BESS PJI Guidelines - 11

Rangan et al.

easily treatable; and where multiple operative procedures are contra-indicated due to risk to patient and/or
the limb.
The technique should also follow good practice
previously outlined with early Microbiology MDT
involvement and with the use of tissue sampling techniques for microbiology and histology sampling.
Once the specimens have been taken and the implants
(and where applicable the cement) have been removed,
empirical treatment with antibiotics can be administered. A thorough debridement and lavage should be
performed prior to insertion of the deﬁnitive implants,
which if cemented, should be done so with a gentamicin
impregnated cement. Other antibiotics may be added at
the advice of your microbiologist.
The Microbiology MDT should coordinate the
administration of the relevant antibiotics in the immediate postoperative period and, if appropriate, with the
aid of the Outpatient Parenteral Antibiotic Therapy
(OPAT) team. If infection still continues despite this,
a two stage revision or excision arthroplasty could be
considered.
3.2.1c Two Stage. The indications for a two-stage revision may be driven primarily by surgical preference.
However, when the bacterium involved is not known
or if known, is highly virulent, such that eradication
might prove diﬃcult, a two-stage revision is preferred.
In undertaking a two-stage revision, the risks of multiple
surgical procedures must be medically acceptable to the
patient and the shoulder should be able to tolerate the
multiple procedures whilst still delivering function.
Notwithstanding this, two-stage revision is considered
the most reproducible way to deliver the eradication
of infection whilst also achieving good clinical
outcomes.26,27
The implant should be removed in the same manner
as outlined in the one-stage technique. Once sampling
and adequate debridement have been undertaken,
intra-operative systemic antibiotics should be administered as deﬁned by the Microbiology MDT; antibiotic
impregnated spacers may be placed to maintain the
joint space and deliver antibiotic treatment. Empirical
systemic antibiotics should be continued in the postoperative period until antibiotic sensitivities are known.
The infection team should coordinate the dose and mode
of delivery of the antibiotic treatment. Following the
completion of the treatment, usually after six weeks,
the patient should remain oﬀ antibiotics for a minimum
of two weeks to allow any residual infection to declare
itself if present. If the patient remains asymptomatic, and
clinical assessment is satisfactory, then the second stage
can proceed. If investigations are abnormal and/or the
patient is still symptomatic, then a radiologically guided
joint aspiration, or possibly needle synovial biopsy, can

S11
be performed prior to repeating antibiotic treatment with
or without a further formal open debridement and repeat
biopsy. The cycle then continues until the second stage of
implant exchange is undertaken (Figure 2).
As in a one-stage technique, the Microbiology MDT
and OPAT teams should coordinate all postoperative
antimicrobial management. If positive cultures are
unexpectedly grown following a second stage revision,
then the appropriate antibiotic regime should be pursued whilst also considering another revision if the
symptoms merit further intervention.
3.2.1d Excision Arthroplasty þ/À spacer. The role of an
excision arthroplasty is primarily aimed at those
patients whose overall health would prevent them
from undertaking prolonged or two-stage surgery or
when the virulence of the organisms are such that
repeated surgical interventions would be considered
unwise to the overall health of the patient or to the
viability of the arm. With no retained implant there is
a good chance of the eradication of the infection, which
may address some of the pain attributed to PJI,
although there is a signiﬁcant risk of functional impairment.27,28 Antibiotic impregnated spacers can also be
used but these may still have to be removed at a later
date.
3.2.2 Elbow PJI. The risk of infection after total elbow
arthroplasty is increased in those of younger age, prolonged surgery, multiple previous surgeries and a diagnosis of inﬂammatory arthropathy.29-32 A patient with
an elbow arthroplasty with proven infection, or in
whom infection is thought highly likely using the criteria outlined in Table 1, should be advised of the diagnosis and all the options for treatment so that an
individualized plan can be formulated through shared
decision making.
The treatment options considered should include
debridement and implant retention, two stage revision,
resection arthroplasty or antibiotic suppression. The
last of these options may be appropriate for a patient
who is systemically well, has well ﬁxed implants
infected with a known organism that responds to oral
antibiotic therapy and for whom the risks of surgery
outweigh the beneﬁts.
3.2.2a Classification. Infected elbow arthroplasty can be
classiﬁed using the system of Yamaguchi et al.33 that
aids treatment planning:
(I) Infection with stable implant
(II) Infection with unstable implants and adequate
bone stock
(III) Infection with poor bone stock that prevents
reimplantation.

Table of Contents for the Digital Edition of BESS PJI Guidelines