The American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures

Members of the Writing and Voting Panels of the AUC for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures; Quinn, Robert H. MD; Murray, Jayson N. MD; Pezold, Ryan MA; Sevarino, Kaitlyn S. MBA

Journal of Bone & Joint Surgery - American Volume:
doi: 10.2106/JBJS.16.01107
Evidence-Based Orthopaedics

    These Appropriate Use Criteria (AUC) for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures are based on a review of the available literature regarding the management of patients with orthopaedic implants undergoing dental procedures1 as well as a list of clinical patient scenarios constructed by an expert Writing Panel and voted on by a separate multidisciplinary Voting Panel. The AUC development methods are adapted from the RAND/UCLA Appropriateness Method (RAM)2. The full Appropriate Use Criteria for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures, with the Appropriate Use Criteria tables, final appropriateness ratings, and a list of panel members, can be accessed on the AAOS web site at: http://www.aaos.org/auc. The AUC is also available as a web-based application; to access this application, please visit http://www.orthoguidelines.org/auc.

    Members of the Writing Panel developed a list of 64 patient scenarios regarding the management of patients with orthopaedic implants based on the identified patient indications (Table I) and defined sub-classifications along with 1 treatment (Table II), for a total of 64 antibiotic prophylaxis voting items (64 scenarios × 1 treatment) (Tables I and II).

    The Writing Panel chose to provide users with an additional tool as a resource, and this choice was reaffirmed by the Voting Panel. In scenarios in which prophylactic antibiotics are rated as Appropriate or May Be Appropriate (any scenario with a median score of 4 or higher), users of the online web application are given the option to “click” on that appropriateness score and be led to a linked tool. The content of this tool is based on a 2007 statement by the American Heart Association but has been amended to more accurately reflect the current state of medicine. It is also preceded with the following disclaimer:

    The AAOS Appropriate Use Criteria goes as far as stating whether or not prophylactic antibiotics may be appropriate for a particular patient profile. These antibiotic dosage recommendations are provided as an additional resource and based solely on the 2007 statement released by the American Heart Association. The only adjustments from the original statement are the removal of Clindamycin and Cefazolin as antibiotic options. This change is based on more recently published evidence.

    Cross reactivity of cephalosporin antibiotics in patients with penicillin allergy is 5% for first generation drugs, and 1% for third generation drugs, so these drugs should be used unless there is a history of anaphylaxis with penicillin administration. If there is a concern, patients should be referred for allergy testing prior to administering antibiotic prophylaxis1.

    The Writing Panel reviewed these scenarios and treatments to ensure that they were representative of patients and scenarios clinicians are likely to encounter. Each independent panel member was given the opportunity to suggest potential modifications to the content or structure of the Writing Panel materials. The Writing Panel provided final determination of modifications to the indications, scenarios, assumptions, and literature review.

    The Voting Panel participated in 2 rounds of voting. During the first round, the Voting Panel was given approximately 1 month to independently rate the appropriateness of the 1 treatment for the 64 antibiotic prophylaxis patient scenarios as “Appropriate,” “May Be Appropriate,” or “Rarely Appropriate” via an electronic ballot (Table III). After the first round of appropriateness ratings were submitted, AAOS staff calculated the median appropriateness ratings for each treatment and patient scenario as well as the level of disagreement among the panel members. The Voting Panel then met via web conference on April 27, 2016, to discuss any scenarios/treatments that had resulted in disagreement during the first round of voting. Following this discussion, members of the Voting Panel had the option to change any of their appropriateness ratings during the second round of electronic voting. There was no attempt to obtain consensus regarding appropriateness.

    With use of the median value of the second-round ratings from the members of the Voting Panel, the final levels of appropriateness were determined. Disagreement among raters can affect the final rating. Agreement and disagreement were determined with use of the BIOMED definitions of Agreement and Disagreement as reported in the RAND/UCLA Appropriate Method User’s Manual2 for a panel of 14 to 16 voting members. For this panel size, agreement was defined as when ≤2 panelists rated outside of the 3-point range containing the median and disagreement was defined as when ≥5 members’ appropriateness ratings fell within the “Appropriate” (7 to 9) and “Rarely Appropriate” (1 to 3) ranges for any scenario. If there was still disagreement in the Voting Panel ratings after the second round of voting, that voting item was labeled as “5” regardless of the median score. In the final tally, 39 (61%) of the 64 prophylactic antibiotic voting items were rated as “Rarely Appropriate,” 17 (27%) were rated as “May Be Appropriate,” and 8 (12%) were rated as “Appropriate” (Fig. 1). Additionally, the Voting Panel members were in agreement on 36 voting items (56%) and were in disagreement on 2 voting items (<3%).

    * Authors: All members of the Writing and Voting Panels of the AUC for the Management of Patients with Orthopaedic Implants Undergoing Dental Procedures, as well as the involved AAOS staff, are listed starting on page i of the online version of the AUC document.

    Disclosure: The complete Disclosures of Potential Conflicts of Interest submitted by the authors of this AUC are provided in Appendix B of the online version of the AUC document.

    Disclaimer: Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment.

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    References

    1. American Academy of Orthopaedic Surgeons. Appropriate use criteria for the management of patients with orthopaedic implants undergoing dental procedures. 2016 Sep 22. http://www.aaos.org/pdupauc. Accessed 2016 Oct 13.
    2. Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lazaro P, van het Loo M, McDonnell J, Vader J, Kahan JP. The RAND/UCLA appropriateness method user’s manual. Santa Monica: RAND Corporation; 2001.
    Copyright 2017 by The Journal of Bone and Joint Surgery, Incorporated