Two-stage revision of infected shoulder arthroplasty using prosthesis of antibiotic-loaded acrylic cement: minimum three-year follow-up

Debridement Technique for Single-Stage Revision Shoulder Arthroplasty

Background

The incidence of revision shoulder arthroplasty continues to rise, and infection is a common indication for revision surgery. Treatment of periprosthetic joint infection (PJI) in the shoulder remains a controversial topic, with the literature reporting varying methodologies, including the use of debridement and implant retention, single-stage and 2-stage surgeries, antibiotic spacers, and resection arthroplasty20. Single-stage revision has been shown to have a low rate of recurrent infection, making it more favorable because it precludes the morbidity of a 2-stage operation. The present video article describes a meticulous debridement technique as it applies to revision shoulder arthroplasty.

Description

The previous deltopectoral incision should be utilized, with extension 1 to 1.5 cm proximally and distally, removing any draining sinuses. First, develop subcutaneous flaps above the muscle layer to better establish normal tissue planes. A large medial subcutaneous flap will allow for identification of the superior border of the pectoralis major. The pectoralis can be traced laterally to its humeral insertion, which is often in confluence with the deltoid insertion. Hohmann retractors can be placed sequentially, working distal to proximal, under the deltoid in order to recreate the subdeltoid space. Next, reestablish the subpectoral space by releasing any scar tissue tethering the pectoralis muscle and conjoined tendon. Dislocate the prosthesis and remove modular components. Restore the subcoracoid space by dissecting between the subscapularis and the conjoined tendon, allowing for axillary nerve identification. Complete a full capsular excision circumferentially around the glenoid, taking care to protect the axillary nerve as it passes from the subcoracoid space under the inferior glenoid to the deltoid muscle. The decision to remove well-fixed components should be made by the surgeon. Any exposed osseous surfaces should undergo debridement to reduce bacterial burden. Reimplantation should focus on obtaining stable bone-implant interfaces to minimize any micromotion that may increase risk of reinfection. Our preference is to irrigate with 9 L of normal saline solution, Irrisept (Irrimax), and Bactisure Wound Lavage (Zimmer Biomet). Multiple cultures should be taken and followed carefully postoperatively to allow tailoring of the antibiotic regimen with infectious disease specialists.

Alternatives

Two-stage revision is the most common alternative treatment for shoulder PJI and consists of removal of components, debridement, and delayed component reimplantation; however, it requires at least 1 return to the operating room for definitive treatment.

Rationale

Serum laboratory studies and joint aspiration are not reliable predictors of shoulder PJI because of the high rate of Cutibacterium acnes infections21,22. The incidence of unexpected positive cultures in seemingly aseptic revisions ranges from 11% to 52.2%6-8,23,24. It is prudent for all revision shoulder arthroplasties to be treated as involving a presumed infection, with thorough debridement, because of the high rate of unexpected positive cultures and the greater prevalence of low-virulence organisms in shoulder arthroplasty for PJI.

Expected Outcomes

The International Consensus Meeting guidelines for PJI were developed in 2018, and patients with higher Infection Probability Scores are theorized to have higher rates of recurrence19,21. With meticulous debridement, the rate of recurrent infections requiring reoperation is just 5% following 1-stage revision shoulder arthroplasty, averaged across all Infection Probability Scores19.

Important Tips

Ensure that an adequate incision is made in order to allow for identification of the deltoid origin on the clavicle and insertion on the humerus.The superior border of the pectoralis major can be traced laterally to the humerus to correctly identify the deltopectoral interval.Subdeltoid dissection is complete when you are able to identify deep deltoid fibers superficially, rotator cuff tendon posteriorly, and humeral bone. Exposure can be improved by abducting and internally rotating the humerus.Capsule excision around the glenoid is complete when the subscapularis can be visualized anteriorly, the fatty tissue of the inferior glenoid space inferiorly, and the rotator cuff tendon (or subdeltoid space if the cuff is absent) posteriorly and superiorly.

Acronyms and Abbreviations

PJI = periprosthetic joint infectionC. acnes = Cutibacterium acnesUPC = unexpected positive cultureIS score = Infection Probability ScoreDAIR = debridement, antibiotics, and implant retentionCT = computed tomographyWBC = white blood cellCRP = C-reactive proteinESR = erythrocyte sedimentation rateCHG = chlorhexidine gluconateAC = acromioclavicularGT = greater tuberositySGHL = superior glenohumeral ligament.

One- vs. Two-Stage Revision for Periprosthetic Shoulder Infections: A Systematic Review and Meta-Analysis

Periprosthetic shoulder infection (PSI) remains a challenging complication after shoulder arthroplasty. Therapeutic options include one- or two-stage revision, irrigation and debridement, and resection arthroplasty. With our systematic review and meta-analysis, we aimed to compare one- and two-stage revisions for periprosthetic shoulder joint infections and determine the most appropriate therapeutic procedure. We performed an extensive literature search in PubMed, Ovid Medline, Cochrane Library, Web of Science, and CINAHL and filtered out all relevant studies. The meta-analysis was performed using the random-effects model, heterogeneity was analyzed using I2, and publication bias was assessed using the Egger's test. A total of 8 studies with one-stage revisions, 36 studies with two-stage revisions, and 12 studies with both one-stage and two-stage revisions were included. According to the random-effects model, the reinfection rate for the entirety of the studies was 12.3% (95% Cl: 9.6-15.3), with a low-to-moderate heterogeneity of I2 = 47.72%. The reinfection rate of the one-stage revisions was 10.9%, which was significantly lower than the reinfection rate of the two-stage revisions, which was 12.93% (p = 0.0062). The one-stage revision rate was significantly lower with 1.16 vs. 2.25 revisions in the two-stage revision group (p < 0.0001). The postoperative functional outcome in one-stage-revised patients was comparable but not statistically significant (p = 0.1523). In one- and two-stage revisions, most infections were caused by Cutibacterium acnes. In summary, our systematic review and meta-analysis show the superiority of single-stage revision regarding reinfection and revision rates in periprosthetic shoulder joint infection.

Periprosthetic shoulder infection management: one-stage should be the way: a systematic review and meta-analysis

BACKGROUND

There is still no consensus among surgeons on whether to perform a 1- or 2-stage surgical revision in infected shoulder arthroplasties. The aim of this systematic review and meta-analysis is to rigorously synthesize published studies evaluating the clinical outcomes, recurrence of infection, and other clinical complications in order to discuss which is the best strategy for treating periprosthetic joint infection after shoulder arthroplasty.

METHODS

Upon research using the PubMed, Scopus, and Web of Science databases, in November 2022, studies that presented 1- or 2-stage surgical revision as a treatment for periprosthetic joint infection after shoulder arthroplasty and assessed the reinfection rate on these patients, as well as other clinical outcomes, with a minimum follow-up of 12 months, were included. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) score. Reinfection and complication rates were extracted, and pooled estimates were calculated using the random-effect model.

RESULTS

After careful screening, 44 studies were included, 5 reporting on 1-stage and 30 on 2-stage revisions and 9 assessing both strategies. A total of 185 shoulders were reported in 1-stage revision studies, whereas 526 shoulders were reported in 2-stage revision studies. The overall pooled random-effects reinfection rate was 6.68% (95% confidence interval [CI]: 3.76-10.13), with low heterogeneity (I2 = 28%, P = .03). One-stage revision showed a reinfection rate of 1.14% (95% CI: 0.00-4.88), whereas 2-stage revision analysis revealed a reinfection rate of 8.81% (95% CI: 4.96-13.33). There were significant statistical differences between 1- and 2-stage reinfection rates (P = .04). The overall pooled rate for other clinical complications was 16.76% (95% CI: 9.49-25.15), with high heterogeneity (I2 = 70%, P < .01). One-stage revision had a complication rate of 6.11% (95% CI: 1.58-12.39), whereas the 2-stage revision complication rate was 21.26% (95% CI: 11.51-32.54). This difference was statistically significant (P = .03).

CONCLUSIONS

This is the first systematic review and meta-analysis showing significant statistical differences between 1- and 2-stage surgical revision in infected shoulder arthroplasties. Provided the right conditions exist, 1-stage revision shows better results in infection control, with lower clinical complications and possible better clinical outcomes.

Management of periprosthetic joint infection of shoulder arthroplasty: Single-stage versus two-stage protocols. A systematic review and meta-analysis of the literature

Background

The treatment of shoulder prosthetic joint infections (PJIs) requiring removal of the prosthesis is not well defined. This article aims to systematically review and compare the results of the literature in single-stage and two-stage protocols in the treatment of shoulder PJI.

Methods

An in-depth search on PubMed/Scopus/Web of Science databases and cross-referencing search was carried out concerning the articles reporting detailed data on the topic.

Results

A total of 486 shoulder PJIs were included: 137 treated with single-stage and 349 with two-stage procedure. A similar distribution between early and not-early infections (19.1% vs 80.9%) was found between the two groups. The overall rate of success in terms of PJI eradication was significantly higher in the single-stage group (95.6% vs 85.7%, p < 0.001). The non-infection-related complications rate was 13.8% in the single-stage group and 37.6% in the two-stage group (p < 0.001), the non-infection-related revision rate was 8% and 18.9%, respectively (p = 0.005).

Discussion

The single-phase protocol showed a higher success rate in eradicating the infection and a lower complication rate. However, the low number of patients included, the low quality of the articles, the lack of data on clinical severity and bacteriological virulence suggest caution in conclusions.

One Versus 2-Stage Revision for Shoulder Arthroplasty Infections: A Systematic Review and Analysis of Treatment Selection Bias

BACKGROUND

There is controversy regarding the optimal treatment for infection following shoulder arthroplasty. The purpose of this systematic review is to analyze the bias in treatment selection, infection clearance rates, and functional outcomes after 1 versus 2-stage revision surgery for periprosthetic shoulder infections.

METHODS

A systematic search strategy following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted in 4 phases. Articles were identified using MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases with Boolean search terms related to infection after shoulder arthroplasty. Included articles were analyzed for quality, and data were extracted for use. Preoperative treatment selection bias was analyzed and postoperative infection clearance rates and functional outcome scores were compared between 1 and 2-stage revision surgery for periprosthetic shoulder infection.

RESULTS

Overall, 163 1-stage shoulder procedures and 289 2-stage shoulder procedures were included in the analysis. Cutibacterium acnes was the organism most frequently grown on culture (37%) followed by coagulase-negative Staphylococcus (19%). The overall infection clearance rate was 95.6% for 1-stage and 85.2% for 2-stage procedures. In a comparison of the change in outcome scores from preoperatively to postoperatively between 1-stage and 2-stage revision, the Constant-Murley Score (CMS) improved 21.0 points (1-stage) versus 22.8 points (2-stage), the American Shoulder and Elbow Surgeons (ASES) score improved 26.2 points versus 33.6 points, and the Simple Shoulder Test (SST) score improved 3.5 points versus 6.4 points, respectively. Overall, 23 of 26 studies cited a reason for selection of a 1 versus 2-stage procedure, which was due to standard treatment protocol in 10 studies, based on the timing of the infection (acute versus subacute versus chronic) in 5, due to a combination of factors (age, comorbidities, intraoperative appearance, adequacy of debridement, bone loss) in 6, and due to preoperative identification of a specific organism in 2.

CONCLUSIONS

One-stage revisions resulted in higher infection clearance rates; however, 2-stage revisions resulted in greater functional improvement as measured with ASES and SST scores from the preoperative assessment to the final postoperative follow-up. The decision between 1 and 2-stage revisions is due to a combination of factors including pathogen type, timing of infection, findings on the preoperative clinical examination, the patient's own decision, the surgeon's preference, and the intraoperative soft-tissue/osseous appearance, which may have biased the overall results. There is no consensus in the literature on the decision between 1 and 2-stage treatment for periprosthetic shoulder infection, which is based on a combination of factors. However, both treatment strategies are effective in treating periprosthetic shoulder infection.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcome and complications following revision shoulder arthroplasty : a systematic review and meta-analysis

AIMS

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis.

RESULTS

A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores.

CONCLUSION

Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618-630.

Single-stage versus two-stage revision for shoulder periprosthetic joint infection: a systematic review and meta-analysis

BACKGROUND

Shoulder periprosthetic joint infection (PJI) is a significant complication after arthroplasty with high morbidity. An evidence-based algorithm for the treatment of shoulder PJI is lacking in current practice. The purpose of this systematic review and meta-analysis was to understand and compare the role of single- and 2-stage shoulder arthroplasty revision for PJI.

METHODS

A comprehensive literature review was performed to identify all studies related to shoulder arthroplasty for PJI in PubMed, Scopus, and EMBASE. Inclusion criteria for this systematic review were studies that reported on single- or 2-stage revision, with infection eradication and a minimum follow-up of 12 months and a minimum of 5 patients for analysis. A random-effects meta-analysis was performed, and heterogeneity was assessed with Cochrane Q and I2.

RESULTS

A total of 13 studies reporting on single-stage revision and 30 studies reporting on 2-stage revision were included in final analysis. The majority of positive cultures from single-stage revision for PJI resulted in Cutibacterium acnes with 113 of 232 (48.7%) reported cases compared with 190 of 566 (33.7%) reported cases for 2-stage revision. However, there was a lower percentage of methicillin-resistant Staphylococcus aureus positive cultures, with 2.5% for single-stage compared with 9.7% for 2-stage revision. The overall pooled random-effect reinfection incidence was 0.05 (95% confidence interval: 0.02-0.08), with moderate heterogeneity (I² = 34%, P = .02). The reinfection rate was 6.3% for single-stage and 10.1% for 2-stage revision, but this was not significant (Q = 0.9 and P = .40).

CONCLUSION

Based on a systematic review with meta-analysis, single-stage revision for shoulder PJI is an effective treatment. Indeed, our analysis showed single-stage to be more effective than 2-stage, but this is likely confounded by a treatment bias given the higher propensity of virulent and drug-resistant bacteria treated with 2-stage in the published literature. This implies that shoulder surgeons treating PJI can be reassured of a low recurrence rate (6.3%) when using single-stage treatment for C acnes or other sensitive, low-virulence organisms.

Permanent Spacers Are a Reliable Solution for Peri-prosthetic Shoulder Infection: A Systematic Review

BACKGROUND

Peri-prosthetic shoulder infection (PSI), a highly disabling complication of shoulder arthroplasty, often requires additional surgery and prolonged antibiotic therapy. Of strategies proposed to manage this devastating condition, the use of cement spacers, perhaps even as a definitive treatment, is debated.

QUESTIONS/PURPOSES

We sought to systematically review the literature on antibiotic-loaded cement spacers as a viable, perhaps definitive, treatment for PSI, evaluating the eradication rates, mechanical reliability, and functional results related to its use.

METHODS

We conducted a systematic review of studies published from January 1, 1980, through September 1, 2019. Following the Cochrane Handbook of Systematic Reviews of Interventions and Preferred Reporting Items for Systematic Review and Meta-analysis, we searched for studies reporting functional and clinical outcomes in patients with PSI treated with a permanent spacer of the shoulder. Two independent reviewers searched eight databases, as well as reference lists of the retrieved articles.

RESULTS

After exclusion criteria were applied, 12 studies were included, involving a total of 143 patients. The mean age was 65.8 years; the mean follow-up was 37.4 months. A total of 133 patients (93%) were free from infection at latest follow-up. The mean post-operative active elevation of the shoulder ranged from 48.6 to 90°, the mean abduction ranged from 51 to 75°, and external rotation ranged from 3.6 to 29°. The mean Constant-Murley score ranged from 20.6 to 42 points (out of 100, from worst to best).

CONCLUSION

The use of a permanent cement spacer is a reliable solution to PSI in low-demand, older patients with comorbidities, a population in whom it is desirable to avoid additional surgery. Our review found a high rate of infection eradication and moderate-to-good objective and subjective results. However, the overall level of evidence of included studies was very low, and higher-quality studies are needed to clarify the role of permanent spacers in the treatment of PSI.

[Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture]

OBJECTIVE

To summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture.

METHODS

Between June 2014 and January 2018, 17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated. There were 8 males and 9 females, aged from 52 to 78 years (mean, 63.8 years). The infection occurred at 19-66 months after the initial internal fixation (mean, 34.8 months). Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases. The preoperative Constant score, American shoulder and elbow surgeons (ASES) score, and visual analogue scale (VAS) score were 36.41±8.65, 31.06±7.43, and 7.29±0.99, respectively. The preoperative ranges of forward flexion, abduction, external rotation were (45.88±12.46), (42.18±12.31), and (16.76±4.92)°, respectively. The preoperative range of internal rotation was buttock in 9 cases, lumbosacral joint in 3 cases, L 3 in 5 cases. At the first-stage surgery, the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation. After the infections disappeared, the two-stage reverse total shoulder arthroplasty was performed. The mean interval between the two procedures was 4.2 months (range, 3.0-6.5 months).

RESULTS

All the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred. All patients were followed up 15-32 months (mean, 22.0 months). At last follow-up, the ranges of forward flexion, abduction, and external rotation were (109.00±23.66), (98.53±16.92), (41.41±6.82)°, respectively; and the range of internal rotation was lumbosacral joint in 5 cases, L 3 in 8 cases, T 12 in 4 cases. The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion ( P<0.05). The Constant score (64.88±8.70), ASES score (65.18±8.10), and VAS score (2.94±1.25) were significantly superior to the preoperative scores ( P<0.05). X-ray films showed that no prosthesis loosening occurred.

CONCLUSION

Two-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture, which has advantages of low risk of infection recurrence, good shoulder function, and satisfactory short-term effectiveness.

One- or two-stage exchange for periprosthetic shoulder infection: Systematic review and meta-analysis

INTRODUCTION

One-stage exchange is the gold-standard for management of periprosthetic shoulder infection. The present review compares efficacy between 1- and 2-stage exchange in this indication.

MATERIAL AND METHODS

We performed a systematic literature review and meta-analysis following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) criteria. The literature search used the Medline, Embase and Central data-bases. The studies included assessed 1- and 2-stage exchange in periprosthetic shoulder infection. The main outcome was reinfection rate, and the secondary outcome postoperative complications rate.

RESULTS

Twenty-one studies, for 501 patients, were included: 5 assessing 1-stage exchange, 11 2-stage, and 5 both. Mean follow-up was 4.3 years (range, 2-6.1 years). Mean reinfection rates ranged between 0 and 50% in 1-stage exchange and between 0 and 36.8% in 2-stage exchange. The combined rate was 7% (95% CI, 3.8-12.5%) in 1-stage and 21.3% (95% CI, 16-27.9%) in 2-stage exchange. Mean complications rates ranged between 0 and 50% in 1-stage exchange and between 5.7% and 73%% in 2-stage exchange. The combined rate was 17% (95% CI, 11.9-23.9%) in 1-stage and 32.8% (95% CI, 25.8-40.6%) in 2-stage exchange.

DISCUSSION

To our knowledge, the present meta-analysis is the first to assess results in 1- and 2-stage exchange for chronic periprosthetic shoulder infection.

CONCLUSION

One-stage exchange seemed to provide better results, with less reinfection and fewer complications than 2-stage exchange.

LEVEL OF EVIDENCE

I, meta-analysis.

Outcomes of revision surgery after periprosthetic shoulder infection: a systematic review

BACKGROUND

Periprosthetic shoulder infection (PSI) is one of the most challenging complications after shoulder arthroplasty. Different treatments have been proposed, but the best surgical procedure remains disputed in the current literature. This systematic review investigated the outcomes of revision surgery after PSI.

METHODS

The PubMed and Scopus databases were used to search keywords in April 2018. Of 2157 titles, 34 studies were finally analyzed. Demographics, laboratory and microbiological data, types of implants, surgical techniques with complications and reoperations, eradication rates, and clinical and functional outcomes were reported.

RESULTS

A total of 754 patients were identified. Cutibacterium acnes (C. acnes) was the most common microorganism found both in PSI (33%) and persistent infections (40%). Preoperatively, C-reactive protein was elevated in 70% of patients with PSI. Reverse shoulder arthroplasty had a lower prevalence of infection (P < .001). The eradication rate was 96% with 1 stage, 93% with permanent spacers, 86% with 2 stages, 85% with resection arthroplasty, and 65% with irrigation and débridement. One-stage revision was the best treatment, considering postoperative flexion and abduction, compared with resection arthroplasty, permanent spacers, and 2-stage revision. One-stage revision showed fewer postoperative complications than irrigation and débridement, resection arthroplasty, and 2-stage surgery. Two-stage surgery was the most common treatment, and the functional score demonstrated no differences between 2-stage and 1-stage procedures.

CONCLUSIONS

Our review suggests that a 1-stage procedure should be recommended to treat PSI. Two-stage revision could be reserved for select cases in which the bacterium involved is unknown.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.

One- and two-stage surgical revision of infected shoulder prostheses following arthroplasty surgery: A systematic review and meta-analysis

Periprosthetic joint infection (PJI) is a catastrophic complication of shoulder arthroplasty. Commonly used surgical treatments include one- or two-stage revision, but their effectiveness in controlling infection is uncertain. We aimed to compare re-infection (recurrent and new infections) rates; clinical measures of function and pain; and noninfection complication rates of one- and two-stage revision surgery for shoulder PJI using a systematic review and meta-analysis. We searched MEDLINE, Embase, Web of Science, and The Cochrane Library to February 2018. Longitudinal studies conducted in patients with shoulder PJI treated exclusively by one- or two-stage revision were eligible. No clinical trials were identified. Re-infection rates were meta-analysed using random-effect models after arcsine transformation. The re-infection rate (95% CI) in pooled analysis of eight one-stage studies (147 participants) was 5.3% (1.4-10.6). The corresponding rate for 27 two-stage studies (351 participants) was 11.5% (6.0-18.1). Postoperative clinical measures of function and pain were not significantly different between the two revision strategies. The pooled noninfection complication rate (95% CI) for one-stage and two-stage revision was 12.1% (6.1-19.5) and 18.9% (8.4-31.9) respectively. New evidence suggests one-stage revision is at least equally as effective as the two-stage in controlling infection, maintaining joint function, and improving complications in shoulder PJI.