{"paper_id":"2bea906e-bfd5-4b89-8970-14038c7688a3","body_text":"Concordance of three different methods to obtain samples for culture in reverse total shoulder arthroplasty. A prospective study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Concordance of three different methods to obtain samples for culture in reverse total shoulder arthroplasty. A prospective study. Carlos Torrens, Raquel Companys, Amaya Suárez-López, Daniel Pérez-Prieto, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5226593/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Mar, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted 9 You are reading this latest preprint version Abstract Purpose The objective of this study was to analyze the concordance of the results obtained when culturing samples that are obtained with three different methods. Methods Prospective study that includes primary Reverse shoulder arthroplasties. From all the patients, 9 cultures were obtained. There were 3 cultures obtained from skin at the beginning of surgery, 3 from the tissue around the insertion of the long biceps on the glenoid side and 3 from the tissue around the greater tuberosity on the humeral side. At each location one culture was obtained from a swab, another one was obtained from the instruments on the table, and another one was obtained from a newly-opened set of instruments. Results There were 87 patients included, leaving 783 culture samples for the analysis. Of those 783 samples, 69 turned to be positive: 57 were positive for C. acnes , 5 for S. epidermidis , 4 for other coagulase-negative staphylococcus and 3 were positive for other indolent microorganisms. Comparing the results obtained with the three different methods, the kappa coefficient for all positive cultures was 0.1894 for cultures taken from skin, 0.4891 for cultures from the glenoid and 0.5456 for cultures from the greater tuberosity. Therefore, the kappa coefficient obtained for the three different locations ranged from poor to moderate. Conclusion The samples obtained with swab, tissue cultures taken with the instruments of the table and tissue cultures taken with new sets of instruments lead to different culture results in shoulder arthroplasty. culture swab contamination infection reverse shoulder arthroplasty. INTRODUCTION Periprosthetic shoulder infection constitutes the most devastating complication in shoulder arthroplasty. Isolation of the causative bacteria is crucial not only for diagnostic purposes but also to facilitate the start-up of the targeted antibiotic therapy. Bacteria isolation is a major criterion of infection in the most used definitions of periprosthetic joint infections, including the one defined by the European Bone and Joint Infection Society (EBJIS) and the one defined by the International Consensus on Musculoskeletal Infection (ICM) [ 1 , 2 ]. Different techniques, such as tissue sampling of the apparently contaminated areas, swabs to collect material from contaminated zones and sonication in the case of implant removal, are used to obtain the material for culturing to isolate the causative bacteria. There is a lack of standardization as to the best way to obtain the samples for culturing. Although tissue sampling remains the golden standard method, quite often there is a lack of information on how the tissue samples are obtained [ 3 – 6 ]. Collecting the samples from the instruments on the table may increase the risk of contamination, especially if cultures are taken after prolonged periods of time on the table. Opening a new sterile set of instruments to collect each sample has been suggested to avoid contamination of the instruments [ 7 ]. However, they are more expensive. Although they are thought to be superior, no study has demonstrated it so far. Moreover, how the samples of tissue are collected is infrequently specified in the methods section. Swabs have been shown to be less effective than tissue cultures in periprosthetic joint infection diagnosis in the hip and knee, but there is little information on the effectiveness of swabs in shoulder [ 8 – 11 ]. However, several studies dealing with Periprosthetic joint infection (PJI) of the shoulder still only use swabs to collect the samples for culturing while others use swabs together with tissue or fluid cultures. It is sometimes a requirement to use swabs because of the study design, for example when dealing with volunteers or when assessing instrument contamination. However, there is quite often no standardized criterion around the best method to use. The objective of this study was to analyze the concordance of the results obtained when culturing samples that are obtained with three different methods, from swabs, from the instruments on the table and from sterile instruments after opening a new set. MATERIALS AND METHODS This was a prospective study that included all primary Reverse shoulder arthroplasties (RSA) implanted from April 2020 to July 2022 in a one tertiary university hospital. Inclusion and Exclusion Criteria The criteria for inclusion were patients that were candidates to receive a primary RSA for any reason who had not had a previous surgery in the affected shoulder. The criteria for exclusion were patients with an active infection, patients who had undergone any invasive shoulder treatment and/or invasive imaging exploration during the last 6 months prior to surgery, patients with previous surgery in the shoulder involved as well as those unwilling to participate in the study. In all the cases included, a Delta X-tend (DePuy-Synthes, Warsaw, IN, USA) RSA was implanted via the deltopectoral approach. All the patients received standard preoperative antibiotic prophylaxis with cefazolin (2g IV) 30 to 60 minutes before the incision. The skin was prepared with the Bactiseptic solution (Vesismin Chemicals, Barcelona, Spain), which is composed of 2% chlorhexidine gluconate and 70% isopropyl alcohol. In all the patients included, 9 cultures were obtained after the antibiotic had been administrated and the skin surgically prepared. There were 3 cultures obtained from skin at the beginning of surgery, 3 from the tissue around the insertion of the long biceps on the glenoid side and 3 from the tissue around the greater tuberosity on the humeral side at the end of the surgery. At each location (skin, glenoid and greater tuberosity), one culture was obtained with the use of a swab, another one with the instruments of the table, and another one after opening a new set of instruments. The order in which the cultures were obtained at each location was determined by a computer-generated randomized list to avoid differences in potential contamination among the different methods of obtaining the cultures (swab, table instruments and new sets of instruments). The cultures obtained in the operating room were processed in the Microbiology laboratory, using the usual process of the culture of prosthetic infection. The samples were seeded in a chocolate agar medium and thioglycolate enrichment medium in the first 6 hours of collection, under sterile condition using laminar flow hood. They were incubated in a CO 2 oven at 35 ±2ºC for a total of 15 days. After the first 5 days of incubation, the thioglycolate medium that was kept in an oven was passed to chocolate agar as well as an anaerobic medium (SCS lacquered blood) for a total of 10 days. Direct sowing was also done. All the colonies that were isolated in the previously described culture media were identified using the Maldi Toff MS system (Mass Spectrometer (Vitek MS, Biomerieux). Statistical analysis Sample size calculation Proposing a study of concordance between the three methods, while taking into account the following considerations, a percentage of positives around 20%, a desirable kappa value of 0.85, a lower limit of the confidence interval of 0.7, an alpha=P(type I error) = 5%, and 87 patients were needed for the estimation of the kappa coefficient. The determination of the sample size was done using the R kappa Size package version 2.1. The levels of concordance were classified as: less than 0 (no agreement), 0 to 0.2 (poor agreement), 0.21 to 0.4 (fair agreement), 0.41 to 0.6 (moderate agreement), 0.61 to 0.8 (good agreement) and 0.81 to 1 (very good agreement) [14]. A general description of the data was made. Subsequently, the agreement in the classification between the three methods and pairs of them was analyzed using the kappa index. Then, possible relationships between concordances (or the lack thereof) with clinical and patient-related factors were explored. Analyses were performed using the STATA 15.1 statistical package. All the included patients signed informed consent to participate in this study. This study was approved by the Parc de Salut Mar Ethical Committee (2020/9141/I). Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. RESULTS There were 88 patients included during the inclusion period. All the cultures could not be obtained in one patient. Therefore, the patient was dropped from the study, leaving a total of 87 patients included. There were 67 females and 20 males with a mean age of 73.3 (7.9). The mean BMI of the patients included was 28.7 (5.2). An RSA was implanted because of a rotator cuff-deficient shoulder in 34 patients (39.1%), an acute fracture in 29 patients (33.3%), fracture sequelae in 12 patients (13.8%), a primary arthrosis in 10 patients (11.5%), and because of an idiopathic avascular necrosis in 2 patients (2.3%). Description of the positive culture samples found in the cohort of patients studied. Nine samples were obtained from each of the 87 patients included, leaving 783 culture samples for the analysis. Of these 783 samples, 69 turned to be positive: 57 were positive for C. acnes , 5 for S. epidermidis , 4 for other coagulase-negative staphylococcus ( S. hominis S. oralis S. haemolyticus S. warneri ) and 3 were positive for other indolent microorganisms ( B. cereus, M. catharralis, Kocuria spp ). Upon analysing the results by culture method, of the 69 positive culture samples, 21 were identified with the swab method, 23 with the use of the instruments from the table and 25 were identified with the use of a new set of instruments. The distribution of the positive samples by microorganism and method is shown in Table 1. Of the 57 culture samples that were positive for C. acnes , 18 were obtained with the swab method, 17 with the use with the instruments from the table and 22 with the use of the use of a new set of instruments. Of the 5 culture samples that were positive for S. epidermidis , 2 were obtained with the swab method, 1 with the use of the instruments from the table and 2 with the use of the use of a new set of instruments. Of the 87 patients included, 23 patients presented at least one positive culture for C. acnes (26,4%), 4 patients at least one positive culture for S. epidermidis , and 5 patients at least one positive culture for some of the indolent microorganisms previously described. More than one distinct microorganism was present in 3 patients. Concordance of the results obtained with the three different culture methods. Comparing the results obtained with the three different methods at the three different locations for all positive cultures, the kappa coefficient was of 0.1894 for cultures taken from skin, 0.4891 for cultures taken from the glenoid and 0.5456 for cultures taken from the greater tuberosity. If only cultures positive for C. acnes are analysed, the kappa coefficient was of 0.2611 for cultures taken from skin, 0.4787 for cultures taken from the glenoid and 0.4242 for cultures taken from the greater tuberosity. Therefore, the kappa coefficient obtained for the three different culture sample locations with the three different methods ranged from poor to moderate. (Table 2) Comparison of the results obtained with the swab and the instruments from the table techniques against the new set of instruments technique (considered the Gold Standard) When considering the cultures obtained from the skin, comparing the swab technique to the Gold Standard (new set of instruments technique), the sensitivity was 20%, and the specificity was 97.4%. Comparing the cultures obtained from skin with the instruments from the table to the Golden Standard, the sensitivity was 20%, and the specificity was 90.9%. When considering the cultures obtained from the glenoid, comparing the swab technique to the Gold Standard, the sensitivity was 50%, and the specificity was 96.3%. Comparing the cultures obtained from glenoid with the instruments of the table to the Golden Standard, the sensitivity was 50%, and the specificity was 95.1%. When considering the cultures obtained from the greater tuberosity, comparing the swab technique to the Gold Standard, the sensitivity was 66.7%, and the specificity was 93.6%. Comparing the cultures obtained from the greater tuberosity with the instruments of the table to the Golden Standard, the sensitivity was 55.6%, and the specificity was 97.4%. (Table 3) At the two-year follow-up, the functional outcome, measured with the aid of the Constant Score, was of 60.3 (SD 11.1) and did not differ significantly between the patients having positive cultures (Constant Score of 62.8 (SD 13.5)) and those having negative cultures (Constant Score of 59.4 (SD 10.1)), p=0.159. Any of the patients included developed a periprosthetic joint infection at the two-year follow-up, however, the cultures obtained after opening a new set of instruments detected more microorganisms when compared with the swaps and with the instruments on the table. This was even more relevant for the C. acnes detection. When considering all the patients with a positive culture for C. acnes , the sensitivity to detect C. acnes for the technique of the new set of instruments was of 65.2. The sensitivity of the swap technique was of 56.5 and the sensitivity of the instruments on the table was of 52.2. Moreover, when using the technique of the new set of instruments, the false negative results were of 16%, compared to 20% with the swap technique and 17% with the instruments on the table technique. DISCUSSION The results of the present study show that different methods to obtain samples for culturing may yield differing results. Little concordance is to be expected with the types of bacteria isolated when using different methods of sampling. When the results obtained with the culture of the tissue with sterile instruments are taken as the golden standard, the sensitivity of the results obtained with the culture of a swab, or the tissue taken with the instruments from the table is also very low. One definitive criterion to determine a PJI is the isolation of the causative bacteria, in accordance with both the European Bone and Joint Infection Society (EBJIS) and in the International Consensus on Musculoskeletal Infection (ICM) infections definition [1,2]. Having two positive cultures with phenotypically identical virulent organisms constitutes per se a definition of infection [15]. It seems logical to think that it is crucial to trust in the results of the tissue culturing since it will define the subsequent treatment including the targeted antibiotic depending on the bacteria isolated. Much too often, the method to obtain samples for culturing is not reported in the methods section, making it difficult to interpret the results [3-6]. Neither are the technique of obtaining the samples, the number of the cultures obtained or the method of culturing them reported. All of them have an influence on the ability to isolate the bacteria [17-19]. Yet, they are not always standardized or even reported. Different methods to obtain samples for culturing like collecting tissue of the more apparent contaminated areas, using swabs to collect material from the contaminated areas and culturing the material obtained after sonication if there is implant removal have been described. In the hip and knee, it has been stated that tissue sampling is not inferior to the culturing of sonication fluid if enough tissue cultures are obtained [16,17]. However, swab cultures have lower sensitivity and specificity when compared with tissue cultures in revision surgery in the hip and knee. Moreover, swab cultures showed more false-negatives, especially with streptococcal infections. They also showed more false-positive results, especially with staphylococcal infections. Overgrowth of facultative bacteria and die-off of organisms have also been related to the use of swabs [8-11]. Today, several studies still use the material collected with swab for periprosthetic infection detection purpose despite performing worse than the tissue culture. Its use should be discouraged. Its use should probably be limited to basic research studies like studies with volunteers or to detect contamination of the instruments when tissue cultures are not possible [12,13]. To reduce the cross-contamination, the method of opening a new set of instruments each time that a tissue culture is obtained has been gaining ground (also known as Oxford sampling method) [7]. Some studies have shown that the instruments on the table are at risk of contamination during surgery. Therefore, there is a risk of getting misleading results from the cultures if they are used to obtain the samples for culturing. Several recent studies on the shoulder declare, in the methods section, that the tissue samples were obtained after opening new sets of instruments, which strengthens the value of the results obtained [18.19,20]. However, some studies still use swabs as the method to obtain the samples, while others use tissue sampling but without specifying whether the instruments used to collect the sample were those on the table or ones specifically opened for that purpose [21,22]. Quite often, the method of collecting the samples is simply not reported, once again making it difficult to interpret the results. In the hip and knee, it has been demonstrated that the culture of synovial fluid leads to greater sensitivity and specificity for diagnosis of PJI when compared to standard tissue and swab samples [9]. However, it is quite common to have dry joints with the suspicion of PJI in the shoulder.That makes it difficult to obtain fluid for culturing and leaves the tissue culture as the most effective method of sampling [22]. In the present study, it has been demonstrated that if tissue culturing with the samples obtained after opening a new set of instruments is taken as the golden standard, then the sensitivity of the cultures obtained with the swab and tissue obtained with the instruments from the table is low (ranging from 20% to 66.7%). The Positive Predictive Value of the swab and tissue obtained with the instruments from the table is also low when compared to tissue obtained with a new set of instruments, having values ranging from 22.2% to 71.4%. Moreover, the number of microorganisms detected by the cultures obtained with the new set of instruments technique is higher than that obtained with the swap or instrument on the table technique. This is especially remarkable for the microorganism more commonly involved in periprosthetic shoulder infections, the Cutibacterium acnes . Because of that, the new set of instruments technique should be the preferred method to obtain cultures in shoulder surgery. The results of this study suggest that there is a need to standardize the methods for collecting tissue samples since different methods can bring different results. There is also a need to report the method used to obtain the samples to avoid getting misleading results and arriving at conclusions. These results are especially relevant when testing the efficacy of different antibiotic prophylaxis and different topical skin preparations. Among the limits of the study, there is the fact that even though 87 patients with 783 cultures were included, only 69 cultures turned out to be positive. The results of the study may be limited to the population of primary reverse shoulder arthroplasty candidates included, which may not be the same as in other shoulder PJI. Among the strengths are the homogeneity of the sample, the standardization of the method used to culture the samples and the randomization in the order of obtaining the samples with the different methods. In conclusion, samples obtained with the swab, tissue cultures taken with the instruments from the table and tissue cultures taken with new sets of instruments lead to different culture results in shoulder arthroplasty depending on the one used. If the results obtained with the samples taken with the new sets of instruments are considered the golden standard, then the sensitivity of the swab and tissue cultures with the instruments from the table is low. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [C T], [R C], [A S-L], [D P-P], [F ], and [A A]. The first draft of the manuscript was written by [C T] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Garrigues GE, Zmistowski B, Cooper AM, Green A, ICM Shoulder Group. (2019) Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elbow Surg 28: S8-S12. https://doi.org/10.1016/j.jse.2019.04.034 . McNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC et al. (2021) The EBJIS definition of periprosthetic joint infection. Bone Joint J 103-B(1):18–25. https://doi.org/10.1302/0301-620X.103B1.BJJ-2020-1381.R1 . Ahsan ZS, Somerson JS, Matsen III FA. (2017) Characterizing the Propionibacterium load in revision shoulder arthroplasty. J Bone Joint Surg Am 99: 150–154. https://doi.org/10.2106/JBJS.16.00422 . Foruria AM, Fox TJ, Sperling JW, Cofield RH. (2013) Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty. J Shoulder Elbow Surg 22: 620–627. https://doi.org/10.1016/j.jse.2012.07.0317 . Frangiamore SJ, Saleh A, Grosso MJ, Alolabi B, Bauer TW, Iannotti JP et al. (2015) Early versus late culture growth of Propionibacterium acnes in revision shoulder arthroplasty. J Bone Joint Surg Am 97:1149–58. https://doi.org/10.2106/JBJS.N.00881 . Pottinger P, Butler-Wu S, Neradilek MB, Merritt A, Bertelsen A, Jette JL, et al. (2012) Prognostic factors for bacterial cultures positive for Propionibacterium Acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening. J Bone Joint Surg Am 94: 2075–2083. https://doi.org/10.2106/JBJS.K.00861 . 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Antibiotics 12:13. https://doi.org/10.3390/antibiotics12010013 . Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1def.docx Table2def.docx Table3def.docx Cite Share Download PDF Status: Published Journal Publication published 07 Mar, 2025 Read the published version in European Journal of Orthopaedic Surgery & Traumatology → Version 1 posted Editorial decision: Revision requested 24 Nov, 2024 Reviews received at journal 21 Nov, 2024 Reviews received at journal 07 Nov, 2024 Reviewers agreed at journal 01 Nov, 2024 Reviewers agreed at journal 31 Oct, 2024 Reviewers invited by journal 30 Oct, 2024 Editor assigned by journal 10 Oct, 2024 Submission checks completed at journal 10 Oct, 2024 First submitted to journal 08 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-5226593\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":364533673,\"identity\":\"38ef3d00-5c6d-4345-8682-075e859def41\",\"order_by\":0,\"name\":\"Carlos 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19:54:14\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":489042,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5226593/v1/d3891f3d-c509-4cc6-b272-f975939b8bdd.pdf\"},{\"id\":66568826,\"identity\":\"96e2c752-2e02-4d17-bfc6-8726a1d2b3df\",\"added_by\":\"auto\",\"created_at\":\"2024-10-14 11:17:43\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":21970,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Table1def.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5226593/v1/0ee57af3fcb5f2b256055797.docx\"},{\"id\":66569658,\"identity\":\"4bc1ff2c-b2e7-434b-a134-681e16fef24e\",\"added_by\":\"auto\",\"created_at\":\"2024-10-14 11:25:43\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":22853,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Table2def.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5226593/v1/a0cc5c938693f42a2e230bc5.docx\"},{\"id\":66568824,\"identity\":\"27afc688-9edd-4d05-84bf-83df1018daa6\",\"added_by\":\"auto\",\"created_at\":\"2024-10-14 11:17:43\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":19805,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Table3def.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-5226593/v1/42bb5b728fe878d74815796e.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Concordance of three different methods to obtain samples for culture in reverse total shoulder arthroplasty. A prospective study.\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003ePeriprosthetic shoulder infection constitutes the most devastating complication in shoulder arthroplasty. Isolation of the causative bacteria is crucial not only for diagnostic purposes but also to facilitate the start-up of the targeted antibiotic therapy. Bacteria isolation is a major criterion of infection in the most used definitions of periprosthetic joint infections, including the one defined by the European Bone and Joint Infection Society (EBJIS) and the one defined by the International Consensus on Musculoskeletal Infection (ICM) [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eDifferent techniques, such as tissue sampling of the apparently contaminated areas, swabs to collect material from contaminated zones and sonication in the case of implant removal, are used to obtain the material for culturing to isolate the causative bacteria. There is a lack of standardization as to the best way to obtain the samples for culturing. Although tissue sampling remains the golden standard method, quite often there is a lack of information on how the tissue samples are obtained [\\u003cspan additionalcitationids=\\\"CR4 CR5\\\" citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Collecting the samples from the instruments on the table may increase the risk of contamination, especially if cultures are taken after prolonged periods of time on the table. Opening a new sterile set of instruments to collect each sample has been suggested to avoid contamination of the instruments [\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. However, they are more expensive. Although they are thought to be superior, no study has demonstrated it so far. Moreover, how the samples of tissue are collected is infrequently specified in the methods section.\\u003c/p\\u003e \\u003cp\\u003eSwabs have been shown to be less effective than tissue cultures in periprosthetic joint infection diagnosis in the hip and knee, but there is little information on the effectiveness of swabs in shoulder [\\u003cspan additionalcitationids=\\\"CR9 CR10\\\" citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. However, several studies dealing with Periprosthetic joint infection (PJI) of the shoulder still only use swabs to collect the samples for culturing while others use swabs together with tissue or fluid cultures. It is sometimes a requirement to use swabs because of the study design, for example when dealing with volunteers or when assessing instrument contamination. However, there is quite often no standardized criterion around the best method to use.\\u003c/p\\u003e \\u003cp\\u003e The objective of this study was to analyze the concordance of the results obtained when culturing samples that are obtained with three different methods, from swabs, from the instruments on the table and from sterile instruments after opening a new set.\\u003c/p\\u003e\"},{\"header\":\"MATERIALS AND METHODS\",\"content\":\"\\u003cp\\u003eThis was a prospective study that included all primary Reverse shoulder arthroplasties (RSA) implanted from April 2020 to July 2022 in a one tertiary university hospital.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eInclusion and Exclusion Criteria\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe criteria for inclusion were patients that were candidates to receive a primary RSA for any reason who had not had a previous surgery in the affected shoulder.\\u003c/p\\u003e\\n\\u003cp\\u003eThe criteria for exclusion were patients with an active infection, patients who had undergone any invasive shoulder treatment and/or invasive imaging exploration during the last 6 months prior to surgery, patients with previous surgery in the shoulder involved as well as those unwilling to participate in the study.\\u003c/p\\u003e\\n\\u003cp\\u003eIn all the cases included, a Delta X-tend (DePuy-Synthes, Warsaw, IN, USA) RSA was implanted via the deltopectoral approach. All the patients received standard preoperative antibiotic prophylaxis with cefazolin (2g IV) 30 to 60 minutes before the incision. The skin was prepared with the Bactiseptic solution (Vesismin Chemicals, Barcelona, Spain), which is composed of 2% chlorhexidine gluconate and 70% isopropyl alcohol.\\u003c/p\\u003e\\n\\u003cp\\u003eIn all the patients included, 9 cultures were obtained after the antibiotic had been administrated and the skin surgically prepared. There were 3 cultures obtained from skin at the beginning of surgery, 3 from the tissue around the insertion of the long biceps on the glenoid side and 3 from the tissue around the greater tuberosity on the humeral side at the end of the surgery. At each location (skin, glenoid and greater tuberosity), one culture was obtained with the use of a swab, another one with the instruments of the table, and another one after opening a new set of instruments. The order in which the cultures were obtained at each location was determined by a computer-generated randomized list to avoid differences in potential contamination among the different methods of obtaining the cultures (swab, table instruments and new sets of instruments).\\u0026nbsp;The cultures obtained in the operating room were processed in the Microbiology laboratory, using the usual process of the culture of prosthetic infection. The samples were seeded in a chocolate agar medium and thioglycolate enrichment medium in the first 6 hours of collection, under sterile condition using laminar flow hood. They were incubated in a CO\\u003csub\\u003e2\\u003c/sub\\u003e oven at 35 \\u0026plusmn;2\\u0026ordm;C for a total of 15 days. After the first 5 days of incubation, the thioglycolate medium that was kept in an oven was passed to chocolate agar as well as an anaerobic medium (SCS lacquered blood) for a total of 10 days. Direct sowing was also done. All the colonies that were isolated in the previously described culture media were identified using the Maldi Toff MS system (Mass Spectrometer (Vitek MS, Biomerieux).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eStatistical analysis\\u003c/p\\u003e\\n\\u003cp\\u003eSample size calculation\\u003c/p\\u003e\\n\\u003cp\\u003eProposing a study of concordance between the three methods, while taking into account the following considerations, a percentage of positives around 20%, a desirable kappa value of 0.85, a lower limit of the confidence interval of 0.7, an alpha=P(type I error) = 5%, and 87 patients were needed for the estimation of the kappa coefficient. The determination of the sample size was done using the R kappa Size package version 2.1. The levels of concordance were classified as: less than 0 (no agreement), 0 to 0.2 (poor agreement), 0.21 to 0.4 (fair agreement), 0.41 to 0.6 (moderate agreement), 0.61 to 0.8 (good agreement) and 0.81 to 1 (very good agreement) [14].\\u003c/p\\u003e\\n\\u003cp\\u003eA general description of the data was made. Subsequently, the agreement in the classification between the three methods and pairs of them was analyzed using the kappa index. Then, possible relationships between concordances (or the lack thereof) with clinical and patient-related factors were explored. Analyses were performed using the STATA 15.1 statistical package.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll the included patients signed informed consent to participate in this study. This study was approved by the Parc de Salut Mar Ethical Committee (2020/9141/I).\\u003c/p\\u003e\\n\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\"\\u003cp\\u003eThere were 88 patients included during the inclusion period. All the cultures could not be obtained in one patient. Therefore, the patient was dropped from the study, leaving a total of 87 patients included. There were 67 females and 20 males with a mean age of 73.3 (7.9). The mean BMI of the patients included was 28.7 (5.2). An RSA was implanted because of a rotator cuff-deficient shoulder in 34 patients (39.1%), an acute fracture in 29 patients (33.3%), fracture sequelae in 12 patients (13.8%), a primary arthrosis in 10 patients (11.5%), and because of an idiopathic avascular necrosis in 2 patients (2.3%).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDescription of the positive culture samples found in the cohort of patients studied.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNine samples were obtained from each of the 87 patients included, leaving 783 culture samples for the analysis. Of these 783 samples, 69 turned to be positive:\\u0026nbsp;57 were positive for \\u003cem\\u003eC. acnes\\u003c/em\\u003e, 5 for\\u003cem\\u003e\\u0026nbsp;S. epidermidis\\u003c/em\\u003e,\\u0026nbsp;4 for other coagulase-negative \\u003cem\\u003estaphylococcus\\u003c/em\\u003e (\\u003cem\\u003eS. hominis S. oralis S. haemolyticus S. warneri\\u003c/em\\u003e) and 3 were positive for\\u0026nbsp;other indolent microorganisms\\u0026nbsp;(\\u003cem\\u003eB. cereus, M. catharralis, Kocuria spp\\u003c/em\\u003e). Upon analysing the results by culture method, of the 69 positive culture samples, 21 were identified with the swab method, 23 with the use of the instruments from the table and 25 were identified with the use of a new set of instruments. The distribution of the positive samples by microorganism and method is shown in Table 1. Of the\\u0026nbsp;57 culture samples that were positive for \\u003cem\\u003eC. acnes\\u003c/em\\u003e, 18 were obtained with the swab method, 17 with the use with the instruments from the table and 22 with the use of the use of a new set of instruments. Of the 5 culture samples that were positive for \\u003cem\\u003eS. epidermidis\\u003c/em\\u003e, 2 were obtained with the swab method, 1 with the use of the instruments from the table and 2 with the use of the use of a new set of instruments.\\u003c/p\\u003e\\n\\u003cp\\u003eOf the 87 patients included,\\u0026nbsp;23 patients presented at least one positive culture for \\u003cem\\u003eC. acnes\\u003c/em\\u003e (26,4%), 4 patients at least one positive culture for \\u003cem\\u003eS. epidermidis\\u003c/em\\u003e, and 5 patients at least one positive culture for some of the indolent microorganisms previously described. More than one distinct microorganism was present in 3 patients.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConcordance of the results obtained with the three different culture methods.\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eComparing the results obtained with the three different methods at the three different locations for all positive cultures, the kappa coefficient was of 0.1894 for cultures taken from skin, 0.4891 for cultures taken from the glenoid and 0.5456 for cultures taken from the greater tuberosity. If only cultures positive for \\u003cem\\u003eC. acnes\\u003c/em\\u003e are analysed, the kappa coefficient was of 0.2611 for cultures taken from skin, 0.4787 for cultures taken from the glenoid and 0.4242 for cultures taken from the greater tuberosity. Therefore, the kappa coefficient obtained for the three different culture sample locations with the three different methods ranged from poor to moderate. (Table 2)\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eComparison of the results obtained with the swab and the instruments from the table techniques against the new set of instruments technique (considered the Gold Standard) \\u0026nbsp;\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWhen considering the cultures obtained from the skin, comparing the swab technique to the Gold Standard (new set of instruments technique), the sensitivity was 20%, and the specificity was 97.4%. Comparing the cultures obtained from skin with the instruments from the table to the Golden Standard, the sensitivity was 20%, and the specificity was 90.9%. When considering the cultures obtained from the glenoid, comparing the swab technique to the Gold Standard, the sensitivity was 50%, and the specificity was 96.3%. Comparing the cultures obtained from glenoid with the instruments of the table to the Golden Standard, the sensitivity was 50%, and the specificity was 95.1%. When considering the cultures obtained from the greater tuberosity, comparing the swab technique to the Gold Standard, the sensitivity was 66.7%, and the specificity was 93.6%. Comparing the cultures obtained from the greater tuberosity with the instruments of the table to the Golden Standard, the sensitivity was 55.6%, and the specificity was 97.4%. (Table 3)\\u003c/p\\u003e\\n\\u003cp\\u003eAt the two-year follow-up, the functional outcome, measured with the aid of the Constant Score, was of 60.3 (SD 11.1) and did not differ significantly between the patients having positive cultures (Constant Score of 62.8 (SD 13.5)) and those having negative cultures (Constant Score of 59.4 (SD 10.1)), p=0.159.\\u003c/p\\u003e\\n\\u003cp\\u003eAny of the patients included developed a periprosthetic joint infection at the two-year follow-up, however, the cultures obtained after opening a new set of instruments detected more microorganisms when compared with the swaps and with the instruments on the table. This was even more relevant for the \\u003cem\\u003eC. acnes\\u0026nbsp;\\u003c/em\\u003edetection. When considering all the patients with a positive culture for \\u003cem\\u003eC. acnes\\u003c/em\\u003e, the sensitivity to detect \\u003cem\\u003eC. acnes\\u003c/em\\u003e for the technique of the new set of instruments was of 65.2. The sensitivity of the swap technique was of 56.5 and the sensitivity of the instruments on the table was of 52.2. Moreover, when using the technique of the new set of instruments, the false negative results were of 16%, compared to 20% with the swap technique and 17% with the instruments on the table technique.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eThe results of the present study show that different methods to obtain samples for culturing may yield differing results. Little concordance is to be expected with the types of bacteria isolated when using different methods of sampling. \\u0026nbsp;When the results obtained with the culture of the tissue with sterile instruments are taken as the golden standard, the sensitivity of the results obtained with the culture of a swab, or the tissue taken with the instruments from the table is also very low.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOne definitive criterion to determine a PJI is the isolation of the causative bacteria, in accordance with both the European Bone and Joint Infection Society (EBJIS) and in the International Consensus on Musculoskeletal Infection (ICM) infections definition [1,2]. Having two positive cultures with phenotypically identical virulent organisms constitutes per se a definition of infection [15]. It seems logical to think that it is crucial to trust in the results of the tissue culturing since it will define the subsequent treatment including the targeted antibiotic depending on the bacteria isolated. Much too often, the method to obtain samples for culturing is not reported in the methods section, making it difficult to interpret the results [3-6]. Neither are the technique of obtaining the samples, the number of the cultures obtained or the method of culturing them reported. All of them have an influence on the ability to isolate the bacteria [17-19]. Yet, they are not always standardized or even reported.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eDifferent methods to obtain samples for culturing like collecting tissue of the more apparent contaminated areas, using swabs to collect material from the contaminated areas and culturing the material obtained after sonication if there is implant removal have been described. In the hip and knee, it has been stated that tissue sampling is not inferior to the culturing of sonication fluid if enough tissue cultures are obtained [16,17]. However, swab cultures have lower sensitivity and specificity when compared with tissue cultures in revision surgery in the hip and knee. Moreover, swab cultures showed more false-negatives, especially with streptococcal infections. They also showed more false-positive results, especially with staphylococcal infections. Overgrowth of facultative bacteria and die-off of organisms have also been related to the use of swabs [8-11]. Today, several studies still use the material collected with swab for periprosthetic infection detection purpose despite performing worse than the tissue culture. Its use should be discouraged. Its use should probably be limited to basic research studies like studies with volunteers or to detect contamination of the instruments when tissue cultures are not possible [12,13].\\u003c/p\\u003e\\n\\u003cp\\u003eTo reduce the cross-contamination, the method of opening a new set of instruments each time that a tissue culture is obtained has been gaining ground (also known as Oxford sampling method) [7]. Some studies have shown that the instruments on the table are at risk of contamination during surgery. Therefore, there is a risk of getting misleading results from the cultures if they are used to obtain the samples for culturing. Several recent studies on the shoulder declare, in the methods section, that the tissue samples were obtained after opening new sets of instruments, which strengthens the value of the results obtained [18.19,20]. However, some studies still use swabs as the method to obtain the samples, while others use tissue sampling but without specifying whether the instruments used to collect the sample were those on the table or ones specifically opened for that purpose [21,22]. Quite often, the method of collecting the samples is simply not reported, once again making it difficult to interpret the results.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the hip and knee, it has been demonstrated that the culture of synovial fluid leads to greater sensitivity and specificity for diagnosis of PJI when compared to standard tissue and swab samples [9]. \\u0026nbsp;However, it is quite common to have dry joints with the suspicion of PJI in the shoulder.That makes it difficult to obtain fluid for culturing and leaves the tissue culture as the most effective method of sampling [22]. In the present study, it has been demonstrated that if tissue culturing with the samples obtained after opening a new set of instruments is taken as the golden standard, then the sensitivity of the cultures obtained with the swab and tissue obtained with the instruments from the table is low (ranging from 20% to 66.7%). The Positive Predictive Value of the swab and tissue obtained with the instruments from the table is also low when compared to tissue obtained with a new set of instruments, having values ranging from 22.2% to 71.4%. Moreover, the number of microorganisms detected by the cultures obtained with the new set of instruments technique is higher than that obtained with the swap or instrument on the table technique. This is especially remarkable for the microorganism more commonly involved in periprosthetic shoulder infections, the \\u003cem\\u003eCutibacterium acnes\\u003c/em\\u003e. Because of that, the new set of instruments technique should be the preferred method to obtain cultures in shoulder surgery.\\u003c/p\\u003e\\n\\u003cp\\u003eThe results of this study suggest that there is a need to standardize the methods for collecting tissue samples since different methods can bring different results. There is also a need to report the method used to obtain the samples to avoid getting misleading results and arriving at conclusions. These results are especially relevant when testing the efficacy of different antibiotic prophylaxis and different topical skin preparations.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAmong the limits of the study, there is the fact that even though 87 patients with 783 cultures were included, only 69 cultures turned out to be positive. The results of the study may be limited to the population of primary reverse shoulder arthroplasty candidates included, which may not be the same as in other shoulder PJI. Among the strengths are the homogeneity of the sample, the standardization of the method used to culture the samples and the randomization in the order of obtaining the samples with the different methods.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn conclusion, samples obtained with the swab, tissue cultures taken with the instruments from the table and tissue cultures taken with new sets of instruments lead to different culture results in shoulder arthroplasty depending on the one used. If the results obtained with the samples taken with the new sets of instruments are considered the golden standard, then the sensitivity of the swab and tissue cultures with the instruments from the table is low.\\u0026nbsp;\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eFunding\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [C T], [R C], [A S-L], [D P-P], [F ], and [A A]. The first draft of the manuscript was written by [C T] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eGarrigues GE, Zmistowski B, Cooper AM, Green A, ICM Shoulder Group. (2019) Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: the definition of periprosthetic shoulder infection. J Shoulder Elbow Surg 28: S8-S12. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jse.2019.04.034\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jse.2019.04.034\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcNally M, Sousa R, Wouthuyzen-Bakker M, Chen AF, Soriano A, Vogely HC et al. (2021) The EBJIS definition of periprosthetic joint infection. Bone Joint J 103-B(1):18\\u0026ndash;25. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1302/0301-620X.103B1.BJJ-2020-1381.R1\\u003c/span\\u003e\\u003cspan address=\\\"10.1302/0301-620X.103B1.BJJ-2020-1381.R1\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAhsan ZS, Somerson JS, Matsen III FA. (2017) Characterizing the \\u003cem\\u003ePropionibacterium\\u003c/em\\u003e load in revision shoulder arthroplasty. 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J Shoulder Elbow Surg 22: 620\\u0026ndash;627. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jse.2012.07.0317\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jse.2012.07.0317\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFrangiamore SJ, Saleh A, Grosso MJ, Alolabi B, Bauer TW, Iannotti JP et al. (2015) Early versus late culture growth of Propionibacterium acnes in revision shoulder arthroplasty. 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Injury 50:1649\\u0026ndash;1655. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.injury.2019.05.014\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.injury.2019.05.014\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFritsche T, Schnetz M, Klug A, Fischer S, Ruckes C, Hunfeld KP et al. (2023) Tissue sampling is noninferior in comparison to sonication in orthopedic revision surgery. Arch Orthop Trauma Surg 143:2901\\u0026ndash;2911. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1007/s00402-022-04469-3\\u003c/span\\u003e\\u003cspan address=\\\"10.1007/s00402-022-04469-3\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTrampuz A, Piper KE, Jacobson MJ, Hanssen AD, Unni KK, Osmon DR et al. (2007) Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 357:654\\u0026ndash;663. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1056/NEJMoa061588\\u003c/span\\u003e\\u003cspan address=\\\"10.1056/NEJMoa061588\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFalstie-Jensen T, Lange J, Daugaard H, Sorensen AKB, Ovesen J, Soballe K. (2021) Unexpected positive cultures after revision shoulder arthroplasty: does it affect outcome? 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J Shoulder Elbow Surg 28: 839\\u0026ndash;846. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jse.2018.10.016\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jse.2018.10.016\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHudek R, Sommer F, Abdelkawi AF, Kerwat M, M\\u0026uuml;ller HH, Gohlke F. (2016) Propionibacterium acnes in shoulder surgery: is loss of hair protective for infection? J Shoulder Elbow Surg 25: 973\\u0026ndash;980. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.1016/j.jse.2015.10.018\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.jse.2015.10.018\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHotchen AJ, Corrigan RA, Dudareva M, Bernard A, Ferguson J, Atkins B et al. (2023) Pre-referral microbiology in long bone infection: What can it tell us? Antibiotics 12:13. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://doi.org/10.3390/antibiotics12010013\\u003c/span\\u003e\\u003cspan address=\\\"10.3390/antibiotics12010013\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables 1 to 3 are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"european-journal-of-orthopaedic-surgery-and-traumatology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ejos\",\"sideBox\":\"Learn more about [European Journal of Orthopaedic Surgery \\u0026 Traumatology](http://link.springer.com/journal/590)\",\"snPcode\":\"590\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/590/3\",\"title\":\"European Journal of Orthopaedic Surgery \\u0026 Traumatology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false},\"keywords\":\"culture, swab, contamination, infection, reverse shoulder arthroplasty.\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-5226593/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-5226593/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003e The objective of this study was to analyze the concordance of the results obtained when culturing samples that are obtained with three different methods.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eProspective study that includes primary Reverse shoulder arthroplasties. From all the patients, 9 cultures were obtained. There were 3 cultures obtained from skin at the beginning of surgery, 3 from the tissue around the insertion of the long biceps on the glenoid side and 3 from the tissue around the greater tuberosity on the humeral side. At each location one culture was obtained from a swab, another one was obtained from the instruments on the table, and another one was obtained from a newly-opened set of instruments.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThere were 87 patients included, leaving 783 culture samples for the analysis. Of those 783 samples, 69 turned to be positive: 57 were positive for \\u003cem\\u003eC. acnes\\u003c/em\\u003e, 5 for \\u003cem\\u003eS. epidermidis\\u003c/em\\u003e, 4 for other coagulase-negative \\u003cem\\u003estaphylococcus\\u003c/em\\u003e and 3 were positive for other indolent microorganisms. Comparing the results obtained with the three different methods, the kappa coefficient for all positive cultures was 0.1894 for cultures taken from skin, 0.4891 for cultures from the glenoid and 0.5456 for cultures from the greater tuberosity. Therefore, the kappa coefficient obtained for the three different locations ranged from poor to moderate.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThe samples obtained with swab, tissue cultures taken with the instruments of the table and tissue cultures taken with new sets of instruments lead to different culture results in shoulder arthroplasty.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Concordance of three different methods to obtain samples for culture in reverse total shoulder arthroplasty. A prospective study.\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-10-14 11:17:38\",\"doi\":\"10.21203/rs.3.rs-5226593/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2024-11-24T20:13:45+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2024-11-22T01:09:11+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2024-11-07T19:09:37+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"209312699144813694807563066085719212335\",\"date\":\"2024-11-01T14:32:06+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"277999865264757392962809733897200928304\",\"date\":\"2024-10-31T21:34:02+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2024-10-30T14:25:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-10-10T11:22:10+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-10-10T11:21:10+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"European Journal of Orthopaedic Surgery \\u0026 Traumatology\",\"date\":\"2024-10-08T15:14:26+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"european-journal-of-orthopaedic-surgery-and-traumatology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"ejos\",\"sideBox\":\"Learn more about [European Journal of Orthopaedic Surgery \\u0026 Traumatology](http://link.springer.com/journal/590)\",\"snPcode\":\"590\",\"submissionUrl\":\"https://submission.springernature.com/new-submission/590/3\",\"title\":\"European Journal of Orthopaedic Surgery \\u0026 Traumatology\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Springer Hybrid\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":false}}],\"origin\":\"\",\"ownerIdentity\":\"e002d371-faf2-4c5f-8c8d-580a5d3f4bd4\",\"owner\":[],\"postedDate\":\"October 14th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-03-10T19:54:10+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-5226593\",\"link\":\"https://doi.org/10.1007/s00590-025-04206-7\",\"journal\":{\"identity\":\"european-journal-of-orthopaedic-surgery-and-traumatology\",\"isVorOnly\":false,\"title\":\"European Journal of Orthopaedic Surgery \\u0026 Traumatology\"},\"publishedOn\":\"2025-03-07 15:57:06\",\"publishedOnDateReadable\":\"March 7th, 2025\"},\"versionCreatedAt\":\"2024-10-14 11:17:38\",\"video\":\"\",\"vorDoi\":\"10.1007/s00590-025-04206-7\",\"vorDoiUrl\":\"https://doi.org/10.1007/s00590-025-04206-7\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-5226593\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-5226593\",\"identity\":\"rs-5226593\",\"version\":[\"v1\"]},\"buildId\":\"J0_U0BvcaRcwD8yVFaRlm\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}