At their meeting on Dec. 7, 2012, the AAOS Board of Directors approved a new clinical practice guideline (CPG) on “The Prevention of Orthopaedic Implant Infections in Patients Undergoing Dental Procedures.” The evidence-based CPG, the first to be codeveloped by the AAOS and the American Dental Association (ADA), includes three recommendations (See Table 1) and will replace previous AAOS information statements on the topic.

According to David S. Jevsevar, MD, MBA, chair of the AAOS Evidence-Based Practice Committee, recommendation 1 is supported by limited evidence, but has the highest level of available evidence of the three recommendations. It proposes that the practitioner consider changing the longstanding practice of routinely prescribing prophylactic antibiotics for patients with orthopaedic implants who undergo dental procedures.

Recommendation 2 addresses the use of oral topical antimicrobials, and recommendation 3 addresses the maintenance of good oral hygiene.

“This guideline was based on research that examined a large group of patients, all having a prosthetic hip or knee, and half with an infected prosthetic joint,” said Elliot Abt, DDS, MS, MSc, one of the ADA representatives on the volunteer workgroup that developed the guidelines. “The limited research suggested that invasive dental procedures, with or without antibiotics, had no effect on the likelihood of developing a periprosthetic joint infection (PJI).”

Background
The previous AAOS information statement, “Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements,” was published in 2003 and updated in 2009. Both information statements were developed as educational tools and based solely on the opinion of the authors. This new collaborative Clinical Practice Guideline, however, was developed using a systematic, evidence-based process.

To develop the CPG, the workgroup first formulated a set of preliminary recommendations that specified what should be done when, where, to whom, and for how long. These were intended to function as the questions for systematic review by the AAOS/ADA research team. Once all relevant published articles were assembled and graded (Level I to IV), the workgroup then provided a final strength for each recommendation.

“The process used meets or exceeds all recommended Institute of Medicine standards for the development of systematic reviews and clinical practice guidelines, except for allowing patient input in the selection of topics and questions,” noted Dr. Jevsevar. “Of note, the AAOS CPG program does not allow workgroup members with relevant conflicts of interest, and the collaborating societies followed the same conflict of interest rules in selecting their representatives.”

In 2010, more than 302,000 hip replacements and 658,000 knee replacements were performed in the United States. Based on the studies reviewed for this guideline, the mean rate of hip, knee, and spine implant infections was 2 percent; management typically requires further surgery and prolonged antibiotic treatment. Causes included entry of microbes into the wound during surgery, hematogenous spread, recurrence of sepsis in a previously infected joint, and contiguous spread of infection from a local source.

In light of the significant morbidity associated with orthopaedic implant infections, preventing such infections in patients undergoing dental procedures is highly desirable. However, prophylactic antibiotics entail risks to individual patients and, if widely used, are plausible contributors to the growing problem of bacterial resistance resulting from antibiotic overuse.

New wording, implementation aids
The Evidence-Based Practice Committee, Guidelines Oversight Committee, Appropriate Use Criteria Committee, Council on Research and Quality, and the AAOS Board of Directors recently approved changing the word, “weak” to the word “limited” in all AAOS evidence-based CPG recommendations ratings.

In addition, a brief statement addressing the implications for practice for each rating (strong, moderate, limited, inconclusive, and consensus) was added to further clarify the meaning of the strength of recommendation rating for practitioners using the guidelines (Table 2). The ADA participants had no objections to these changes. The criteria and definition/description of the ratings did not change; the term “limited” is intended to be the equivalent of the previous term “weak.”

Finally, a shared decision-making tool—a template designed to be used by both orthopaedic surgeons and dentists—was developed to accompany the guideline. Shared decision making is a collaborative process that enables patients and their healthcare providers to make treatment decisions together, taking into account both the best scientific evidence available and the patient’s values and preferences. The tool supplements, but does not replace, informed consent procedures.

Because a limited CPG recommendation requires a greater amount of patient education, as well as consideration of patient values and clinician experience, the shared decision-making tool is meant to aid in this process.

“As clinicians, we want what is in the best interest of our patients, so this CPG is not meant to be a stand-alone document,” said Dr. Jevsevar. “Instead it should be used as an educational tool to guide clinicians through treatment decisions with their patients to improve quality and effectiveness of care.

“The experience of each clinician is valuable in this process. For example, subgroup analysis for patients at potentially higher risk was not performed. The provider of care should utilize his or her experience and clinical decision-making skills to identify those high-risk patients (eg, immunocompromised) and determine the best care choices for those patients,” he continued. “A limited recommendation implies that the CPG recommendation does not apply to all patients uniformly, but rather that the interaction between patient and clinician is critical to determining the applicability.

“The AAOS gets kudos on its CPGs because they’re well done,” added Dr. Jevsevar, “but our members have found them difficult to apply in practice. We added implications within the body of the guidelines so that people could understand them. The idea is that, if you’re dealing with a patient, how would you think about that information? How would you present it to the patient? How would you use it to make a decision?”

The full guideline, along with all supporting documentation and workgroup disclosures, is available on the AAOS website, www.aaos.org/guidelines

Leeaht Gross, MPH, is the evidence-based medicine coordinator in the AAOS department of research & scientific affairs. She can be reached at gross@aaos.org

Guideline development
The Clinical Practice Guideline on the Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures was developed by a volunteer workgroup chaired by William C. Watters III, MD, and Michael P. Rethman, DDS, MS. Members of this workgroup included Richard Parker Evans, MD; Richard J. O’Donnell, MD; Calin S. Moucha, MD; Paul A. Anderson, MD; Elliot Abt, DDS; Harry C. Futrell, DMD; Stephen O. Glenn, DDS; Mark J. Steinberg, DDS, MD; John Hellstein, DDS, MS; John E. O’Toole, MD; Anthony Rinella, MD; David J. Kolessar, MD; Karen C. Carroll, MD, FCAP; Kevin L. Garvin, MD; Douglas R. Osmon, MD; and Angela Hewlett, MD, MS. Michael Goldberg, MD, served as the attending guidelines oversight chair and is currently Guidelines Oversight Committee chair. The ADA staff included Nicholas Buck Hanson, MPH, lead analyst, and Helen Ristic, PhD. The AAOS staff included Patrick Sluka, MPH; Deborah Cummins, PhD; Sharon Song, PhD; and William R. Martin III, MD.

Funding was provided by the AAOS and ADA. The guideline is based on a systematic review of the current scientific and clinical research.

The methods used to prepare the guideline were rigorous, employed to minimize bias and to develop a set of reliable, transparent, and accurate clinical recommendations for the prevention of orthopaedic implant infections in patients undergoing dental procedures. These methods are detailed in the full guideline.

The development of AAOS Evidence-Based Clinical Practice Guidelines are overseen by the Guidelines Oversight Committee and the Evidence-Based Practice Committee. It was approved by the AAOS Board of Directors on December 7, 2012. The complete guideline is available at www.aaos.org/guidelines

References

1. HCUPnet: Healthcare Cost and Utilization Project (HCUP). 1993–2010. Agency for Healthcare Research and Quality, Rockville, MD. http://hcupnet.ahrq.gov/ Accessed November 29, 2012.
2. American Academy of Orthopaedic Surgeons and the American Dental Association Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures Guideline. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2012.
3. Della Valle CJ, Zuckerman JD, Di Cesare PE: Periprosthetic sepsis. Clin Orthop 2004;(420):26-31.