title: The Zeitgeist of Challenging the Evidence. A Perspective on the International Consensus Meeting on Periprosthetic Joint Infection.
abstract: BACKGROUND
  The economic burden of the treatment of periprosthetic joint infection (PJI) is high and the treatment of PJI has a high degree of international controversy. Several papers have declared the International Consensus Meeting on Periprosthetic Joint Infection (ICMPJI) to be the "flawless pledge of international academics" to overcome the challenges of musculoskeletal infections. The purpose of this paper is to highlight for the first time some essential insights into the key dilemmas that are associated with this international consensus process.
  
  
  METHODS
  The proceedings of the ICMPJI was reviewed, and the critical consensus agreements that were reached were communicated via e-mail to 48 leading orthopaedic surgeons, microbiologists and statisticians around the world. Of these, 30 responded, 8 did not, and 10 of respondents were not aware of the ICMPJI.
  
  
  RESULTS
  A thorough review of the ICMPJI proceedings identified a clear need to resolve some of the dilemmas that we highlight in this paper. The Delphi procedure has been described as a survey technique that enables a group dynamic-based practice. Although there have been several published reports on this procedure, its scientific merit is still being debated. Several challenges and questions have been raised regarding the application of the Delphi technique, but there is no doubt that it is a vital approach for achieving consensus on subjects where none currently exists.
  
  
  CONCLUSIONS
  Performing prospective clinical studies in this area is currently the best and only option to overcome this challenge. In the long term, this approach will not only incorporate the standard of clinical evidence but also adopt regional mores for treating infection, which include patient values, cultural differences and local financial resources.
authors.affiliation: Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Hangama C
authors.initials: HC
authors.lastname: Fayaz
authors.affiliation: Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Jesse B
authors.initials: JB
authors.lastname: Jupiter
keywords: Delphi Procedure; International Consensus Meeting; Level of Evidence; Periprosthetic Joint Infection; Quality of patient care; Trans-continental controversy