www.elsevier.com/locate/semanthroplasty Available online at www.sciencedirect.com Algorithm for the evaluation of the painful total shoulder arthroplasty: Searching for sepsis Filippo Familiari, MD, Amrut U. Borade, MD, Alan Gonzalez-Zapata, MD, Tina Raman, MD, and Edward G. McFarland, MD n Department of Orthopaedic Surgery, The Johns Hopkins University, 601 N. Caroline St, Baltimore, MD 21287 article info Keywords: algorithm pain total shoulder arthroplasty infection abstract One of the most serious complications after shoulder arthroplasty is periprosthetic joint infection. The reported incidence after primary procedures ranges from 0.7% to 4%, and the rates after revision surgery are even higher. Data on periprosthetic joint infection are derived in large part from the reported experience in managing infection at the sites of total knee and total hip arthroplasties; there is much less information available with which to guide decision making for the shoulder. This review focuses specifically on the current and future tools for diagnosing periprosthetic infections after shoulder arthroplasty. & 2014 Elsevier Inc. All rights reserved. 1. Introduction One of the most devastating complications of joint replace- ment, regardless of the joint affected, is a postoperative infection. Because more total knee and total hip arthroplas- ties than shoulder arthroplasty are performed each year, most of the current literature on periprosthetic joint infection (PJI) is related to hip and knee replacement. However, shoulder arthroplasty has been found to be a successful operation and is being increasingly offered to more patients. According to the Agency for Healthcare Research and Quality Database [1], 5000 shoulder arthroplasties were performed yearly from 1990 through 1992, 7000 yearly from 1996 through 2002, and more than 53,000 in 2011. It is predicted that by 2020, there will be 75,000 shoulder arthroplasties performed yearly. As shoulder arthroplasty becomes more popular, the impact of PJI will certainly increase, because it is recognized as a major source of morbidity and because it may account for an increasing proportion of healthcare expenditures [2–4]. Studies have reported a post-shoulder arthroplasty infec- tion rate of 0.7–4% and even higher rate after revision surgery [5–12]. A systematic review of the literature pertain- ing to TSA from 1996 through 2005, including 39 clinical studies with a minimum follow-up of 2 years, showed an overall rate of infection of 0.7% [7]. Singh et al. [11], using prospectively collected data on patients with primary TSA from 1976 through 2008 at the Mayo Clinic, reported 5-, 10-, and 20-year PJI rates of 0.7%, 1.5%, and 2.8%, respectively. One of the obstacles in PJI research has been a lack of consensus on what criteria should be met to definitively establish the diagnosis. In 2011, the Musculoskeletal Infection Society convened a workgroup to evaluate the available evidence and to propose a definition for PJI [13]. This group’s definition of PJI consists of two major and six minor criteria; the presence of at least one of the major criteria or the presence of four of the six minor criteria would indicate PJI. In 2013, this definition of PJI was slightly modified by removing “presence of purulence in the affected joint” and adding the http://dx.doi.org/10.1053/j.sart.2015.02.014 1045-4527/& 2014 Elsevier Inc. All rights reserved. n Correspondence to: Edward G. McFarland, MD, Johns Hopkins Division of Shoulder and Elbow Surgery, 10753 Falls Road, Suite 215, Pavilion II, Lutherville, MD 21093. E-mail address: editorialservices@jhmi.edu (E.G. McFarland). S EMINARS IN A RTHROPLASTY 25 (2014) 295 – 304