{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T00:53:25Z","timestamp":1790297605609,"version":"4.1.0"},"reference-count":36,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T00:00:00Z","timestamp":1776729600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Treatment of failed osteosynthesis of fractures of the proximal humerus with one-stage or two-stage surgery is difficult and clinical results are poor. The aim of this work is to evaluate the microbiological positivity of devices removed due to osteosynthesis failure. Furthermore, the clinical outcomes of these patients were evaluated at a follow-up of minimum 6 months, to assess the recovery of range of motion and the reduction in pain. Methods: A retrospective analysis was performed on 15 patients treated from September 2021 to September 2023 for failure of previous proximal humerus synthesis. These treatments included implant removal and arthrolysis. None of these patients showed signs of infection. Demographic data, VAS, ASES, Constant score, and range of motion (ROM) were assessed before surgery and at least 6 months of follow-up. Removed devices were processed in MicroDTTect\u00ae system, to increase the sensitivity of microbiological cultures. The cultural and clinical results of device removal surgery were analyzed. Results: Culture results were positive in eight out of 15 patients. Slow-growing anaerobic bacteria were the most isolated microorganisms, particularly C. acnes (62.5%). Improvement in patients\u2019 passive ROM was observed. The patients went from a preoperative VAS of 8.4 (\u00b11.1) to a VAS of 2 (\u00b11.1) at follow-up. Similarly, we observed an increase in ASES from 9 \u00b1 6 to 50.2 \u00b1 2.3 and Constant score from 17 (15\u201318) to 40.7 \u00b1 3.3 at a follow-up of at least 6 months. Conclusions: Two-stage procedure should always be considered in the context of proximal humerus synthesis failure. Arthrolysis with postoperative physiotherapy prepares the shoulder for definitive prosthesis implantation.<\/jats:p>","DOI":"10.3390\/jcm15083162","type":"journal-article","created":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T11:42:45Z","timestamp":1776771765000},"page":"3162","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Unexpected Positive Cultures After Failed Proximal Humerus Osteosynthesis: Why a Two-Stage Procedure Could Be Safer"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0439-7848","authenticated-orcid":false,"given":"Raffaele","family":"Garofalo","sequence":"first","affiliation":[{"name":"IRCCS Humanitas Reserch Hospital, Humanitas University, 20089 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nunzio","family":"Lassandro","sequence":"additional","affiliation":[{"name":"Ecclesiastical Entity Regional General Hospital \u201cF. Miulli\u201d, 70021 Acquaviva delle Fonti, BA, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelo De","family":"Crescenzo","sequence":"additional","affiliation":[{"name":"Ecclesiastical Entity Regional General Hospital \u201cF. Miulli\u201d, 70021 Acquaviva delle Fonti, BA, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Riccardo","family":"Ranieri","sequence":"additional","affiliation":[{"name":"IRCCS Humanitas Reserch Hospital, Humanitas University, 20089 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelo","family":"Del Buono","sequence":"additional","affiliation":[{"name":"Villa Lucia Hospital, 70014 Conversano, BA, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8368-6092","authenticated-orcid":false,"given":"Alberto","family":"Fontanarosa","sequence":"additional","affiliation":[{"name":"Ecclesiastical Entity Regional General Hospital \u201cF. Miulli\u201d, 70021 Acquaviva delle Fonti, BA, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2161","DOI":"10.1016\/j.injury.2018.11.009","article-title":"Fractures in older adults. A view of the future?","volume":"49","author":"Duckworth","year":"2018","journal-title":"Injury"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1037","DOI":"10.1001\/jama.2015.1629","article-title":"Surgical vs Nonsurgical Treatment of Adults with Displaced Fractures of the Proximal Humerus","volume":"313","author":"Rangan","year":"2015","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Howard, L., Berdusco, R., Momoli, F., Pollock, J., Liew, A., Papp, S., Lalonde, K.-A., Gofton, W., Ruggiero, S., and Lapner, P. (2018). Open reduction internal fixation vs non-operative management in proximal humerus fractures: A prospective, randomized controlled trial protocol. BMC Musculoskelet. Disord., 19.","DOI":"10.1186\/s12891-018-2223-3"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S43","DOI":"10.1016\/j.injury.2014.10.022","article-title":"Fractures and fracture-dislocations of the proximal humerus: A retrospective analysis of 82 cases treated with the Philos\u00ae locking plate","volume":"45","author":"Erasmo","year":"2014","journal-title":"Injury"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1016\/j.injury.2010.11.058","article-title":"A systematic review of locking plate fixation of proximal humerus fractures","volume":"42","author":"Sproul","year":"2011","journal-title":"Injury"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1689","DOI":"10.1016\/j.jse.2019.11.026","article-title":"Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate","volume":"29","author":"Barlow","year":"2020","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1674","DOI":"10.1016\/j.jse.2019.02.017","article-title":"Complications after surgical treatment of proximal humerus fractures in the elderly\u2014An analysis of complication patterns and risk factors for reverse shoulder arthroplasty and angular-stable plating","volume":"28","author":"Klug","year":"2019","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2070","DOI":"10.2106\/JBJS.N.00405","article-title":"Reverse Shoulder Arthroplasty for the Treatment of Nonunions of the Surgical Neck of the Proximal Part of the Humerus (Type-3 Fracture Sequelae)","volume":"96","author":"Raiss","year":"2014","journal-title":"J. Bone Jt. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"S3","DOI":"10.1016\/S0020-1383(13)70172-4","article-title":"The treatment of proximal humerus nonunions in older patients with reverse shoulder arthroplasty","volume":"43","author":"Martinez","year":"2012","journal-title":"Injury"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1097\/CORR.0000000000002480","article-title":"Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years","volume":"481","author":"Lanzetti","year":"2022","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1007\/s11420-015-9450-z","article-title":"High Rates of Occult Infection after Shoulder Fracture Fixation: Considerations for Conversion Shoulder Arthroplasty","volume":"11","author":"Klatte","year":"2015","journal-title":"HSS J."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1080\/17453674.2018.1489095","article-title":"Growth of Cutibacterium acnes is common on osteosynthesis material of the shoulder in patients without signs of infection","volume":"89","author":"Both","year":"2018","journal-title":"Acta Orthop."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Akg\u00fcn, D., Peters, P.-M., Maziak, N., Plachel, F., Minkus, M., and Moroder, P. (2020). High rate of unexpected positive cultures in presumed aseptic revision of stiff shoulders after proximal humerus osteosynthesis. BMC Musculoskelet. Disord., 21.","DOI":"10.1186\/s12891-020-03430-y"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1422","DOI":"10.1016\/j.jse.2018.05.024","article-title":"Culture positivity in primary total shoulder arthroplasty","volume":"27","author":"Wong","year":"2018","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1016\/j.jse.2012.07.007","article-title":"Propionibacterium acnes: An underestimated etiology in the pathogenesis of osteoarthritis?","volume":"22","author":"Levy","year":"2013","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.jse.2020.04.020","article-title":"Cutibacterium acnes is an intracellular and intra-articular commensal of the human shoulder joint","volume":"30","author":"Hudek","year":"2021","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2142","DOI":"10.1016\/j.jse.2024.04.010","article-title":"Unexpected positive cultures of humeral head detected with dithiothreitol in primary shoulder arthroplasty","volume":"33","author":"Fontanarosa","year":"2024","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Fischer, K., Tschismarov, R., Pilz, A., Straubinger, S., Carotta, S., McDowell, A., and Decker, T. (2020). Cutibacterium acnes Infection Induces Type I Interferon Synthesis Through the cGAS-STING Pathway. Front. Immunol., 11.","DOI":"10.3389\/fimmu.2020.571334"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"838","DOI":"10.1016\/j.jse.2015.03.008","article-title":"Propionibacterium acnes infection in shoulder arthroscopy patients with postoperative pain","volume":"24","author":"Horneff","year":"2015","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2075","DOI":"10.2106\/JBJS.K.00861","article-title":"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","volume":"94","author":"Pottinger","year":"2012","journal-title":"J. Bone Jt. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1016\/j.arthro.2014.04.092","article-title":"Arthroscopy After Locked Plating of Proximal Humeral Fractures: Implant Removal, Capsular Release, and Intra-articular Findings","volume":"30","author":"Katthagen","year":"2014","journal-title":"Arthroscopy"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1127","DOI":"10.1016\/S0140-6736(74)90884-8","article-title":"Measurement of pain","volume":"304","author":"Huskisson","year":"1974","journal-title":"Lancet"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1067\/mse.2002.127096","article-title":"American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: Reliability, validity, and responsiveness","volume":"11","author":"Michener","year":"2002","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1097\/00003086-198701000-00023","article-title":"A clinical method of functional assessment of the shoulder","volume":"214","author":"Constant","year":"1987","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1539","DOI":"10.1016\/j.jse.2018.06.012","article-title":"Neer Award 2018: Benzoyl peroxide effectively decreases preoperative Cutibacterium acnes shoulder burden: A prospective randomized controlled trial","volume":"27","author":"Kolakowski","year":"2018","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1016\/j.jse.2019.09.038","article-title":"Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes\u2013positive culture rate in shoulder surgery: A prospective randomized controlled trial","volume":"29","author":"Stull","year":"2020","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Kolenda, C., Josse, J., Batailler, C., Faure, A., Monteix, A., Lustig, S., Ferry, T., Laurent, F., and Dupieux, C. (2021). Experience with the Use of the MicroDTTect Device for the Diagnosis of Low-Grade Chronic Prosthetic Joint Infections in a Routine Setting. Front. Med., 8.","DOI":"10.3389\/fmed.2021.565555"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Drago, L., and Roman\u00f2, C.L. (2022). Commentary: Dithiothreitol (DTT), When Used as Biofilm Detaching Method to Diagnose Implant-Associated Infections, Does Not Affect Microorganisms\u2019 Viability, According to the Current Literature. Front. Microbiol., 12.","DOI":"10.3389\/fmicb.2021.814945"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1016\/j.anaerobe.2019.07.001","article-title":"Peptoniphilus asaccharolyticus\u2014Commensal, pathogen or synergist? Two case reports on invasive Peptoniphilus asaccharolyticus infection","volume":"59","author":"Heimann","year":"2019","journal-title":"Anaerobe"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1878","DOI":"10.1128\/JCM.01686-08","article-title":"Microbiologic Diagnosis of Prosthetic Shoulder Infection by Use of Implant Sonication","volume":"47","author":"Piper","year":"2009","journal-title":"J. Clin. Microbiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"2060","DOI":"10.1016\/j.jse.2017.07.006","article-title":"Routine cultures for seemingly aseptic revision shoulder arthroplasty: Are they necessary?","volume":"26","author":"Brolin","year":"2017","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_32","first-page":"417","article-title":"Anatomic and reverse shoulder prostheses in fracture sequelae of the humeral head","volume":"44","author":"Berth","year":"2010","journal-title":"Acta Orthop. Traumatol. Turc."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1655","DOI":"10.1016\/j.jse.2016.02.012","article-title":"Reverse shoulder arthroplasty for proximal humeral fractures: Outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis","volume":"25","author":"Shannon","year":"2016","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1016\/j.jse.2022.09.006","article-title":"Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection","volume":"32","author":"Lo","year":"2022","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"S175","DOI":"10.1016\/j.jse.2019.01.026","article-title":"Primary reverse shoulder arthroplasty using contemporary implants is associated with very low reoperation rates","volume":"28","author":"Kang","year":"2019","journal-title":"J. Shoulder Elb. Surg."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1016\/j.jinf.2020.01.008","article-title":"Incidence, temporal trends and potential risk factors for prosthetic joint infection after primary total shoulder and elbow replacement: Systematic review and meta-analysis","volume":"80","author":"Kunutsor","year":"2020","journal-title":"J. Infect."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/8\/3162\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,21]],"date-time":"2026-04-21T12:25:12Z","timestamp":1776774312000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/8\/3162"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,21]]},"references-count":36,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcm15083162"],"URL":"https:\/\/doi.org\/10.3390\/jcm15083162","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,21]]}}}