The 2023 Orthopaedic Research Society International Consensus Meeting on musculoskeletal infection

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Abstract

The Orthopaedic Research Society's Research Interest Group completed its international consensus meeting (ICM) on musculoskeletal infections (MSKI) following the 2023 Annual Meeting. The work products from this ICM include the 65 questions with recommendation and rationale, and the voting results from the 72 delegates. There are also five Consensus Articles in this issue of the Journal of Orthopaedic Research from the ICM Sections: Host Immunity, Established Infection‐Treatment, Clinical Questions not addressed by the prior MSKI ICMs, In Vitro, and Animal Models. This Introduction summarizes the 3‐year Delphi process used by the ICM with timelines and critical milestones. It also highlights several challenges that had to be addressed, and a large body of work that remains.

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Most cited references 5

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2018 International Consensus Meeting on Musculoskeletal Infection: Research Priorities from the General Assembly Questions

Edward M. Schwarz, Javad Parvizi, Thorsten Gehrke … (2019)

Musculoskeletal infections (MSKI) remain the bane of orthopedic surgery, and result in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis, and treatment has remained largely unchanged over the last 50 years, a 2nd International Consensus Meeting on Musculoskeletal Infection (ICM 2018, https://icmphilly.com) was completed. Questions pertaining to all areas of MSKI were extensively researched to prepare recommendations, which were discussed and voted on by the delegates using the Delphi methodology. The questions, including the General Assembly (GA) results, have been published (GA questions). However, as critical outcomes include: (i) incidence and cost data that substantiate the problems, and (ii) establishment of research priorities; an ICM 2018 research workgroup (RW) was assembled to accomplish these tasks. Here, we present the result of the RW consensus on the current and projected incidence of infection, and the costs per patient, for all orthopedic subspecialties, which range from 0.1% to 30%, and $17,000 to $150,000. The RW also identified the most important research questions. The Delphi methodology was utilized to initially derive four objective criteria to define a subset of the 164 GA questions that are high priority for future research. Thirty-eight questions (23% of all GA questions) achieved the requisite > 70% agreement vote, and are highlighted in this Consensus article within six thematic categories: acute versus chronic infection, host immunity, antibiotics, diagnosis, research caveats, and modifiable factors. Finally, the RW emphasizes that without appropriate funding to address these high priority research questions, a 3rd ICM on MSKI to address similar issues at greater cost is inevitable.

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2018 international consensus meeting on musculoskeletal infection: Summary from the biofilm workgroup and consensus on biofilm related musculoskeletal infections

Kordo Saeed, Alex C. McLaren, Edward M. Schwarz … (2019)

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Adjuvant antibiotic‐loaded bone cement: Concerns with current use and research to make it work

Edward M. Schwarz, Alex C. McLaren, Thomas Sculco … (2021)

Antibiotic-loaded bone cement (ALBC) is broadly used to treat orthopaedic infections based on the rationale that high-dose local delivery is essential to eradicate biofilm-associated bacteria. However, ALBC formulations are empirically based on drug susceptibility from routine laboratory testing, which is known to have limited clinical relevance for biofilms. There are also dosing concerns with nonstandardized, surgeon-directed, hand-mixed formulations, which have unknown release kinetics. On the basis of our knowledge of in vivo biofilms, pathogen virulence, safety issues with nonstandardized ALBC formulations, and questions about the cost-effectiveness of ALBC, there is a need to evaluate the evidence for this clinical practice. To this end, thought leaders in the field of musculoskeletal infection (MSKI) met on 1 August 2019 to review and debate published and anecdotal information, which highlighted four major concerns about current ALBC use: (a) substantial lack of level 1 evidence to demonstrate efficacy; (b) ALBC formulations become subtherapeutic following early release, which risks induction of antibiotic resistance, and exacerbated infection from microbial colonization of the carrier; (c) the absence of standardized formulation protocols, and Food and Drug Administration-approved high-dose ALBC products to use following resection in MSKI treatment; and (d) absence of a validated assay to determine the minimum biofilm eradication concentration to predict ALBC efficacy against patient specific micro-organisms. Here, we describe these concerns in detail, and propose areas in need of research.

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Author and article information

Contributors

Thomas F. Moriarty: (View ORCID Profile)

Noreen J. Hickok: (View ORCID Profile)

Kordo Saeed: (View ORCID Profile)

Thomas P. Schaer: (View ORCID Profile)

Antonia F. Chen: (View ORCID Profile)

Edward M. Schwarz: (View ORCID Profile)

Journal

Title: Journal of Orthopaedic Research

Abbreviated Title: Journal Orthopaedic Research

Publisher: Wiley

ISSN (Print): 0736-0266

ISSN (Electronic): 1554-527X

Publication date Created: March 2024

Publication date (Electronic): October 12 2023

Publication date (Print): March 2024

Volume: 42

Issue: 3

Pages: 497-499

Affiliations

[1 ] AO Research Institute Davos Davos Switzerland

[2 ] Department of Orthopaedic Surgery Thomas Jefferson University Philadelphia Pennsylvania USA

[3 ] University Hospital Southampton, NHS Foundation Trust University of Southampton Southampton UK

[4 ] Department of Clinical Studies University of Pennsylvania School of Veterinary Medicine, New Bolton Center Kennett Square Pennsylvania USA

[5 ] Department of Orthpaedic Surgery Harvard Medical School Boston Massachusetts USA

[6 ] Department of Orthopaedics, Center for Musculoskeletal Research University of Rochester Rochester New York USA

Article

DOI: 10.1002/jor.25714

SO-VID: 8eb6dfe9-eefa-42b6-9716-8d10e3cda191

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http://onlinelibrary.wiley.com/termsAndConditions#vor

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