Coming to Consensus on Issues of PJI Management

    Orthopaedic surgeons know without question that periprosthetic joint infection (PJI) is a devastating complication of total joint arthroplasty.

    What’s less clear is how to optimally prevent, diagnose, and treat these infections.

    Javad Parvizi, MD, FRCS, and Thorsten Gehrke, MD, took up the challenge of better defining solutions to these issues nearly a year ago when they began organizing a global consensus-building project on PJI.

    Their efforts – and the efforts of hundreds of experts in PJ from around the world – culminated in a two-day, face-to-face meeting – officially known as the International Consensus Group on Periprosthetic Joint Infection – July 31-August 1, 2013, in Philadelphia, Pennsylvania. The meeting was timed to occur right before this year’s annual meeting of the Musculoskeletal Infection Society, also being held in Philadelphia.

    Dr. Parvizi is Professor of Orthopedic Surgery, Rothman Institute at Thomas Jefferson University, in Philadelphia, and Dr. Gehrke is Director of the ENDO-Klinik Hamburg, a specialist clinic for bone and joint surgery in Hamburg, Germany.

    Evidence and Expert Opinion

    “There is little evidence in support of some practices we perform on a daily basis in medicine,” Dr. Parvizi said. “How long should a surgeon wash his/her hands prior to surgery? What is considered as a contraindication to elective arthroplasty? Should patients with inflammatory arthritis stop their disease-modifying agents prior to TJA?”

    Periprosthetic joint infection is one of those areas of medicine. “The main impetus for this meeting was to generate consensus for many practices that will lead to prevention or better treatment of PJI,” Dr. Parvizi said.

    Level 1 evidence, of course, would be the ideal, but Dr. Parvizi acknowledged that such studies would either be logistically impossible or take many years to complete. Patients are suffering now, and orthopaedic surgeons need answers.

    The consensus group meeting in Philadelphia was intended as an alternative that would tap into the “collective wisdom of the experts from around the world to decide on some best practices” in PJI, Dr. Parvizi said.

    More than 400 delegates were chosen for the PJI consensus project based on their publication records and areas of expertise; approximately 300 of them made the trip to Philadelphia for the face-to-face meeting.

    Dr. Parvizi and Dr. Gehrke drew from a wide pool of research and clinical experts for the consensus project. “We had specialists from orthopedic surgery, infectious disease, musculoskeletal pathology, rheumatology, musculoskeletal imaging – radiology and nuclear medicine – veterinary surgery, dermatology, and anesthesiology,” Dr. Parvizi noted. 

    15 Aspects of PJI Management

    Delegates were divided into 15 workgroups, each group addressing one aspect of PJI management:

    • Mitigation and education on comorbidities (medical optimization)
    • Patient preparation (skin preparation/hand-washing)
    • Perioperative antibiotics
    • Operative environment
    • Blood conservation
    • Prosthesis selection
    • Diagnosis (laboratory, imaging, pathology)
    • Wound management
    • Spacer
    • Irrigation and debridement
    • Antibiotic treatment and timing of reimplantation
    • One-stage vs. two- stage exchange
    • Management of fungal or atypical PJI
    • Antimicrobial therapy
    • Prevention of late PJI (dental prophylaxis, antibiotic prophylaxis, monitoring)

    “The consensus covers every aspect of practice, starting from preparation of the patient prior to surgery all the way to post-surgical treatment,” Dr. Parvizi said.

    Each workgroup had an international and a US leader assigned to lead the group’s discussions as well as oversee the consensus-building process within the group. In addition, each workgroup also had a liaison whose duty it was to collect the evidence (whenever available) in support of statements made by the group and to review the pertinent literature.

    The workgroups were tasked with choosing the questions for which they felt the overall group would need to reach. They began drafting their consensus documents in May 2013, and after multiple rounds of discussion and revision that took place though email and a social network set up for this purpose (ForMD), brought these documents to Philadelphia for the face-to-face meeting and voting on their questions.

    A Good Day for Consensus

    On July 31, each workgroup met in a separate room for 3 hours or so to finalize their consensus statements and questions. Delegates from all 15 workgroups then came together in a general assembly for further discussion that lasted until midnight.

    Final questions and consensus statements were then loaded onto the audience response system for voting the next day, and on August 1, delegates from 58 countries met and voted on the consensus. A total of 264 questions/consensus statements were presented and voted on that day.

    It was evident that the workgroups had been diligent and rigorous in developing and providing support for their consensus statements/questions: Of the 264 statements/questions on which the delegates voted, only four failed to achieve consensus, defined as greater than 75% of the delegates agreeing via the audience response system vote.

    The areas in which consensus was not reached were:

    • Optimal dressing to use following TJA
    • Non-surgical strategies to address a draining wound after TJA
    • Definition of late PJI
    • Whether use of tantalum (porous metal) may be protective against PJI

    Not willing to abandon these important issues, Dr. Parvizi said plans have been put in place to initiate studies that will address these questions in the near future.

    Examples of Consensus Statements

    The resulting consensus document, which is currently undergoing review by the delegates, is 370 pages long and contains numerous recommendations will Dr. Parvizi said will impact the practice of orthopedic surgery.

    Following are examples of the consensus statements in the draft document:

    Workgroup 1: Mitigation and education on comorbidities

    Question 1B: What are the potential risk factors for development of surgical site infection (SSI) or periprosthetic joint infection (PJI) after elective total joint arthroplasty (TJA)?

    Consensus: The risk factors for SSI or PJI include history of previous surgery, uncontrolled diabetes mellitus, malnutrition, morbid obesity, active liver disease, active renal disease, excessive smoking (>one pack per day), excessive alcohol consumption (>40 units per week), intravenous drug abuse, recent hospitalization, extended stay in a rehabilitation facility, male gender, diagnosis of post-traumatic arthritis, inflammatory arthropathy, prior surgical procedure in the affected joint, and severe immunodeficiency.

    Delegate Vote: Agree: 94%, Disagree: 4%, Abstain: 2% (Strong Consensus)

    Workgroup 3: Perioperative antibiotics

    Question 2: Is there an optimal antibiotic that should be administered for routine perioperative surgical prophylaxis?

    Consensus: A first- or second-generation cephalosporin (cefazolin or cefuroxime) should be administered for routine perioperative surgical prophylaxis. Isoxazolyl penicillin is used as an appropriate alternative.

    Delegate Vote: Agree: 89%, Disagree: 8%, Abstain: 3% (Strong Consensus)

    Workgroup 7: Diagnosis

    Question 1A: What is the definition of periprosthetic joint infection (PJI)?

    Consensus: PJI is defined as:

    – Two positive periprosthetic cultures with phenotypically identical organisms, or

    – A sinus tract communicating with the joint, or

    – Having 3 of the following minor criteria:

    – Elevated serum erythrocyte sedimentation rate (ESR) AND C- reactive protein (CRP)

    – Elevated synovial fluid white blood cell (WBC) count OR ++ change on leukocyte esterase test strip

    – Elevated synovial fluid neutrophil percentage (PMN%)

    – Positive histological analysis of periprosthetic tissue

    – A single positive culture

    Delegate Vote: Agree: 85%, Disagree: 13%, Abstain: 2% (Strong Consensus)

    Workgroup 12: One-stage vs. two-stage exchange

    Question 1: What are the indications and contraindications for one-stage exchange arthroplasty?

    Consensus: One stage-exchange arthroplasty is a reasonable option for treatment of periprosthetic joint infection (PJI) in circumstances where effective antibiotics are available except in patients with systemic manifestations of infection (sepsis) in whom resection arthroplasty and reduction of bioburden may be necessary. Relative contraindications to one-stage exchange may include lack of identification of an organism preoperatively, the presence of a sinus tract or severe soft tissue involvement that may lead to the need for flap coverage.

    Delegate Vote: Agree: 78%, Disagree: 17%, Abstain: 5% (Strong Consensus)

    Next Steps

    Once the recommendations are approved by the delegates, the consensus document will be made available on the websites of more than 100 societies in more than 60 countries, Dr. Parvizi said. It will also be published as a book and an ebook, and a concise version will be published as a peer-reviewed manuscript.

    Although the document is currently in English, “we will have it translated to 18 different languages,” Dr. Parvizi said, emphasizing not only the contributions of delegates from around the world, but also the worldwide immediacy of addressing the problem of PJI.

    Dr. Parvizi believes the consensus document will be widely accepted and the recommendations implemented in practice.

    “The questions that were evaluated by these workgroups are those that orthopedic surgeons face on a daily basis,” he said. “The intention of this meeting was to come up with ‘best practice guidelines’ for management of PJI that will help orthopedic surgeons do the right thing for their patients.”

    “I would not imagine any resistance to these guidelines,” he added. “After all, they were generated after thorough evaluation of the literature, when present, or cumulative wisdom of over 400 delegates from around the world with absolute dedication to the field of PJI. I wish we could generate this type of best practice guideline for other areas in medicine.”