Although our specialty is some 50 years into a shared, worldwide experience with modern THA, there remain important gaps in our knowledge. Some of these issues are small, and in a few years, we will look back and wonder why there were even conversations at all.
However, some of these gaps are critical, and cry out for our attention. By any metric, the “unknowns” in the area of periprosthetic joint infection (PJI) meet this definition. Whether we look at the number of patients harmed by this complication (many thousands per year), or the costs of care associated with it (hundreds of millions, surely), the problem is enormous. But those are just the statistics. The tragedies are in the office: seen in the faces of patients and family members, and in the lives disrupted, or worse.
In order to address our knowledge gaps, we must first identify them. Leaders from the Musculoskeletal Infection Society (whose official journal is Clinical Orthopaedics and Related Research®) and the European Bone and Joint Infection Society convened the International Consensus Meeting on Periprosthetic Joint Infection to do exactly that.
CORR® is pleased to publish the consensus statement that emerged from this meeting, which is a detailed, thoughtful document on every pressing issue related to PJI. This summary is available as supplemental material to the methods paper describing how the group defined and arrived at consensus, which is published in “International Consensus on Periprosthetic Joint Infection” (DOI 10.1007/s11999-013-3329-4).
The process was lengthy, labor-intensive, and very well-conceived. Delegates from numerous disciplines including infectious disease, musculoskeletal pathology, microbiology, anesthesiology, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, and pharmacy, joined orthopaedic and clinician-scientists to evaluate the available evidence when present, or to reach consensus regarding current practices for management of PJI when the evidence was deficient. Some questions never will be answered by randomized controlled trials; we think that surgeons will find the discussion of those topics by this diverse, expert body particularly useful, as Level V evidence (expert opinion) may be all we have to go on in those areas, at least for the foreseeable future.
A few key measures summarize the size and scope of this project:
Preparation time: 10 months
Specific questions answered: 207
Countries represented: 52
Specialty societies represented: More than 100.
Delegates involved: 400 (more than 300 of these delegates attended the meeting in person).
Publications evaluated: More than 3500.
Communications exchanged during consensus-building: More than 25000, via email and a “social” website created for the purpose.
The consensus document itself was created using the Delphi method under the leadership of William L. Cats-Baril PhD, an internationally known expert in consensus development.
The consensus group has asked me to emphasize that clinicians must exercise wisdom and judgment in making decisions for their individual patients. Because of the complexities associated with musculoskeletal infections around orthopaedic implants, there will be many circumstances that will require approaches other than those endorsed in the document. Their warning in this regard is important, and well worth heeding.
Finally, the astute reader will notice that the layout of the methods paper “International Consensus on Periprosthetic Joint Infection” (DOI 10.1007/s11999-013-3329-4) and the consensus statement are more similar to our columns than to the scientific manuscripts published in CORR®. This reflects the fact that although the document went through tens of thousands of hours of review by the hundreds of delegates involved in the consensus process, it was not peer-reviewed nor edited by CORR®. Notwithstanding this, we believe that readers will find that the quality of the document speaks for itself, and we are proud to publish it in CORR®.
Footnotes
The author certifies that he, or any members of his immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request.
The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or the Association of Bone and Joint Surgeons®.