoulder surgery is increasingly being performed on an outpatient basis . The aim of this case series was to prospect ively evaluate a large series of interscalene catheters for ambulatory shoulder surgery in a private practice setting . Methods : A single operator placed nonstimulating catheters using a combination of ultrasound and nerve stimulation . Following postanesthesia care unit ( PACU ) discharge , opioid‐like analgesic adjuvants other than tramadol were avoided unless patients experienced inadequate pain relief . All patients were assessed in the PACU , on the first postoperative morning , and at 3 weeks for catheter effectiveness and for acute and chronic complications . Pain scores and patient satisfaction were assessed in subgroups of 100 consecutive patients . Results : Three hundred patients were studied .  The first attempt catheter success rate was 96 % . In all but 1 patient , ineffective catheters in the PACU were effectively reinserted . Thirteen patients experienced inadequate pain relief after leaving the PACU . Of these patients , 5 were rescued with additional ropivacaine , 3 had the catheter effectively reinserted , and 5 were managed with oral opioids . One patient required antibiotic treatment for catheter site infection . Neurological sequelae potentially attributable to the catheter were present in 3 patients at 3 weeks , and remained in 1 patient at 4 weeks . This patient 's symptoms resolved at 6 months . Conclusions : Continuous interscalene block for ambulatory shoulder surgery in a private practice setting had a high success rate , a low complication rate , and enabled the avoidance of the use of potent opioids in 98 % of patients BACKGROUND Recent studies have identified Propionibacterium acnes as the causal organism in an increasing number of postoperative shoulder infections . Most reports have found a high rate of P acnes infection after open surgery , particularly shoulder arthroplasty . However , there are limited data regarding P acnes infections after shoulder arthroscopy . MATERIAL S AND METHODS We prospect ively collected data on all shoulder arthroscopies performed by the senior author from January 1 , 2009 , until April 1 , 2013 . Cultures were taken in all revision shoulder arthroscopy  cases performed for pain , stiffness , or weakness . In addition , 2 cultures were taken from each of a cohort of 32 primary shoulder arthroscopy cases without concern for infection to determine the false-positive rate . RESULTS A total of 1,591 shoulder arthroscopies were performed during this period , 68 ( 4.3 % ) of which were revision procedures performed for pain , stiffness , or weakness . A total of 20 revision arthroscopies ( 29.4 % ) had positive culture findings , and 16 ( 23.5 % ) were positive for P acnes . In the control group , 1 patient ( 3.2 % ) had P acnes growth . CONCLUSIONS The rate of P acnes infection in patients undergoing revision shoulder arthroscopy  is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness Background Frozen shoulder has not previously been shown to be associated with infection . The present study set out to confirm the null hypothesis that there is no relationship between infection and frozen shoulder using two modern scientific methods , extended culture and polymerase chain reaction ( PCR ) for bacterial nucleic acids . Methods A prospect i ve cohort of 10 patients undergoing arthroscopic release for stage II idiopathic frozen shoulder had  two biopsies of tissue taken from the affected shoulder joint capsule at the time of surgery , along with control biopsies of subdermal fat . The biopsies and controls were examined with extended culture and PCR for microbial nucleic acid . Results Eight of the 10 patients had positive findings on extended culture in their shoulder capsule and , in six of these , Propionibacterium acnes was present . Conclusions The findings mean that we must reject the null hypothesis that there is no relationship between infection and frozen shoulder . More studies are urgently needed to confirm or refute these findings . If they are confirmed , this could potentially lead to new and effective treatments for this common , painful and disabling condition . Could P. acnes be the Helicobacter of frozen shoulder BACKGROUND Deep infection following shoulder surgery is a rare but devastating problem . The use of an effective skin-preparation solution may be an important step in preventing infection . The purpose s of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder . METHODS A prospect i ve study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution . Each shoulder was prepared with one of three r and omly selected solutions : ChloraPrep ( 2 % chlorhexidine gluconate and 70 % isopropyl alcohol ) , DuraPrep ( 0.7 % iodophor and 74 % isopropyl alcohol ) , or povidone-iodine scrub and paint ( 0.75 % iodine scrub and 1.0 % iodine paint ) . Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients , to determine the native bacteria around the shoulder , and following skin preparation for all patients . RESULTS Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation . The overall rate of positive cultures was 31 % in the povidone-iodine group , 19 % in the DuraPrep group , and 7 % in the ChloraPrep group . The positive culture rate for the ChloraPrep group was lower than that for the povidone-iodine group ( p < 0.0001 ) and the DuraPrep group ( p = 0.01 ) . ChloraPrep and DuraPrep were more effective than povidone-iodine in eliminating coagulase-negative Staphylococcus from the shoulder region ( p < 0.001 for both ) . No significant difference was detected among the agents in their ability to eliminate Propionibacterium acnes from the shoulder region . No infections occurred in any of the patients treated in this study at a minimum of ten months of follow-up . CONCLUSIONS ChloraPrep is more effective than DuraPrep and povidone-iodine at eliminating overall bacteria from the shoulder region . Both ChloraPrep and DuraPrep are more effective than povidone-iodine at eliminating coagulase-negative Staphylococcus from the shoulder
target: Conclusion There are many risk factors associated with developing an infection after elective shoulder surgery .
  The findings of this systematic review are clinical ly relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden .
background: Purpose Infection is a concern after all orthopedic procedures , including shoulder surgery .
  This systematic review of literature aim ed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery .