One-Stage or Two-Stage Revision for Infected Shoulder Arthroplasty: A Head-to-Head Meta-Analysis of Comparative Studies

Clinical Snapshot

Key Findings

• P Value: Reinfection: p=0.06; Infection control success: p=0.48; Overall complications: p=0.24

• Effect Size: Reinfection: OR 0.46 (favours single-stage); Infection control success: OR 1.57 (favours single-stage); Overall complications: OR 0.52 (favours single-stage) — all non-significant

• Primary Outcome: Reinfection rate and infection control success comparing single-stage versus two-stage revision for shoulder PJI

• Nnt Or Sensitivity: No NNT calculable given non-significant results and wide CIs. Heterogeneity: I²=0% for reinfection and complications; I²=17% for infection control success. GRADE certainty: Low for all outcomes.

• Confidence Interval: Reinfection: 95% CI 0.21–1.04; Infection control success: 95% CI 0.45–5.40; Overall complications: 95% CI 0.18–1.53

Clinical Application

Single-stage revision is technically feasible in appropriately selected patients and offers potential advantages including reduced surgical burden, shorter hospitalisation, lower cumulative anaesthetic risk, and avoidance of the functional and psychological morbidity associated with a spacer interval. However, patient selection criteria remain undefined by current evidence. Two-stage revision remains the more widely practised approach in high-volume shoulder arthroplasty centres globally. In Australia, shoulder arthroplasty volumes have increased substantially, with reverse total shoulder arthroplasty now the dominant implant type. PJI management falls within the scope of orthopaedic surgeons with shoulder subspecialty training. The TGA does not specifically regulate the choice of revision strategy. No PBS-listed antibiotic spacer products exist specifically for shoulder PJI; antibiotic-loaded cement spacers are used off-label. RACGP guidelines do not address surgical revision strategy for shoulder PJI directly — this remains a specialist decision. Australian surgeons should note that the evidence base is insufficient to deviate from individualised, multidisciplinary decision-making. Referral to high-volume shoulder revision centres is appropriate given the rarity and complexity of shoulder PJI. The findings do not support a protocol-level change in Australian practice at this time. Adult patients with confirmed periprosthetic joint infection following shoulder arthroplasty (total shoulder, reverse total shoulder, or hemiarthroplasty) being considered for revision surgery. Most applicable to chronic PJI presentations where the choice between single- and two-stage revision is clinically contested.

Abstract

BACKGROUND: Periprosthetic joint infection (PJI) following shoulder arthroplasty is a devastating complication associated with substantial morbidity and revision burden. While 2-stage revision has traditionally been regarded as the gold standard for chronic shoulder PJI, single-stage revision has emerged as a potential alternative. The aim of this systematic review was to directly compare infection-related outcomes and complications between single-stage and 2-stage revision arthroplasties for shoulder PJI. METHODS: This systematic review was prospectively registered with PROSPERO (CRD420251159566) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, EMBASE, and Web of Science were searched up to September 22, 2025. Comparative observational studies and randomized controlled trials (RCTs) evaluating single-stage vs. 2-stage revision for shoulder PJI in adults were eligible; no RCTs were identified. Primary outcomes were reinfection and infection control success; overall complications were secondary. Odds ratios (ORs) were calculated within each study and pooled using a random-effects model. Risk of bias was assessed with the Risk of Bias in Non-randomized Studies of Interventions tool, and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. RESULTS: Thirteen retrospective comparative studies involving 260 patients (127 single-stage and 133 two-stage) were included. Compared with 2-stage revision, single-stage revision showed a lower, but not statistically significant, odds of reinfection (OR 0.46, 95% confidence interval [CI] 0.21-1.04; p = 0.06; I2 = 0%) and overall complications (OR 0.52, 95% CI 0.18-1.53; p = 0.24; I2 = 0%) and a higher, but nonsignificant, odds of infection control success (OR 1.57, 95% CI 0.45-5.40; p = 0.48; I2 = 17%). CONCLUSION: Single-stage revision demonstrated infection control and complication rates comparable with 2-stage revision for shoulder PJI. Although no statistically significant differences were observed, trends favored single-stage revision. Given that the certainty of the evidence was graded as low, these findings should be interpreted with caution, and high-quality RCTs are required to define optimal patient selection and surgical strategy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

References

1. 1.Selim, A., Ibrahim, A., Abbas, A., Sadiq, S., Farhan-Alanie, M. M., Ahmed, M. L., & Rhee, J. (2026). One-stage or two-stage revision for infected shoulder arthroplasty: A head-to-head meta-analysis of comparative studies. JBJS Reviews. Advance online publication. https://doi.org/10.2106/JBJS.RVW.26.00055