BESS PJI Guidelines - 12

S12

Shoulder & Elbow 10(1S)

Figure 2. Basic algorithm for two-stage revision.

3.2.2b Debridement, Antibiotics and implant retention
(DAIR). DAIR should be considered in patients with
Yamaguchi type 1 infected elbow arthroplasty within
three months of implantation and with a duration of
symptoms of less than three weeks. The soft tissue
cover should be good and the organism should be sensitive to antibiotics active against bioﬁlms.34 Surgery
should be performed in an appropriate facility with
expertise in the management of infected elbow arthroplasty. The surgery should include biopsy as outlined
above, radical debridement to remove any necrotic or
obviously infected soft tissue and exchange of all elements of the prosthesis that can be removed without stem
extraction. This should include all bushing and humeral
spools where possible. Thorough lavage with at least 6
litres of saline should be performed before exchange.35

cement spacer inserted. Further surgical debridement
may be required if signs of infection persist or the
soft tissue contamination is severe.
The second stage of reimplantation can be performed a minimum of three months after the last surgical debridement as long as the patient does not meet
any of the criteria in Table 1 to raise suspicion of
ongoing infection. The patient should have been free
from antibiotic treatment with no clinical recurrence
for a period of four to six weeks prior to reimplantation. Repeat biopsy or aspiration prior to reimplantation may be considered.
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.

3.2.2c Two stage revision. For patients with Yamaguchi
type 1 infected elbow arthroplasty not meeting the criteria for DAIR and those with Yamaguchi type 2 infection with a loose implant a two-stage revision should be
considered. The surgery should include biopsy, meticulous sampling and debridement of the soft tissues,
removal of the implants and all the cement using osteotomes, power burrs, curettes and an ultrasound device
if needed.36 Windowing of the bones may be required
for well-ﬁxed implants. Copious lavage with 6 litres of
saline should be performed and an antibiotic laden

3.2.2d Resection arthroplasty. A patient with a Yamaguchi
type 3 infected elbow with bone stock inadequate to
permit re-implantation may be considered for radical
debridement of infected and necrotic tissue, removal of
all implants and cement, and copious lavage with
saline.37 This is most likely to be successful in cases
where both columns of the humerus are preserved.
The elbow should be placed in to a cast or static
splint at 90 degrees of elbow ﬂexion for a period of
six weeks. Skeletal reconstruction with allograft may
be an option to permit reimplantation but there is

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