BESS PJI Guidelines - 13

Rangan et al.

insuﬃcient evidence to recommend this without further
research.
3.2.2e One stage revision. We have deliberately listed this
as the last surgical option for Elbow PJI. There is insufﬁcient evidence in the literature to recommend single
stage revision although there may be rare circumstances
where it is considered in the best interest of the
patient.38 Any decision to perform a single stage revision will require multi-disciplinary team discussion and
should only be considered in rare instances where a two
stage revision is not in the best interest of the patient
and the infection is known to be caused by a low virulence organism with known sensitivities. The decision
should balance the risks of a two stage surgery against
the risk of recurrent infection following a single stage
revision and the need for revision implant removal,
with the potential for additional bone loss that may
prevent further re-implantation.

3.3 Resources needed for peri-operative care
Revision surgery should be performed in designated
centres that have appropriate on-site support. The
centre should have all the appropriate equipment available, to avoid additional loan costs. Immediate and
reasonable access to relevant multi-disciplinary
teams is important, speciﬁcally vascular surgery, plastic
surgery and infectious diseases teams. Appropriate
specialist rehabilitation services should be made available for patients undergoing revision surgery. Such
rehabilitation may be undertaken closer to home if
necessary.

S13

4.1 Coding and Finance
Appropriate diagnostic and procedural coding of procedures is vital for correct HRG mapping and for
accurate data collection. For best practice in coding it
is important for clinicians to engage with trained coders
to ensure that all clinical coding standards are followed.
It is also critical that all complications and comorbidities (CCs) are recorded. The current HRG4þ system is
very granular and payment is dependent on the number
of CCs.
The most common diagnostic and procedural codes
for PJI are listed in Appendix 2. Also listed are the base
HRGs that the procedures map to. The precise HRG
will be determined by a number of factors including the
number of complications and comorbidities.
Appropriate remuneration of actual costs for this
specialist service provision is critical. Such service
reconﬁguration must not be delivered at negative cost
to the centre and funds will need to follow service delivery. With an increasing workload, it is important that
adequate and appropriate funding is provided to the
centre in order to cover the additional resource costs
for staﬃng, training, theatre and ward costs, equipment
and rehabilitation.
Declaration of Conflicting Interests
The author(s) declared no potential conﬂicts of interest with
respect to the research, authorship, and/or publication of this
article.

Funding
The author(s) received no ﬁnancial support for the research,
authorship, and/or publication of this article.

4 Outcome Metrics
The following metrics should be routinely recorded by
any centre managing shoulder and elbow PJI.
Contributing data and cases to the National Joint
Registry (NJR) is mandatory.
Length of stay
Re-admission rate within 30 days
Mortality rates
PROM pre-revision procedure, and minimum 6
months post procedure
. Revision data/conversion data and PROMS to be
entered into the National Joint Registry
. Recurrent infection/complications/other adverse
events
. Further revision prosthetic procedures
.
.
.
.

We have recommended a list of auditable standards
for use by centres managing shoulder and elbow PJI,
which are listed in Appendix 1

References
1. Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and
management of prosthetic joint infection: clinical practice
guidelines by the Infectious Diseases Society of America.
Clinical infectious diseases: an official publication of the
Infectious Diseases Society of America 2013; 56: e1-e25.
10.1093/cid/cis803.
2. Parvizi J, Zmistowski B, Berbari EF, et al. New
Definition for Periprosthetic Joint Infection: From the
Workgroup of the Musculoskeletal Infection Society.
Clinical Orthopaedics and Related Research 2011; 469:
2992-4.
3. Oussedik S, Gould K, Stockley I and Haddad FS.
Defining peri-prosthetic infection. Do we have a workable
gold standard? 2012; 94-B: 1455-6. 10.1302/0301620x.94b11.30244. http://bjj.boneandjoint.org.uk/content/
jbjsbr/94-B/11/1455.full.pdf.
4. National Joint Registry for England, Wales, Northern
Ireland and Isle of Man. 14th Annual Report. 2017.
http://www.njrreports.org.uk/Portals/0/PDFdownloads/
NJR14thAnnualReport2017.pdf.

http://bjj.boneandjoint.org.uk/content/jbjsbr/94-B/11/1455.full.pdf http://bjj.boneandjoint.org.uk/content/jbjsbr/94-B/11/1455.full.pdf http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR14thAnnualReport2017.pdf http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR14thAnnualReport2017.pdf

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