BOOM Meeting Sets Initial Standards for Periprosthetic Infection Management While Exposing Evidence Gaps in Orthopedic Oncology

The Birmingham Orthopedic Oncology Meeting (BOOM) initiative represents a critical step toward establishing a standardized framework for the real-world management of periprosthetic joint infections (PJI) in orthopedic oncology, while unearthing critical gaps in standardized surgical approaches and evidence to guide antibiotic use, according to R. Lor Randall, MD, FACS.

In January 2024, investigators from around the world convened in Birmingham, United Kingdom, for the inaugural BOOM meeting. ^1,2 This 2-day consensus meeting focused on unresolved challenges in orthopedic oncology, including the prevention and management of PJI in this patient population. Consensus results from the meeting, later published in The Bone & Joint Journal, underscored several areas of consensus, such as the role of revision strategies, antibiotic prophylaxis, and debridement, antibiotics, and implant retention (DAIR).² To build on this work, a follow-up meeting was held in January 2026 in Cape Town, South Africa, with a focus on PJI challenges in patients with chondrosarcoma or PJIs undergoing reconstruction.³

“This consensus provides much-needed initial clarity for the day-to-day management of PJIs in patients [with sarcoma] but also underscores how much work remains to elevate the evidence base,” Randall stated in an interview with OncLive^®. “[Medical oncologists] interface with patients who have bone sarcomas and display these massive endoprostheses, bone allografts, or a variety of other things in limb salvages, so it’s helpful for them to have this perspective.”

In addition to explaining the purpose of the BOOM meeting, Randall detailed 4 key takeaways for clinical management from BOOM; outlined challenges and important considerations for integrating consensus-based recommendations into practice; and underscored the importance of multidisciplinary coordination between orthopedic and medical oncologists.

Randall is the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at the University of California Davis Comprehensive Cancer Center in Sacramento.

OncLive: What was the clinical impetus for the BOOM Meeting, and how was it structured?

Randall: PJIs [after] these massive orthopedic reconstructions remain one of the most devastating complications we orthopedic oncologists [see]. Unlike primary arthroplasty or regular joint replacements, where infection rates are typically 1% to 2%, in oncologic reconstructions, it’s approximately 10%. The consequences can be quite profound, including amputation in a substantial portion of patients. The challenge is that high-level evidence in ortho-oncology is limited. Rather than a traditional systemic review, the BOOM committee used a modified Delphi consensus process, bringing together 309 delegates from 53 countries to vote on 20 key statements regarding infection prevention and management. What emerged is both reassuring and instructive.

What were the primary takeaways from the BOOM meeting regarding international consensus and the impact of the PARITY trial on antibiotic prophylaxis?

There was a strong international consensus in 18 of 20 statements, despite the acknowledged low quality of the evidence. That tells us that even in the absence of randomized data, there are areas where expert practice has clearly converged.

One of the most important shifts reflects the impact of the [phase 3] PARITY trial [NCT01479283].⁴ This was a prospective, randomized trial looking at oncologic limb salvage.[Patients were randomly assigned] to receive [1- or 5-day postoperative prophylactic intravenous cephalosporin regimens]. There was strong consensus that 24 hours of postoperative prophylaxis is as effective as a prolonged course of 5 days, as there were fewer antibiotic-associated or related complications. However, for high-risk reconstructions, particularly pelvic surgery, delegates did agree that extended prophylaxis up to 48 hours may be reasonable, especially given the higher rate of Gram-negative infections in that population.

What are the modern standards for managing wound drainage and determining the risk of deep infection?

Another consideration is wound management. Wound drainage can be an ongoing issue; these are big wounds, major dissections, and sometimes there’s radiation involved. Historically, prolonged drainage in large wounds has often been tolerated. The consensus was clear: drainage beyond 5 to 7 days should cause concern for deep infection. If drainage persists beyond 7 to 10 days, the consensus was that early surgical intervention should be considered, which represents a more aggressive stance than prior international guidance and reflects a growing recognition that watchful waiting in this population can be devastating.

What is the clinical role of DAIR in treating infections in massive segmental replacements, and what are its limitations?

Taking out these endoprosthetics and putting in a spacer, or not putting in a spacer, debilitates these patients and impairs their quality of life [QOL]. DAIR…makes sense from a functional standpoint, but whether it’s effective in getting rid of the infection is debated. DAIR was considered an acceptable strategy, particularly in acute infections with short-term duration. However, it achieved only weak consensus compared with other statements. The debate centered around variability in DAIR definitions and techniques. Some surgeons exchange modular components; others perform debridement and retention alone. Resource variability globally, [particularly] in places where health care economics are not so favorable, also influenced practice. What was clear is that the long-term infection control appears lower with DAIR compared with staged revision, but again, this is balanced by the morbidity associated with removal of the implant.

Which revision strategies are most effective for complex reconstructions, and how do biologic options compare with endoprostheses?

Regarding revision strategies, there was strong consensus that single-stage, two-stage, and what we call a one-and-a-half-stage revision are all acceptable strategies. However, two-stage revision remains the most reliable method for infection control, particularly in complex megaprosthetic reconstructions. [This] means that some of these patients will have a compromised limb when the implant is removed. They may be in a spacer or in DAIR, but the patient will have a really challenging time during that anywhere from 6-to-10-week period where the implant is out, and that can be really debilitating and affect their overall QOL and oncologic outcomes. Single-stage revision may be appropriate when the infecting organism is highly sensitive to oral antibiotics and full component exchange is possible.

[However], what’s really emerging is what we call the one-and-a-half-stage strategy, which is a compromise of sorts: implant removal with placement of a functional, antibiotic-loaded interval prosthesis—something that isn’t meant to necessarily stand the test of time but does enable a patient to function at a higher level than if the implant were entirely removed. This is considered acceptable, though evidence remains quite limited.

Another aspect is: what about biology versus endoprosthesis? Importantly, there’s a consensus that infection rates in modern series do not differ significantly between biologic reconstructions and metallic endoprostheses. Infection risk alone should not dictate reconstruction choice. However, when allografts or bone transplants are used and become infected, their success rates are low, and conversion to staged metallic reconstructions is also recommended.

Why is a multidisciplinary approach essential for managing infections during active chemotherapy in sarcoma?

Management during active chemotherapy requires multidisciplinary coordination with our medical oncology colleagues. The consensus emphasized that infection control must be prioritized to allow safe continuation of chemotherapy, especially the cytotoxic variant. Minor procedures may allow treatment to continue, but major surgery may necessitate temporary interruption. What about organisms and prognosis? Infections caused by MRSA, Gram-negative organisms, fungi, or polymicrobial infections carry a worse prognosis. Multidisciplinary infectious disease input is essential in these cases.

Do you anticipate any barriers in terms of integrating these consensus-based recommendations into practice? How should they be enacted for the management of immunocompromised patients?

That is a very important question. We want to be clear: these are global consensus statements, and unfortunately, standard practices in different nations and countries vary. [If] there is consensus about a certain type of technology or a certain type of procedure, but it's not available in a country, we don't want to insinuate that not being able to follow those consensus guidelines is substandard care. We need to be very careful with the framework of these suggestions; there is evidence to support these [recommendations] based upon a consensus of experts, but it doesn't mean it establishes the standard of care in the United States. What we can take from this is that groups like the National Comprehensive Cancer Network and other [healthcare professionals involved in] managing patients can use these consensus statements to tier their recommendations.

Regarding the question of chemotherapy, that really is tricky. Cytotoxic chemotherapy affects the immune system, and patients can get septic. If a patient does have signs or symptoms concerning for a deep implant infection while they’re on chemotherapy, the orthopedic oncologist needs to be in lockstep with the medical oncologist and potentially suspend the chemotherapy for a period.

What is the broader significance of the BOOM meeting for orthopedic oncology care?

This was the largest global consensus meeting; the first one, again, was from Birmingham, and there was just one in South Africa. In orthopedic oncology, it provides practical, real-world guidance in areas where randomized trial data are sparse. At the same time, it highlights 2 major unmet needs: one, orthopedic oncologists and our multidisciplinary teams need clear definitions and standardized protocols for this DAIR procedure and revision strategies; and two, we need better evidence to guide prolonged antibiotic use with staged revisions. The BOOM collaboration has created an international research platform to address these controversies; it really has become the standard-bearer for consensus building in orthopedic oncology.

References

1. Birmingham Orthopedic Oncology Meeting. Clockwork Medical. Presented: July 6, 2023. Accessed March 24, 2026. https://boomconsensus.org/
2. Jeys L, Botello E, Boyle RA, et al. A modified Delphi consensus on periprosthetic infection in orthopaedic oncology: a report from the Birmingham Orthopaedic Oncology Meeting (BOOM). Bone Jone J. 2025;107-B(12):1352-1359. doi:10.1302/0301-620X.107B12.BJJ-2024-1039.R4
3. 26th & 27th January 2026, the Westin Hotel, the Waterfront, Cape Town, South Africa. Clockwork Medical. 2026. Accessed March 24, 2026. https://clockworkmedical.com/meeting/boom-2026/
4. Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) Investigators, Ghert M, Schneider P, et al. Comparison of prophylactic intravenous antibiotic regimens after endoprosthetic reconstruction for lower extremity bone tumors: a randomized clinical trial. JAMA Oncol. 2022;8(3):345-353. doi:10.1001/jamaoncol.2021.6628