BESS PJI Guidelines - 5

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GUIDELINES

Investigation and Management of
Periprosthetic Joint Infection in the
Shoulder and Elbow: Evidence and
consensus based guidelines of the
British Elbow and Shoulder Society

Shoulder & Elbow
2018, Vol. 10(1S) S5-S19
! The Author(s) 2018
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DOI: 10.1177/1758573218772976
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Amar Rangan, Mark Falworth, Adam C Watts,
Matthew Scarborough, Michael Thomas, Rohit Kulkarni and
Jonathan Rees; On behalf of the BESS PJI Group

1. Introduction
1.1 Background
Periprosthetic Joint Infection (PJI) is a relatively rare
but potentially devastating complication aﬀecting
shoulder and elbow joint arthroplasty. The increasing
use of these procedures in the surgical management of
arthritis and trauma means that the incidence of PJI is
also likely to rise. The much larger burden of PJI in hip
and knee arthroplasty has made international groups
develop consensus deﬁnitions on diagnosis and guidance on investigations required to conﬁrm PJI.1-3
Infection reported as a cause for revision within the
UK National Joint Registry (NJR) currently is 0.27%
for shoulder arthroplasty and 1.13% for elbow arthroplasty.4 Although the numbers of PJI are relatively low
with shoulder and elbow arthroplasty the impact on
patients, the treating surgical teams and healthcare
resources remains signiﬁcant.
Scoping reviews of the current body of literature on
shoulder and elbow PJI conﬁrmed a limited quality of
published papers, mostly based on small retrospective
case series and cohort studies.5,6 The British Elbow and
Shoulder Society (BESS) has therefore developed these
clinical guidelines on investigation and management of
shoulder and elbow PJI by combining available evidence from the literature with consensus developed by
a working group of BESS surgeons, infectious disease
physicians and BESS physiotherapists.

1.2 Definition
PJI may occur either by contamination during surgery,
by contiguous spread through adjacent tissue planes or
by haematogenous spread of infection from another

source. We adopt the view that wound contamination
during surgery by higher virulence organisms leads to
PJI manifesting less than 3months from surgery and
contamination by lower virulence organisms leads to
PJI manifesting between 3 months and 24 months
from surgery. Late PJI manifesting more than
24 months from surgery is usually via haematogenous
seeding, or less commonly by contiguous spread of
infection, for example from surgery to adjacent tissues
breaching healed tissue planes.
The diagnosis of PJI may be straightforward in some,
but a complex process in others with little global consensus on the best approach to deﬁnitively conﬁrm or
exclude the diagnosis of infection. Diagnosis of PJI is
usually made based on a combination of clinical, radiographic and intraoperative ﬁndings alongside blood
results and microbiological cultures.7 Clinical diagnosis
of PJI can be diﬃcult, as low-grade infections may present with non-speciﬁc and vague symptoms such as pain
and stiﬀness. Presence of a combination of clinical features that include pain, peri-articular warmth, erythema,
eﬀusion, and fever should raise the index of suspicion for
PJI. These have been referred to as ''clinical ﬁndings that
raise or lower the pre-test probability of PJI''.8 Plain
radiographs may demonstrate progressive radiolucent
lines along the bone-prosthesis interface, other areas of
osteolysis or osteopenia. These radiological features in
isolation are non-speciﬁc, particularly in late PJI, where

United Kingdom of Great Britain and Northern Ireland
Corresponding author:
Amar Rangan, United Kingdom of Great Britain and Northern Ireland.
United Kingdom of Great Britain and Northern Ireland.
Email: amar.rangan@york.ac.uk
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