Revised statement on fragility fractures also issued
At its September meeting, the AAOS Board of Directors approved a suite of appropriate use criteria (AUC) providing guidance on when it may be appropriate to consider antibiotic administration prior to dental procedures in patients with replacement joint implants.

The AUC guidelines, developed through a collaboration of orthopaedic surgeons, dentists, oral surgeons, and epidemiologists, counsel that most patients with replacement joints are not at risk for infection following dental procedures and do not require antibiotic administration. Prophylactic antibiotic therapy, however, should be considered for certain subsets of patients—primarily those with severely compromised immune systems related to AIDS/HIV, uncontrolled diabetes, chemotherapy, or a recent history of joint infection, along with those taking certain drugs for rheumatoid arthritis or to prevent organ transplant complications.

As with previously issued AUC, the access page to the algorithm-style app for "The Management of Patients with Orthopaedic Implants Undergoing Dental Procedures" proffers a general statement regarding the guidelines along with several associated assumptions.

In part, the statement reads:

With this AUC, we have attempted to define clinical situations in which antibiotic prophylaxis in certain at-risk dental patients could reduce a theoretical risk of postsurgical prosthetic joint infection. This AUC was developed as a decision support tool to facilitate the treatment of defined "high-risk" and "immune-compromised" patients who are on the more severe end of the clinical spectrum of disease. In the absence of readily available laboratory data or suggestive clinical suspicion, it would be reasonable to assume that most patients will fall outside of these criteria and therefore lie outside the confines of our strict definitions. As always, sound judgment should guide clinical decisions about when it may be necessary or prudent to delay a dental procedure until more information is available.

The assumptions made for planned dental procedures are as follows:

• The chance of oral bacteremia being related to joint infections is extremely low, with no evidence for an association.
• Oral bacteremia frequently occurs secondary to activities of daily living such as tooth brushing and eating.
• Virtually all dental office procedures have the potential to create bacteremia.

The AUC app, available through the AAOS OrthoGuidelines website (http://www.orthoguidelines.org/go/auc/) uses clinician input to gauge risk related to the type of dental procedure, given the patient's implant status and overall health. Each of the 64 scenarios has an antibiotic "appropriateness rating" from 1 to 9, as determined by a 14-member voting panel of orthopaedic surgeons, dentists, oral surgeons, and epidemiologists. A rating between 7 and 9 means that antibiotic use is "appropriate for the indication provided … and is likely to improve the patient's health outcomes or survival." A rating of 4 to 6 indicates that antibiotics "may be appropriate;" while a rating of 1 to 3 means they are "rarely appropriate." Specific antibiotics and dosage are provided for scenarios when antibiotic treatment is recommended.

In one scenario (shown in Fig. 1), a cautionary "Yellow" treatment recommendation, indicating that it "May be appropriate to prescribe prophylactic antibiotics," appears if the surgeon indicates the following:

• The planned dental procedure involves manipulation of gingival tissue or the periapical region of teeth or of the oral mucosa.
• The patient is severely immunocompromised and is an active known diabetic with hemoglobin A1C < 8 or blood glucose < 200, with no history of periprosthetic or deep prosthetic joint infection that required an operation.
• It has been 1 year or more since the joint replacement procedure.
• With one additional click, appropriate antibiotic options for that scenario are provided.

Because infections can be so dangerous, "surgeons and dentists prefer to err on the side of caution in the most high-risk patients," said Robert H. Quinn, MD, AUC section leader, AAOS Committee on Evidence-Based Quality and Value. "And yet, antibiotic overuse throughout the healthcare system has made many types of bacteria resistant to treatment. We hope these guidelines will help decrease antibiotic use in patients with artificial joints, but still provide reasonable scenarios when they might be considered."

Revised position statement
The Board of Directors also approved a revised statement affirming that physicians should proactively screen, monitor, and, if necessary, assist in getting osteoporosis treatment for elderly and other at-risk patients after an initial bone fracture to prevent subsequent fractures.

The position statement, "Orthopaedic Care of Patients with Fragility Fractures," was revised in conjunction with the American Orthopaedic Association (AOA), the Orthopaedic Trauma Association, and the International Geriatric Fracture Society (IGFS).

The statement recommends the screening and monitoring of patients who are seen in an emergency department or a primary care physician's or orthopaedic surgeon's office for osteoporosis and subsequent fracture risk. In addition, "best practice" information on osteoporosis and fragility fracture diagnosis and treatment—the Academy's hip fracture and osteoporosis clinical practice guidelines and AUC and related performance measures, the IGFS's Critical Care Pathways, and the AOA's "Own the Bone" program—should be distributed and established as standard of care.

The statement makes the following recommendations:

• Develop and implement data registries that track the crucial processes of care, patient demographics, and outcomes related to fractures.
• Disseminate educational materials to orthopaedic surgeons to help them better identify at-risk patients.
• Continue to partner with the Centers for Medicare & Medicaid Services to reduce the variation in fragility fracture care, including development of a hip fracture bundle and criteria and appropriate mechanisms to encourage adherence to the unique evaluation, treatment, and monitoring of osteoporosis patients required to prevent subsequent, debilitating fractures.

"Assessment tools to predict risk for a second fragility fracture are available, and interventions to treat patients at risk of a subsequent fracture are cost-effective," said David D. Teuscher, MD, chair of the AAOS Task Force on Fragility Fractures. "Yet the overwhelming majority of these patients are not effectively treated to prevent a second fragility fracture. If physicians don't suspect osteoporosis, they won't detect it and can't protect against the risk of future fractures. We believe it's our responsibility to take the lead on this issue and, through this position statement, we have a tremendous opportunity to vastly improve patient care in this arena."

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

Sheryl Cash is the manager, media relations, for AAOS public and media relations. She can be reached at scash@aaos.org

Additional Information:

• Management of Patients with Orthopaedic Implants Undergoing Dental Procedures
• Orthopaedic Care of Patients with Fragility Fractures