EDITORIAL
Is this the era of consensus?
R. Morgan-Jones, F. S. Haddad From The British Editorial Society of Bone & Joint Surgery, London, United Kingdom
R. Morgan-Jones, MB.BCh, M.Med.Sci, FRCS(Tr&Orth), Consultant Orthopaedic Surgeon University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK. F. S. Haddad, MD(Res), MCh(Orth), FRCS(Orth), Editorin-Chief The Bone & Joint Journal, 22 Buckingham Street, London WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2013 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B11. 33224 $2.00 Bone Joint J 2013;95-B:1441–2.
The Bone & Joint Journal seeks to provide the highest possible level of evidence. However, there are several complex issues, such as, for instance, the management of deep periprosthetic infections, where so many disparate views exist that consensus is a necessary starting point.1,2 The consensus principle is underused in the orthopaedic community, but has great potential in an era where many informed international voices should be heard. Such a tool may protect surgeons and patients from guidelines that are narrow in scope and potentially based on limited, flawed or biased data and opinions. The principles of decision making by consensus are well known. There are four broad requirements.3-5 First, the consensus must be inclusive. As many members of the community must be involved as possible, and no expert in the field should be intentionally excluded. All parties are expected to participate fully and to contribute in a variety of roles to the final decision. Secondly, cooperation is essential. The participants need to build on each other’s suggestions and concerns to formulate recommendations that adhere to the published evidence and expertise of the parties involved. It is important not to ignore the minority. Thirdly, egalitarianism is important. The input of the loud expert should not be greater than that of their quieter colleague. Everyone should have an equal opportunity to amend or veto ideas. Fourthly and potentially most importantly, the goal of a consensus must remain orientated towards a solution. An effective decision making body works towards a common solution despite differences, collaboratively shaping proposals until they meet as many of the participants’ views and concerns as possible. That may, of course, mean that there is no clear consensus other than that there are residual unanswered questions. The consensus process involves a collaborative inclusive discussion, rather than an
VOL. 95-B, No. 11, NOVEMBER 2013
adversarial debate. As such, it is more likely to reach common ground, but the answers may have a number of perspectives to them rather than having the clarity that some desire. Even if a consensus meeting does not generate the final answer, it will usually lead to the formation of interested groups to work together collaboratively to study unanswered questions. Of prime importance when designing a consensus meeting is determining who the target audience is. It is important to identify all relevant interested parties, inform them, drill down to the key topic in focus, decide how narrow or how wide that should be, gather the literature and start to formulate the right questions. The process must be inclusive and achievable within a given time frame and must have clear rules at the outset. Some groups require everyone to consent if a proposal is to be passed. Others will rely on a majority or a vote. Sometimes statements have to remain open ended. In addition, it is essential to understand that a member of a working group may consent to a consensus proposal in order to allow an international perspective, while accepting that it is not their first choice of methodological approach. Parvizi, Gehrke and Chen2 are to be congratulated on the concept of the International Consensus on Periprosthetic Joint Infections. Their Specialty Update is a reminder of the increasing importance of this problem. The document that was produced illustrates the great strengths of a worldwide approach, but at the same time shows the limitations of a project based on interpretation of the literature where many questions remain unanswered. The meeting was a fascinating learning experience involving representatives of the orthopaedic community from many diverse parts of the world. We should reflect on some of the highlights of the meeting. Only one statement reached 100% agreement: the number of people in the operating theatre during an 1441
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R. MORGAN-JONES, F. S. HADDAD
operation and their movements should be kept to a minimum. We should all take that message back to our teams and ensure that theatre discipline in orthopaedics remains paramount. Whether our readers review the tables appended in the update,2 or the entire document, they will find a useful summary of the current state of the art and of the views of the experts. We encourage continued debate in this area and can confirm that BJJ will continue to publish the best material in this area, as it has done over the years.6-15 Ultimately, there is a great deal to be gained by international collaboration, regular communication and integration of the groups at the forefront of this type of work. The excellent work that the International Consensus Group carried out has focused the periprosthetic infection community and should lead us towards better research in this area and better outcomes for our patients. This consensus will help us set a baseline for the various definitions that are necessary for comparison of data and to guide appropriate research projects in this area. It will also help local societies to devise their own guidelines and recommendations. We must also accept that there are still many areas where further research is required. As expected, it was confirmed that there is a great deal of excellent work going on around the world, and that multidisciplinary, multi-institutional, international collaboration is required. We can also see an opportunity beyond the collaboration of traditional research whereby a central detailed register can be established for interested researchers in this area, and by facilitating the gathering of an enormous amount of multinational data and agreeing basic standards of its analysis, reporting and dissemination. By engaging with the expertise of those who have set up and run successful national registers, we should be able to create a platform that really allows us to answer some of the difficult questions that remain unanswered.
References 1. No authors listed. International Consensus on Periprosthetic Joint Infection. http:/ /www.msis-na.org/international-consensus/ (date last accessed 19 Sept 2013). 2. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013;95-B:1450–1452. 3. No authors listed. Consensus Decision-Making. http://www.consensusdecisionmaking.org (date last accessed 19 Sept 2013). 4. Hartnett T. Consensus-Orientated-Decision Making: Facilitating Groups to Widespread Agreement. Vancouver: New Society Publishers, 2011. 5. Massachusetts Institute of Technology. A short guide to consensus building. web.mit.edu/publicdisputes/practice/cbh_ch1.html (date last accessed 19 September 2013). 6. Namba RS, Inacio MC, Paxton EW. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg [Br] 2012;94B:1330–1338. 7. Adeli B, Parvizi J. Strategies for the prevention of periprosthetic joint infection. J Bone Joint Surg [Br] 2012;94-B Suppl A:42–46. 8. Oussedik S, Gould K, Stockley I, Haddad FS. Defining peri-prosthetic infection: do we have a workable gold standard? J Bone Joint Surg [Br] 2012;94-B:1455–1456. 9. Dinneen A, Guyot A, Clements J, Bradley N. Synovial fluid white cell and differential count in the diagnosis or exclusion of prosthetic joint infection. Bone Joint J 2013;95-B:554–557. 10. Esteban J, Alvarez-Alvarez B, Blanco A, et al. Prolonged incubation time does not increase sensitivity for the diagnosis of implant-related infection using samples prepared by sonication of the implants. Bone Joint J 2013;95-B:1001–1006. 11. Glehr M, Leithner A, Friesenbichler J, et al. Argyria following the use of silvercoated megaprostheses: no association between the development of local argyria and elevated silver levels. Bone Joint J 2013;95-B:988–992. 12. Gulhane S, Vanhegan IS, Haddad FS. Single stage revision: regaining momentum. J Bone Joint Surg [Br] 2012;94-B Suppl A:120–122. 13. Munro JT, Garbuz DS, Masri BA, Duncan CP. Articulating antibiotic impregnated spacers in two-stage revision of infected total knee arthroplasty. J Bone Joint Surg [Br] 2012;94-B Suppl A:123–125. 14. Vanhegan IS, Malik AK, Jayakumar P, Ul Islam S, Haddad FS. A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. J Bone Joint Surg [Br] 2012;94-B:619–623. 15. Vanhegan IS, Morgan-Jones R, Barrett DS, Haddad FS. Developing a strategy to treat established infection in total knee replacement: a review of the latest evidence and clinical practice. J Bone Joint Surg [Br] 2012;94-B:875–881.
THE BONE & JOINT JOURNAL
Is this the era of consensus?
R. Morgan-Jones, F. S. Haddad From The British Editorial Society of Bone & Joint Surgery, London, United Kingdom
R. Morgan-Jones, MB.BCh, M.Med.Sci, FRCS(Tr&Orth), Consultant Orthopaedic Surgeon University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK. F. S. Haddad, MD(Res), MCh(Orth), FRCS(Orth), Editorin-Chief The Bone & Joint Journal, 22 Buckingham Street, London WC2N 6ET, UK. Correspondence should be sent to Professor F. S. Haddad; e-mail: [email protected] ©2013 The British Editorial Society of Bone & Joint Surgery doi:10.1302/0301-620X.95B11. 33224 $2.00 Bone Joint J 2013;95-B:1441–2.
The Bone & Joint Journal seeks to provide the highest possible level of evidence. However, there are several complex issues, such as, for instance, the management of deep periprosthetic infections, where so many disparate views exist that consensus is a necessary starting point.1,2 The consensus principle is underused in the orthopaedic community, but has great potential in an era where many informed international voices should be heard. Such a tool may protect surgeons and patients from guidelines that are narrow in scope and potentially based on limited, flawed or biased data and opinions. The principles of decision making by consensus are well known. There are four broad requirements.3-5 First, the consensus must be inclusive. As many members of the community must be involved as possible, and no expert in the field should be intentionally excluded. All parties are expected to participate fully and to contribute in a variety of roles to the final decision. Secondly, cooperation is essential. The participants need to build on each other’s suggestions and concerns to formulate recommendations that adhere to the published evidence and expertise of the parties involved. It is important not to ignore the minority. Thirdly, egalitarianism is important. The input of the loud expert should not be greater than that of their quieter colleague. Everyone should have an equal opportunity to amend or veto ideas. Fourthly and potentially most importantly, the goal of a consensus must remain orientated towards a solution. An effective decision making body works towards a common solution despite differences, collaboratively shaping proposals until they meet as many of the participants’ views and concerns as possible. That may, of course, mean that there is no clear consensus other than that there are residual unanswered questions. The consensus process involves a collaborative inclusive discussion, rather than an
VOL. 95-B, No. 11, NOVEMBER 2013
adversarial debate. As such, it is more likely to reach common ground, but the answers may have a number of perspectives to them rather than having the clarity that some desire. Even if a consensus meeting does not generate the final answer, it will usually lead to the formation of interested groups to work together collaboratively to study unanswered questions. Of prime importance when designing a consensus meeting is determining who the target audience is. It is important to identify all relevant interested parties, inform them, drill down to the key topic in focus, decide how narrow or how wide that should be, gather the literature and start to formulate the right questions. The process must be inclusive and achievable within a given time frame and must have clear rules at the outset. Some groups require everyone to consent if a proposal is to be passed. Others will rely on a majority or a vote. Sometimes statements have to remain open ended. In addition, it is essential to understand that a member of a working group may consent to a consensus proposal in order to allow an international perspective, while accepting that it is not their first choice of methodological approach. Parvizi, Gehrke and Chen2 are to be congratulated on the concept of the International Consensus on Periprosthetic Joint Infections. Their Specialty Update is a reminder of the increasing importance of this problem. The document that was produced illustrates the great strengths of a worldwide approach, but at the same time shows the limitations of a project based on interpretation of the literature where many questions remain unanswered. The meeting was a fascinating learning experience involving representatives of the orthopaedic community from many diverse parts of the world. We should reflect on some of the highlights of the meeting. Only one statement reached 100% agreement: the number of people in the operating theatre during an 1441
1442
R. MORGAN-JONES, F. S. HADDAD
operation and their movements should be kept to a minimum. We should all take that message back to our teams and ensure that theatre discipline in orthopaedics remains paramount. Whether our readers review the tables appended in the update,2 or the entire document, they will find a useful summary of the current state of the art and of the views of the experts. We encourage continued debate in this area and can confirm that BJJ will continue to publish the best material in this area, as it has done over the years.6-15 Ultimately, there is a great deal to be gained by international collaboration, regular communication and integration of the groups at the forefront of this type of work. The excellent work that the International Consensus Group carried out has focused the periprosthetic infection community and should lead us towards better research in this area and better outcomes for our patients. This consensus will help us set a baseline for the various definitions that are necessary for comparison of data and to guide appropriate research projects in this area. It will also help local societies to devise their own guidelines and recommendations. We must also accept that there are still many areas where further research is required. As expected, it was confirmed that there is a great deal of excellent work going on around the world, and that multidisciplinary, multi-institutional, international collaboration is required. We can also see an opportunity beyond the collaboration of traditional research whereby a central detailed register can be established for interested researchers in this area, and by facilitating the gathering of an enormous amount of multinational data and agreeing basic standards of its analysis, reporting and dissemination. By engaging with the expertise of those who have set up and run successful national registers, we should be able to create a platform that really allows us to answer some of the difficult questions that remain unanswered.
References 1. No authors listed. International Consensus on Periprosthetic Joint Infection. http:/ /www.msis-na.org/international-consensus/ (date last accessed 19 Sept 2013). 2. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013;95-B:1450–1452. 3. No authors listed. Consensus Decision-Making. http://www.consensusdecisionmaking.org (date last accessed 19 Sept 2013). 4. Hartnett T. Consensus-Orientated-Decision Making: Facilitating Groups to Widespread Agreement. Vancouver: New Society Publishers, 2011. 5. Massachusetts Institute of Technology. A short guide to consensus building. web.mit.edu/publicdisputes/practice/cbh_ch1.html (date last accessed 19 September 2013). 6. Namba RS, Inacio MC, Paxton EW. Risk factors associated with surgical site infection in 30,491 primary total hip replacements. J Bone Joint Surg [Br] 2012;94B:1330–1338. 7. Adeli B, Parvizi J. Strategies for the prevention of periprosthetic joint infection. J Bone Joint Surg [Br] 2012;94-B Suppl A:42–46. 8. Oussedik S, Gould K, Stockley I, Haddad FS. Defining peri-prosthetic infection: do we have a workable gold standard? J Bone Joint Surg [Br] 2012;94-B:1455–1456. 9. Dinneen A, Guyot A, Clements J, Bradley N. Synovial fluid white cell and differential count in the diagnosis or exclusion of prosthetic joint infection. Bone Joint J 2013;95-B:554–557. 10. Esteban J, Alvarez-Alvarez B, Blanco A, et al. Prolonged incubation time does not increase sensitivity for the diagnosis of implant-related infection using samples prepared by sonication of the implants. Bone Joint J 2013;95-B:1001–1006. 11. Glehr M, Leithner A, Friesenbichler J, et al. Argyria following the use of silvercoated megaprostheses: no association between the development of local argyria and elevated silver levels. Bone Joint J 2013;95-B:988–992. 12. Gulhane S, Vanhegan IS, Haddad FS. Single stage revision: regaining momentum. J Bone Joint Surg [Br] 2012;94-B Suppl A:120–122. 13. Munro JT, Garbuz DS, Masri BA, Duncan CP. Articulating antibiotic impregnated spacers in two-stage revision of infected total knee arthroplasty. J Bone Joint Surg [Br] 2012;94-B Suppl A:123–125. 14. Vanhegan IS, Malik AK, Jayakumar P, Ul Islam S, Haddad FS. A financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. J Bone Joint Surg [Br] 2012;94-B:619–623. 15. Vanhegan IS, Morgan-Jones R, Barrett DS, Haddad FS. Developing a strategy to treat established infection in total knee replacement: a review of the latest evidence and clinical practice. J Bone Joint Surg [Br] 2012;94-B:875–881.
THE BONE & JOINT JOURNAL
