The 1st International Consensus Meeting on Periprosthetic Joint InfectionEdward M. Schwarz Volker Alt Stephen L. Kates
The current healthcare crisis has led to unprecedented political conflict over delivery of healthcare with dramatic consequences for the global economy and human health. Given the stakes, and the critical need for cost‐effective evidence‐based medical solutions, the time has come for physicians and scientists to formally establish what is known and apply this information to institute systems of care that will consistently produce excellent clinical outcomes for all patients. Of equal importance is the identification of non‐evidence‐based clinical practices that may contribute to complications and unnecessary costs, which will need to be eliminated in the era of Accountable Care. With this goal in mind, experts in the field of periprosthetic joint infection (PJI) traveled from all over the world to Philadelphia to engage in deep discussion and passionate debate, just as the Founding Fathers of the United States did, to produce the 1st Consensus Statement on Periprosthetic Joint Infection.
Infection remains a serious clinical problem in orthopedic surgery, as approximately 112,000 orthopedic device‐related infections occur every year in the US alone, with an estimated increase in hospital costs of $15,000–30,000 per incident.1 While the infection rates over the past decade have been only 2–3% and 5% for joint prosthesis and fracture‐fixation devices respectively,1, 2 these problems typically require a very costly and complicated two‐stage reconstruction technique to first remove the infected devices and tissues and control the infection using antibiotic‐laden cement spacers or beads,3 before attempting to replace the hardware. Moreover, revision surgery after infection is associated with failure rates as high as 50% with catastrophic results that could lead to arthrodesis, permanent explantation, amputation, or death.
Ideally, questions on PJI are answered by well‐designed preclinical and clinical research studies. However, many practical questions about standards of care cannot be addressed in this manner, and are best addressed by examination of existing best evidence and consensus of experts in the area of study. The 1st International Consensus Meeting on Periprosthetic Joint Infection (ICMPJI) was organized to deal with these questions, and to synthesize the best available scientific and clinical evidence on each question. Presented below are the Consensus Statements created by the ICMPJI. This effort took the better part of a year to perform the necessary research and literature reviews prior to the meeting. Then, on July 31 and August 1, 2013, the ICMPJI assembled at Thomas Jefferson University in Philadelphia under the leadership of Javad Parvizi, MD and Thorsten Gehrke, MD to review, edit and vote on the many specific questions surrounding PJI.
The group consisted of >400 delegates from many different disciplines (orthopedic surgery, infectious disease, musculoskeletal pathology, microbiology, anesthesiology, dermatology, nuclear medicine, rheumatology, musculoskeletal radiology, veterinary surgery, pharmacy, and numerous scientists) from 52 countries. These experts were divided into 15 categorical groups to scrutinize 207 questions about PJI on the first day, and then the entire ICMPJI voted on the final consensus statement the next day. The 364‐page document generated by this process represents an exhaustive examination of PJI, and will serve to inform clinicians treating this troublesome condition.
While there is tremendous enthusiasm for these Consensus Statements, their impact on clinical practice will not be known for some time. Similarly, the sharp disagreements within the ICMPJI over several consensus questions serve as a call to action, and progress to address these important problems will be monitored in the future. One example of this lack of ICMPJI consensus was in response to the simple question “What defines late prosthetic joint infection?” Thus, the resulting document not only offers guidance to clinicians for patient care, but also helps to frame future research questions on areas requiring investigation about PJI. Moreover, we find the process used by the ICMPJI to be a model of international cooperation that should be applied to all areas of medicine. By using such an organized approach in the Accountable Care era, the critical improvement in patient care and reduction of wasteful and harmful treatments can be achieved.
This work was supported by the AOTrauma Clinical Priority Program on Bone Infection.