Peri-prosthetic joint infection (PJI) is a devastating complication that has a huge burden on patients’ functionality, time and energy of the health care providers all over the world. Orthopedic surgeons together with all disciplines involved in the manage-ment of surgical site infections has put their most effort to find ways of prevention and effective management strategies. While pub-lished research and high level evidence lead to more effective management of peri-prosthetic joint infection, there are many questions remained to be answered without strong evidence in the published literature. Group judgment is an acceptable way to find answer for questions and set the best practice when the strong evidence is lacking.
Despite all extraordinary discoveries in the fields of microbiology, antibiotics and sur-gical techniques the battle against surgical site infection (SSI) is still running. Peri-prosthetic joint infection is the fear of every orthopedic surgeon involved in orthopedic arthroplasty practice.
This year the world orthopedic community experienced one of the unique events in the field of PJI named “World Consensus Meet-ing on PJI”. This meeting that was held from July 31st till August 1st 2013 was the conclu-sion of ten months work of about 400 dele-gates from world orthopedic community. The goal of this group was to find answers and recommendations for more than 207 questions based on the high level evidence if present or reach to a consensus when there is a lack of high level evidence.
The idea of arranging this international con-sensus meeting on PJI was first conceived by two world known experts, Dr. Javad Par-vizi from Rothman Institute, Thomas Jeffer-son University in Philadelphia and Dr. Thor-sten Gehrke, Department of Orthopedic Surgery, ENDO-Klinik, Hamburg, Germany in September 2013. The process of the “In-ternational Consensus Meeting on PJI” had three phases: First through a modified Del-phi process, all 400 participants exchanged ideas remotely through social media to iden-tify all questions regarding prevention, di-agnosis and management of PJI. Selection of these expert delegates was based on two cri-teria: publication record and/or clinical in-terest in management of PJI. The consensus group included orthopedic surgeons, infec-tious disease specialists, scientists, musculo-skeletal pathologists and radiologists, phar-macists, rheumatologists, and experts in many other disciplines. At this 9 month pe-riod, 400 delegates from 58 countries and 100 societies in 15 groups conducted a com-prehensive review of about 3500 publica-tions in current literature relevant to PJI to find out high level evidence for current prac-tices. The cumulative wisdom of 400 dele-gates from 58 countries and over 100 socie-ties used to reach consensus about practices lacking higher level of evidence.
These groups covered the following areas related to PJI: 1) mitigation and education on comorbidities, 2) patient preparation, 3) perioperative antibiotics, 4) operative envi-ronment, 5) blood conservation, 6) prosthesis selection, 7) diagnosis of PJI, 8) wound management, 9) spacer, 10) irrigation and debridement, 11) antibiotic treatment and timing of re-implantation, 12) one-stage ver-sus two-stage exchange, 13) management of fungal or atypical PJI, 14) antimicrobial therapy, and 15) prevention of late PJI. At this stage 23,500 communications ex-changed and finally a draft was prepared to be presented for vote at the final meeting on 1st of August 2013. The draft included rec-ommendations for management on the basis of high level of evidence if present or con-sensus of ideas of experts in areas of lacking high level of evidence.
Finally the draft was presented for vote on 1st of August 2013 in Philadelphia. Two hundred thirty six delegates from 52 coun-tries representing 160 different medical in-stitutions voted on those 207 recommenda-tions. This more than 360 page document is the best practice guidelines for PJI consist-ing of 207 recommendations and answers for 207 questions. There is no doubt that this consensus document is a pillar for “best practice guidelines” that will serve many of our patients for many years to come.
I was proud to serve as a member of the workgroup on perioperative antibiotic, and hereby, a selection of only 2 questions from more than 50 pages of document answering 22 questions in the field of perioperative an-tibiotic prophylaxis will be presented in this issue of SOJ as a review article. Selections of the remaining questions will be included in upcoming issues of SOJ.
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