Prevention

Antibiotics

• Question 1: What are the optimal peri-operative antibiotics for primary shoulder arthroplasty?
• Question 2: What are the optimal peri-operative antibiotics for patients undergoing revision shoulder arthroplasty?
• Question 3: Are there peri-operative antibiotics that should be used for patients who have specific preoperative risk factors (e.g. patient sex and comorbidities) for shoulder PJI?
• Question 4: What is the optimal duration of peri-operative antibiotics following primary or revision shoulder arthroplasty?
• Question 5: Is there a role for post-operative (pending culture results) antibiotics after revision shoulder arthroplasty without suspicion for infection?

Intra-operative

• Question 1: Should antibiotic-impregnated cement be used during shoulder arthroplasty (primary and revision)?
• Question 2: What is the role of topical intrawound antiseptics (dilute betadine lavage, acetic acid, or antibiotics added to the irrigation solution) and antibiotic powder (such as vancomycin) during primary or revision shoulder arthroplasty?
• Question 3: Do surgical drains influence the risk of infection in patients undergoing primary or revision shoulder arthroplasty?
• Question 4: What is the role of tranexamic acid (TXA) during primary or revision shoulder arthroplasty in decreasing the risk of PJI?

Patient Characteristics

• Question 1: What is the role of medical comorbidities as potential risk factors for PJI following primary or revision TSA?
• Question 2: Does previous shoulder surgery (arthroscopic or open non-arthroplasty) increase the risk of PJI?
• Question 3: Does prior corticosteroid injection increase the risk of PJI after primary or revision shoulder arthroplasty?

Skin Preparation

• Question 1: Is there a role for pre-operative skin scrub (home scrubs and washes) prior to primary or revision shoulder arthroplasty?
• Question 2: What Is the optimal perioperative surgical skin prep for primary or revision shoulder arthroplasty?
• Question 3: Is there a role for topical skin treatments prior to primary or revision shoulder arthroplasty?
• Question 4: Should the subcutaneous and dermal tissues be disinfected during shoulder arthroplasty?

Diagnosis

Culture Significance

• Question 1: What is the relevance of positive cultures in the evaluation for shoulder PJI? What defines a clinically relevant positive culture result(s) versus a culture contaminant?
• Question 2: What is the relevance of unexpected positive cultures in revision shoulder arthroplasty without clinical or radiographic signs of infection?
• Question 3: What is the treatment (if any) for unexpected positive cultures (UPC) in revision shoulder arthroplasty without clinical or radiographic signs of infection?
• Question 4: What is the role of quantitative evaluation (e.g. density of bacteria, cuti [propi] score) of positive cultures from the shoulder?

Culture Technique

• Question 1: What is the optimal culture technique (e.g. culture medium, days of incubation) in evaluating patients for shoulder PJI?
• Question 2: Should Cutibacterium acnes (formerly known as Propionibacterium acnes) isolated in samples from the shoulder be sub-typed?
• Question 3: Is there a role for Polymerase chain reaction / next generation sequencing technique in the diagnosis of shoulder PJI?

Diagnostic Criteria

• Question 1: What clinical signs (e.g. gross wound changes [swelling, erythema, or drainage]) are concerning for shoulder PJI?
• Question 2: What radiographic findings are concerning for shoulder PJI?
• Question 3: What intraoperative findings are concerning for shoulder PJI?
• Question 4: What is the role for peri-prosthetic frozen section and permanent histology in evaluation of a shoulder arthroplasty for PJI?
• Question 5: What are the diagnostic criteria of shoulder PJI?

Inflammatory Markers

• Question 1: What is the role for serum ESR, CRP, or WBC count in the evaluation of a shoulder arthroplasty for PJI?
• Question 2: Is there a role for (a) synovial or (b) serum IL-6 in the diagnosis of shoulder PJI?
• Question 3: Is there a role for synovial fluid WBC count and differential in the diagnosis of shoulder PJI?
• Question 4: Is there a role for synovial cytokines in the diagnosis of shoulder PJI?
• Question 5: Is there a role for synovial fluid TNF-alpha and IL-2 in the diagnosis of shoulder PJI?
• Question 6: Is there a role for synovial fluid leukocyte esterase strip testing in the diagnosis of shoulder PJI?
• Question 7: Is there a role for synovial fluid alpha-defensin in the diagnosis of shoulder PJI?
• Question 8: Is there a role for serum D-dimer in the evaluation of PJI following shoulder arthroplasty?
• Question 9: Is there a role for preoperative joint aspiration in the evaluation of a shoulder arthroplasty for PJI

Treatment

Antibiotic for Unexpected Positive Cultures

• Question 1: Is there a role for postoperative antibiotics after performing an irrigation and debridement for hematoma complicating a primary or revision shoulder arthroplasty while awaiting culture results?
• Question 2: Is there a role for postoperative antibiotic treatment for revision arthroplasty with subsequent unexpected positive cultures for a virulent organism (e.g. MRSA, MSSA, or E. coli)?
• Question 3: Is there a role for postoperative antibiotic treatment when a revision arthroplasty is performed with subsequent unexpected positive cultures of the shoulder caused by an indolent organism (e.g. C. acnes or Coagulase Negative Staphylococcus)?

Sampling

• Question 1: Should tissue samples be obtained for culture in all revision shoulder arthroplasties?
• Question 2: Is there a role for obtaining tissue cultures when performing an irrigation and debridement for hematoma after shoulder (primary or revision) arthroplasty?
• Question 3: Should tissue cultures be obtained in primary shoulder arthroplasty cases with history of prior surgery (arthroscopic, open, ORIF, or another non-arthroplasty surgery)?
• Question 4: Is there a role for pre-operative open or arthroscopic tissue biopsy in the evaluation prior to initial revision shoulder arthroplasty?
• Question 5: Does the sampling technique (number of samples, anatomic locations) of the tissue obtained in the evaluation for shoulder PJI affect the result of frozen section and permanent histology?
• Question 6: Is there a role for sonication of retrieved shoulder implants in the diagnosis of shoulder PJI?
• Question 7: Should pre-operative antibiotics be held until after cultures are obtained in revision shoulder arthroplasty?
• Question 8: Does the sampling technique (number of samples, tissue versus fluid versus implant, anatomic locations) affect the results for culture of specimens obtained in the evaluation of shoulder PJI?

Antibiotic for PJI

• Question 1: Is there a need for antibiotic therapy following irrigation and debridement of patients with acute shoulder PJI caused by a virulent organism (e.g. MRSA, MSSA, or E. coli)?
• Question 2: Is there a role for antibiotic therapy in the management of acute shoulder PJI with an indolent organism (e.g. C. acnes or Coagulase Negative Staphylococcus) after irrigation and debridement?
• Question 3: Is there a role for non-operative suppressive treatment in the management of subacute or chronic shoulder PJI?
• Question 4: Is there a role for oral suppressive antimicrobial therapy in the setting of retained prostheses after IV therapy in subacute or chronic PJI?
• Question 5: Is there a role for oral suppressive antimicrobial therapy in acute PJI in the setting of retained prostheses after initial IV therapy? Same duration as for lower extremity arthroplasty? Should it differ by pathogen (e.g. MSSA vs MRSA)?
• Question 6: Should the duration of oral suppressive antimicrobial therapy differ by pathogen (e.g. MSSA vs MRSA) in the treatment of subacute or chronic shoulder PJI?
• Question 7: What are the recommendations for the route (IV versus PO) and duration of postoperative antibiotic treatment when a one-stage revision arthroplasty is performed for subacute or chronic shoulder PJI of the shoulder caused by an indolent organism (e.g. C. acnes or Coagulase Negative Staphylococcus)?
• Question 8: What are the recommendations regarding the route (IV versus PO) and length of postoperative antibiotic treatment when a one-stage revision arthroplasty is performed for subacute/chronic shoulder PJI caused by a virulent organism (e.g. MRSA, MSSA, E. coli)?
• Question 9: What is the optimal antibiotic treatment for culture-negative cases with positive clinical, radiographic, or intraoperative findings for acute shoulder PJI?
• Question 10: What is the optimal antibiotic treatment for culture-negative cases with positive clinical, radiographic, or intraoperative findings for subacute or chronic shoulder PJI?

Bone Graft

• Question 1: Should bone graft or cement be removed during treatment of acute shoulder PJI?
• Question 2: Should bone graft or cement be removed in treatment for subacute or chronic shoulder PJI?

Component Retention

• Question 1: Is there a role for irrigation and debridement with implant retention when treating acute shoulder PJI?
• Question 2: What are the indications for irrigation and debridement with component retention in subacute or chronic shoulder PJI?
• Question 3: Should modular components be exchanged during irrigation and debridement of acute shoulder PJI?
• Question 4: Should modular components be exchanged during irrigation and debridement of subacute or chronic shoulder PJI?
• Question 5: Should well-fixed glenoid components be removed during surgical treatment for subacute or chronic shoulder PJI?
• Question 6: Is there a role for routine exchange of all well-fixed implants in revision shoulder arthroplasty without clinical or radiographic signs of infection?

Implant

• Question 1: What is the optimal implant for treatment of acute PJI: reverse TSA, anatomic TSA, versus hemiarthroplasty?

Resection

• Question 1: What are the indications for resection shoulder arthroplasty in acute PJI?
• Question 2: Is there a role for resection shoulder arthroplasty in the management of subacute or chronic PJI?

Revision

• Question 1: Is there a role for an antibiotic spacer for the treatment of shoulder PJI?
• Question 2: What are the indications for one versus two-stage exchange arthroplasty in the management of acute shoulder PJI?
• Question 3: What are the indications for one versus two stage revision in subacute or chronic shoulder PJI?
• Question 4: Is there a role for preoperative joint aspiration prior to reimplantation during two-stage exchange for shoulder PJI?
• Question 5: Is there a role for pre-reimplantation open or arthroscopic tissue biopsy in the evaluation during two-stage exchange of shoulder periprosthetic joint infection (PJI)?