Reply to the Letter to the Editor: Can Topical Vancomycin Prevent Periprosthetic Joint Infection in Hip and Knee Arthroplasty? A Systematic Review
Bibliographic record
Abstract
To the Editor, We thank Drs. Pijls and Nelissen for their comments and analysis related to our article entitled “Can Topical Vancomycin Prevent Periprosthetic Joint Infection in Hip and Knee Arthroplasty? A Systematic Review” [2]. Their interpretations and experiences are valuable contributions to this important and often challenging topic of periprosthetic joint infection (PJI). We appreciate that Drs. Pijls and Nelissen raised the concept of “vote counting,” which, as they stated in their letter, should be avoided when performing systematic reviews [1]. We acknowledge that this method has limitations and may lead to inaccurate conclusions. However, we would assert that we did not perform vote counting in our study as alleged by Drs. Pijls and Nelissen in their letter. We presented the results and indicated which ones (and how many) identified an advantage associated with vancomycin; the fact that most studies did not was not the key finding. The key finding was how broadly most of those studies’ findings bracketed the line of no-difference. Such consistently wide 95% CIs across so many studies, in this situation, is the key finding, not the number of studies that found a “significant difference.” We refrained from performing a meta-analysis as part of our study because data pooling (meta-analysis) of nonrandomized studies is considered poor meta-analytic practice, as the kinds of biases likely present in studies of that design typically will overstate the apparent benefits of the treatment being studied. Instead, as is appropriate for the kinds of studies we analyzed, we performed a systematic review of the best-available evidence. We also agree that the fact that a study does not identify a statistical difference does not necessarily mean that an effect is absent. Most of the studies included in our review were likely underpowered to demonstrate statistical differences. However, to justify a treatment that has risks, such as vancomycin powder, it seems important to have high-quality studies demonstrating an advantage to doing so. Our systematic review found insufficient evidence at this time to recommend the routine use of topical vancomycin powder for PJI prophylaxis. Adequately powered randomized controlled trials are needed. Furthermore, the random effects model done by Drs. Pijls and Nelissen shows a number needed to treat of approximately 145 in favor of topical vancomycin powder. The authors raise the question: “Do we want to expose 145 patients to possibly reduce one occurrence of PJI considering that we do not know the safety concerns associated with vancomycin and we could possibly introduce antimicrobial resistance, which makes treatment of PJI cases more difficult or even impossible in the future?” While those are valid concerns, we feel that the best way to answer these questions is through a methodologically sound randomized controlled trial.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.022 | 0.147 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.005 | 0.003 |
| Bibliometrics | 0.003 | 0.003 |
| Science and technology studies | 0.002 | 0.003 |
| Scholarly communication | 0.004 | 0.006 |
| Open science | 0.005 | 0.002 |
| Research integrity | 0.024 | 0.027 |
| Insufficient payload (model declined to judge) | 0.005 | 0.004 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".