BESS PJI Guidelines - 6

S6
aseptic loosening may lead to similar ﬁndings. The role
of advanced imaging modalities in diagnosis of PJI
remains uncertain. Laboratory tests on peripheral
blood, synovial ﬂuid and periprosthetic tissue from the
aﬀected joint can help conﬁrm diagnosis. It should be
noted that C-Reactive Protein (CRP) and Erythrocyte
Sedimentation Rate (ESR) measurements form only one
part of the clinical assessment; and although they may
contribute to the diagnostic pathway, they cannot be
used in isolation. Diagnostic criteria have been developed by diﬀerent international consensus groups, with
high concordance demonstrated between the deﬁnitions
recommended by the Musculoskeletal Infection Society
(MSIS) and the Infectious Diseases Society of America
(IDSA).9
Whilst there are no universally accepted guidelines
for diagnosis, we recommend using the MSIS criteria,2
which deﬁnes conﬁrmation of PJI when any one of the
main criteria (in bold) in Table 1 is present. We recommend this to be supplemented with histological examination where tissue from the aﬀected joint is sampled.
The presence of Leucocyte Esterase (LE) þþ in the
synovial ﬂuid, although found to be reliable in knee
arthroplasty for diagnosis if PJI, has been found to
be of doubtful value in shoulder arthroplasty.10

Shoulder & Elbow 10(1S)

the section on working in partnership with patients that
doctors should:
. Listen to patients and respond to their concerns and
preferences
. Give patients the information they want or need in a
way they can understand
. Respect patients' right to reach decisions with the
doctor about their treatment and care
. Support patients in caring for themselves to improve
and maintain their health
This can only be achieved by direct consultation
between the patient and their treating clinician.
Decisions about treatment taken without such direct
consultation between patient and treating clinician are
not appropriate, as they do not adhere to principles of
good medical practice.

2. Care Pathway
2.1 Aims of treatment

The General Medical Council's 'Good Medical
Practice - duties of a doctor' guide11 clearly states in

The overall treatment aim is based on early awareness
of potential PJI, early referral to secondary care and
subsequent potential onward referral for tertiary care.
Treatment decisions can be complex, often require
multidisciplinary treatment and success needs to be deﬁned
individually with patients in a shared decision making
process.

Table 1. MSIS criteria for diagnosis of periprosthetic joint
infection.

2.2 Assessment in Primary Care & Community
Triage Services

1.3 Shared decision making

1. There is a sinus tract communicating with the
prosthesis; or
2. A pathogen is isolated by culture from at least two
separate tissue or fluid samples obtained from the
affected prosthetic joint; or
3. Four of the following six criteria exist:
1. Elevated serum erythrocyte sedimentation rate (ESR) and
serum C-reactive protein (CRP) concentration,
2. Elevated synovial fluid leukocyte count (>1100/ml),
3. Elevated synovial fluid neutrophil percentage (>65%),
4. Presence of purulence in the affected joint,
5. Isolation of a microorganism in one culture of periprosthetic tissue or fluid, or
6. Greater than five neutrophils per high-power field in five
high-power fields observed from histologic analysis of periprosthetic tissue at Â400 magnification.

Having a high index of suspicion is important to prevent undue delay in optimum treatment for the patient.
Plain radiographs of a suspected infected joint in such
circumstances may not be useful and should not unduly
delay referral.
Features to consider:
. Date of joint replacement
. Duration of symptoms - are they since surgery or
sudden and new.
. Global reduction in range of motion, especially
severe loss of passive movement
. Any signs of systemic upset or sources of infection
. Co-morbidities making the patient more susceptible
to infection

2.3 Red Flags for same day emergency referral
A suspected infected joint needs same day urgent referral if an acute infection is suspected. Consider same day

Table of Contents for the Digital Edition of BESS PJI Guidelines