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

BACKGROUND: Periprosthetic joint infection (PJI) is an uncommon but serious complication of shoulder arthroplasty. Many preventive practices are also extrapolated from hip and knee arthroplasty despite important differences in microbiology and surgical procedures. Furthermore, prevention is complicated by the importance of Cutibacterium acnes, which resides within the dermis and sebaceous structures and may not be reliably eliminated by conventional skin preparation. This International Consensus Meeting (ICM) aimed to develop evidence-based consensus recommendations for prevention of shoulder PJI.

METHODS: The Shoulder Group of the 2025 ICM on Orthopedic Infections included international shoulder surgeons, infectious disease physicians, and microbiology experts. More than 100 proposed questions were refined to 86, of which 25 addressed prevention. For each question, delegates performed a systematic literature review and developed a proposed recommendation. Evidence and recommendations were presented to the full group, discussed, revised, and voted upon using a modified Delphi process. Delegates voted agree, disagree, or abstain. Degree of consensus and strength of recommendation were assessed separately.

RESULTS: Consensus was achieved for all 25 questions, with 65%-100% agreement. Male sex and clinical or physical evidence of malnutrition were identified as PJI risk factors. Moderate-strength evidence supported avoiding corticosteroid injection within 3 months of shoulder arthroplasty, while evidence regarding hemoglobin A1c >8% was conflicting. Consensus supported individualized perioperative management of disease-modifying antirheumatic drugs, perioperative antibiotic prophylaxis, alcohol-based skin preparation, and avoidance of razor shaving. Evidence was insufficient to determine the effects of testosterone supplementation, diagnostic indication, continuation of antiplatelet therapy before revision, extended oral antibiotic prophylaxis, or antibiotic prophylaxis for dental and other invasive procedures. Evidence was also insufficient to support specific intraoperative interventions for reducing PJI, including intrawound antibiotics, antiseptic irrigation, iodine-impregnated drapes, electrocautery, tranexamic acid, or selection of a particular arthroplasty type.

CONCLUSION: The 2025 ICM identified several strategies applicable to current practice while highlighting substantial gaps in shoulder-specific evidence. Many recommendations remain based on limited or extrapolated evidence. Prospective shoulder-specific studies using clinical PJI as the primary outcome are needed to determine which prevention strategies provide meaningful benefit.