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The 23 Greatest Research Priorities in Musculoskeletal Infection

By Dr. Edward Schwarz

Musculoskeletal infections (MSKI) remain the bane of orthopaedic surgery, resulting in grievous illness and inordinate costs that threaten healthcare systems. As prevention, diagnosis and treatment remain largely unchanged over the last fifty years, a 2nd International Consensus Meeting on MSKI (ICM 2018) was completed on July 25-27, 2018 in Philadelphia, PA, USA. This 2-year long process derived the final set of 652 consensus questions, which were discussed and voted on by 658 scientists, internists and orthopaedic surgeons representing 92 countries. As critical outcomes of ICM 2018 include determining the current incidence and costs of MSKI, establishing what is currently known about the basic science of MSKI and effective standards of care, and deriving the greatest research priorities, two ICM 2018 research workgroups (RW) were assembled to accomplish these tasks. The findings appear in the May 2019 issue of the Journal of Orthopaedic Research.

The Consensus Article by Saeed et al (DOI: 10.1002/jor.24229) reports the findings of the 28-member Biofilm RW, which highlights 13 cutting-edge areas of MSKI and fundamental knowledge gaps in this field. The RW’s consensus spans conclusions on the molecular nature and function of biofilm, the mechanism by which biofilms resist antibiotics and host immunity, microbial synergizes in polymicrobial infections, diagnostics for biofilm on implants, definitions for minimum biofilm eradication concentration (MBEC) of anti-infective agents, and the potential of bacteriophage therapy. The Consensus Article by Schwarz et al (DOI:10.1002/jor.24293) presents the results of the 29-member General RW and has two salient features: up-to-date data on the current and projected incidences of infection, and costs per patient for all orthopaedic subspecialties, which range from 0.1%-30%, and $17,000-$150,000. The RW also reviewed all of the questions from ICM 2018 and determined that 23 of them are high priorities for research funding. These questions fall within six thematic categories: Acute vs. Chronic Infection, Host Immunity, Antibiotics, Diagnosis, Research Caveats, and Modifiable Factors.

To disseminate this information, the Journal of Orthopaedic Research established a new category of publication: Consensus Articles. These invited peer-reviewed manuscripts are submitted by a large group of recognized thought leaders who utilize an established methodology (e.g. the Delphi method) to derive a consensus on important issues based on established literature, non-peer reviewed information, and expert opinion. The resulting summary is intended to provide a broad audience guidance on the controversies and major unmet needs in the field, and to define the clinical and economic significance of the problems by providing consensus data on the incidences of the clinical problem, and costs. The Orthopaedic Research Society is supporting this effort by hosting free downloadable PDFs of the consensus questions, response, and rationale: Biofilm RW’s PDFs and General Assembly RW’s PDFs.  These high-impact Consensus Articles can positively influence multidisciplinary investigative teams with the will to solve these problems and private foundations, governmental agencies and commercial funding mechanisms who need to provide the medical community the resources necessary to establish best practices with scientific evidence.