Shoulder surgery preparation: a systematic review and meta-analysis

Shoulder infections are an unfortunate and serious complication of surgery. The prevention strategy for infections is multimodal, with a strong reliance on surgical preparation solutions. There is great variability in the use of and effectiveness of surgical preparation solutions; this review aims to identify the most effective methods of shoulder surgical site preparation in the literature.

A systematic review and meta-analysis was conducted by 2 independent reviewers in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) framework. Articles were screened by title, then abstract, and finally by full text by each clinician independently. A third orthopedic clinician adjudicated any disagreement on the application of the inclusion criteria. Studies included were human clinical studies utilizing skin preparation methods for the shoulder in a simulated or real primary surgery setting. English language databases from 1980 until the first of January 2025 were accessed. The terms searched included "shoulder," combined with each of the terms "skin," "wound," "antibiotic," "decolonization," "topical," "eradication," "preparation," and "sterilization." The results were pooled and then analyzed in subgroups according to the timing of skin preparation, the solution used, and the area of sampling.

The search found 13,154 articles, of which 31 studies were included in the final study and captured a total of 2,115 patients who were cultured for organisms. The lowest rates of culture positivity at the time of surgery were associated with the use of benzoyl peroxide (27.1% culture positive) and prior-to-day-of-surgery preparation solution administration (30.5% culture positive). Patients who received preparation solutions with alcohol numbered 1,551, of which 577 (37.2%) had positive cultures. Patients who received preparation solutions without alcohol numbered 564, with 140 (24.8%) culture positive, P < .0001, chi-square = 28.285. Patients who had shoulder preparation only on the day of surgery numbered 2,067 with a total of 703 (34%) with positive cultures. The patients who did not have day-of-surgery preparation were numbered at 39, with 9 (23%) positive cultures, P = .027, chi-square = 4.89.

There is a wide range of available surgical preparation solutions to attempt to prevent day-of-surgery culture positivity. However, even the most robust regiments still have a substantially high culture positivity rate at the time of surgery. Further trials are warranted to unify protocols for the management of perioperative shoulder preparation.