Quick Summary
A deep dive into the 2025 International Consensus Meeting (ICM) updates. New diagnostic criteria, novel biomarkers, and the shifting paradigms in management.
Visual Element: A "Consensus Timeline" graphic showing the evolution of PJI definitions from MSIS 2011 -> ICM 2013 -> MSIS 2018 -> ICM 2025.
Periprosthetic Joint Infection (PJI) remains the most devastating complication of total joint arthroplasty. It is the leading cause of revision knee replacement and the third leading cause of revision hip replacement. The economic burden is astronomical, but the human cost—multiple surgeries, prolonged immobility, and antibiotic toxicity—is incalculable.
The management of PJI has historically been based on "expert opinion" (Eminence-based medicine). However, the International Consensus Meeting (ICM) has shifted this towards Evidence-based medicine. This article summarizes the pivotal updates from the 2025 meeting that every arthroplasty surgeon must know.
Part 1: Diagnosis - The New Definition
We have moved beyond simple "Cell Count and Culture." The 2025 criteria refine the scoring system to include novel biomarkers.
Major Criteria (Definitive Diagnosis)
Presence of ONE of the following:
- Two separate cultures growing the same organism (phenotypically identical).
- Sinus tract communicating with the joint.
Minor Criteria (The Scoring System)
If Major criteria are absent, use the weighted score. (Thresholds have been tweaked for higher sensitivity).
| Marker | Threshold | Score |
|---|---|---|
| Serum CRP | > 10 mg/L | 2 |
| D-Dimer | > 860 ng/mL | 2 |
| Synovial WBC | > 3,000 cells/µL | 3 |
| Synovial PMN % | > 80% | 2 |
| Synovial Alpha-Defensin | Positive | 3 |
| Synovial LE | ++ | 1 |
| Intra-op Purulence | Positive | 3 |
Interpretation:
- Score ≥ 6: PJI.
- Score 2-5: Inconclusive. (Consider Next-Gen Sequencing).
- Score 0-1: Not Infected.
Clinical Pearl: The D-Dimer
Serum D-Dimer is a valuable screening test for PJI. It is elevated in infection (fibrin degradation). However, it is non-specific in the early post-op period (<6 weeks) or in patients with DVT/PE. Its real value is in the chronic PJI workup.
Part 2: Prevention Updates
The best treatment is prevention. The consensus heavily debated several prophylactic measures.
1. Nasal Decolonization
- Consensus: Screening and treating Staph aureus carriers (MSSA and MRSA) reduces SSI.
- Protocol: Mupirocin (Bactroban) nasal ointment x 5 days pre-op + Chlorhexidine body wash.
- New: Povidone-Iodine nasal solution (immediate pre-op application) is an effective alternative with better compliance and lower resistance risk.
2. Intra-operative Irrigation
- Consensus: Dilute Betadine (0.35%) soak for 3 minutes before closure reduces infection rates.
- Note: Do not use full strength (cytotoxic to osteoblasts). Do not use Hydrogen Peroxide (risk of air embolus).
3. Antibiotic Prophylaxis
- Weight-based dosing: Cefazolin 2g (<120kg) or 3g (>120kg).
- Redosing: Every 4 hours (for Cefazolin) or if blood loss > 1500mL.
- Dual Therapy: The addition of Vancomycin to Cefazolin is recommended only for high-risk carriers (MRSA) or institutions with high MRSA prevalence. Routine dual therapy is discouraged due to AKI risk.
Part 3: Management Shifts
The "One-Stage" Revolution
Historically, One-Stage exchange was reserved for "easy" cases. The indications are expanding.
- 2025 View: One-Stage is as effective as Two-Stage for:
- Healthier patients (no severe immunocompromise).
- Good soft tissues.
- Known sensitive organism (This is key. Do not do it for culture-negative PJI).
- Pros: Single surgery, lower cost, better function.
- Cons: If it fails, you are in trouble.
Culture-Negative PJI
This accounts for 20-30% of cases and is a nightmare.
- Cause: Prior antibiotics (most common), fastidious organisms (Cutibacterium acnes), Fungi.
- Strategy: Hold antibiotics for 2 weeks before aspiration if possible. Use blood culture bottles for synovial fluid. Keep cultures for 14-21 days.
- Next-Gen Sequencing (NGS): Identifying bacterial DNA. High sensitivity but low specificity (picks up DNA from dead bacteria). Useful as a "rule-in" for specific pathogens but must be interpreted with caution.
Part 4: Antibiotic Suppression
Is there a role for lifelong antibiotics?
- Indication: Patient too frail for surgery, or refuses surgery.
- Success: Variable. About 50-60% keep the implant for 2 years.
- Consensus: It is a valid palliative option but not a cure.
Conclusion
The 2025 updates push us towards more precise diagnosis (biomarkers) and more aggressive, single-stage management for appropriate candidates. The era of "blindly revising in two stages" is ending. We must be surgical scientists.
ICM 2025 Summary PDF
Download the executive summary of the consensus meeting.
Related Topics
Found this helpful?
Share it with your colleagues
Discussion