Diagnostic value of preoperative joint aspiration for periprosthetic shoulder infection: analysis of microbiological aspects and preoperative ICM minor criteria

Introduction

The incidence of shoulder arthroplasty (SA) has risen significantly and is expected to continue increasing. Periprosthetic shoulder infection (PSI), though rare, remains a major concern due to non-specific symptoms and low-virulent pathogens like Cutibacterium acnes. The diagnostic value of preoperative joint aspiration and the minor criteria of the 2018 International Consensus Meeting (ICM) for PSI diagnosis remains controversial, requiring further investigation. This study evaluates (1) the microbiological accuracy of standardized joint aspiration and (2) the predictive value of preoperative ICM minor criteria for PSI.

Material and methods

A retrospective analysis was conducted on patients undergoing revision surgery after SA, where standardized joint aspiration was performed. Microbiological cultures, synovial fluid markers, and C-reactive protein levels were analyzed and compared to intraoperative biopsy cultures. Sufficient aspiration was defined as obtaining ≥ 1 ml of fluid and culture incubation for ≥ 14 days. Sensitivity, specificity, positive/negative predictive values, and accuracy were calculated. A receiver operating characteristic (ROC) analysis was performed for preoperative ICM criteria.

Results

Of 258 revisions, 235 met inclusion criteria. Cutibacterium acnes was the most frequently cultured pathogen. Joint aspiration showed 84.2% concordance with intraoperative tissue cultures, yielding 81% diagnostic accuracy. Among preoperative ICM minor criteria, white blood cell count/leukocyte esterase (WBC/LE) and alpha-defensin exhibited the highest accuracy (80–81%) for PSI detection. ROC analysis of the preoperative ICM model resulted in an AUC of 0.76.

Conclusions

Preoperative joint aspiration following a standardized protocol demonstrates good diagnostic accuracy for PSI, with Cutibacterium acnes most commonly identified. The preoperative ICM 2018 minor criteria, particularly WBC/LE and alpha defensin, exhibit high accuracy for PSI detection. Therefore, diagnostic joint aspiration should be routinely considered, potentially avoiding more invasive diagnostic procedures. Nevertheless, a suspected aspiration without detection of germs should lead to further diagnostic steps.

Level of evidence

Level III retrospective study.