Proceedings from the 2025 International Consensus Meeting on Orthopedic Infections: Diagnosis of Periprosthetic Shoulder Infection.

Authors

Surena Namdari, Benjamin Zmistowski, Miguel Fiandeiro, Siddharth Gupta, Thema Nicholson, ICM Shoulder Group

Published in

Journal of shoulder and elbow surgery. Nov 05, 2026. Epub Nov 05, 2026.

Abstract

Prosthetic joint infection (PJI) following shoulder arthroplasty is difficult to diagnose because clinical findings are often nonspecific, conventional diagnostic tests have variable sensitivity, and Cutibacterium acnes (C. acnes) may cause indolent infection with limited systemic inflammatory response. Diagnostic criteria have also largely been adapted from hip and knee arthroplasty with limited shoulder-specific validation. This International Consensus Meeting (ICM) reviewed the available evidence and developed consensus recommendations for the diagnosis of shoulder PJI.
The Shoulder Group of the 2025 ICM on Orthopedic Infections included international shoulder surgeons, infectious disease physicians, and microbiology experts experienced in shoulder arthroplasty and PJI. Thirty-two diagnostic questions underwent question-specific literature review, presentation to the consensus group, discussion, and voting. A modified Delphi process was used to establish consensus. Delegates voted to agree, disagree, or abstain. Consensus was categorized by percentage agreement, while strength of recommendation was assessed separately based on evidence quality, consistency, and directness.
Consensus was achieved for 31 analyzed questions, with agreement ranging from 72% to 100%; 29 resulted in recommendations for clinical practice and 2 were identified as requiring further research. Question 47, which addressed the definition of PJI, was reported separately. Humeral component loosening, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were supported as components of the diagnostic criteria, whereas cloudy fluid, postoperative stiffness, serum WBC count, and D-dimer were not supported as independent criteria. Arthroscopic tissue biopsy, frozen section, and selective ultrasound-guided aspiration or synovial biopsy were supported as adjuncts to diagnosis. Five intraoperative tissue specimens, prolonged aerobic and anaerobic culture incubation, and routine perioperative antibiotic prophylaxis were supported. Next-generation sequencing (NGS) and synovial neutrophil testing were supported as adjuncts; alpha-defensin was considered potentially useful but insufficiently validated for formal inclusion; and leukocyte esterase inclusion was not recommended. Routine use of bone scintigraphy, magnetic resonance imaging (MRI), computed tomography (CT), single-photon emission computed tomography (SPECT), or positron emission tomography/computed tomography (PET/CT) was not supported. Evidence remained insufficient to determine the clinical significance of polymicrobial molecular results or routine negative control samples.
The 2025 ICM provides a consensus framework for the diagnosis of shoulder PJI, identifying several measures that can be incorporated into current clinical practice. However, substantial uncertainty remains because most recommendations are supported by limited evidence and several diagnostic tests lack sufficient sensitivity. Prospective, shoulder-specific studies are needed to define diagnostic thresholds and determine the role of emerging molecular, biomarker, and imaging modalities.

PMID:
42988206
Bibliographic data and abstract were imported from PubMed on 06 Nov 2026.

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