The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the, maintenance of good oral hygiene.

Rethman, Michael P. DDS, MS; Watters, William III MD; Abt, Elliot DDS; Anderson, Paul A. MD; Carroll, Karen C. MD, FCAP; Evans, Richard Parker MD; Futrell, Harry C. DMD; Garvin, Kevin MD; Glenn, Stephen O. DDS; Goldberg, Michael J. MD; Hellstein, John DDS, MS; Hewlett, Angela MD, MS; Kolessar, David MD; Moucha, Calin MD; O’Donnell, Richard J. MD; Osmon, Douglas R. MD; O’Toole, John E. MD; Rinella, Anthony MD; Steinberg, Mark J. DDS, MD; Martin, William Robert III MD; Cummins, Deborah S. PhD; Song, Sharon PhD; Sluka, Patrick MPH; Boyer, Kevin MPH; Woznica, Anne MLIS; Ristic, Helen PhD; Hanson, Nicholas Buck MPH

AAOS Guideline on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty Summary of Recommendations The following is a summary of the recommendations of the AAOS’ clinical practice guideline, Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. This summary does not contain rationales that explain how and why these recommendations were developed, nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, and other healthcare practitioners. We recommend against routine post-operative duplex ultrasonography screening of patients who undergo elective hip or knee arthroplasty. (Grade of Recommendation: Strong) Patients undergoing elective hip or knee arthroplasty are already at high risk for venous thromboembolism. The practitioner might further assess the risk of venous thromboembolism by determining whether these patients had a previous venous thromboembolism. (Grade of Recommendation: Weak) Current evidence is not clear about whether factors other than a history of previous venous thromboembolism increase the risk of venous thromboembolism in patients undergoing elective hip or knee arthroplasty and, therefore, we cannot recommend for or against routinely assessing these patients for these factors. (Grade of Recommendation: Inconclusive) Patients undergoing elective hip or knee arthroplasty are at risk for bleeding and bleeding-associated complications. In the absence of reliable evidence, it is the opinion of this work group that patients be assessed for known bleeding disorders like hemophilia and for the presence of active liver disease which further increase the risk for bleeding and bleeding-associated complications. (Grade of Recommendation: Consensus) Current evidence is not clear about whether factors other than the presence of a known bleeding disorder or active liver disease increase the chance of bleeding in these patients and, therefore, we are unable to recommend for or against using them to assess a patient's risk of bleeding. (Grade of Recommendation: Inconclusive) We suggest that patients discontinue antiplatelet agents (e.g., aspirin, clopidogrel) before undergoing elective hip or knee arthroplasty. (Grade of Recommendation: Moderate) We suggest the use of pharmacologic agents and/or mechanical compressive devices for the prevention of venous thromboembolism in patients undergoing elective hip or knee arthroplasty, and who are not at elevated risk beyond that of the surgery itself for venous thromboembolism or bleeding. (Grade of Recommendation: Moderate) Current evidence is unclear about which prophylactic strategy (or strategies) is/are optimal or suboptimal. Therefore, we are unable to recommend for or against specific prophylactics in these patients. (Grade of Recommendation: Inconclusive) In the absence of reliable evidence about how long to employ these prophylactic strategies, it is the opinion of this work group that patients and physicians discuss the duration of prophylaxis. (Grade of Recommendation: Consensus) In the absence of reliable evidence, it is the opinion of this work group that patients undergoing elective hip or knee arthroplasty, and who have also had a previous venous thromboembolism, receive pharmacologic prophylaxis and mechanical compressive devices. (Grade of Recommendation: Consensus) In the absence of reliable evidence, it is the opinion of this work group that patients undergoing elective hip or knee arthroplasty, and who also have a known bleeding disorder (e.g., hemophilia) and/or active liver disease, use mechanical compressive devices for preventing venous thromboembolism. (Grade of Recommendation: Consensus) In the absence of reliable evidence, it is the opinion of this work group that patients undergo early mobilization following elective hip and knee arthroplasty. Early mobilization is of low cost, minimal risk to the patient, and consistent with current practice. (Grade of Recommendation: Consensus) We suggest the use of neuraxial (such as intrathecal, epidural, and spinal) anesthesia for patients undergoing elective hip or knee arthroplasty to help limit blood loss, even though evidence suggests that neuraxial anesthesia does not affect the occurrence of venous thromboembolic disease. (Grade of Recommendation: Moderate) Current evidence does not provide clear guidance about whether inferior vena cava (IVC) filters prevent pulmonary embolism in patients undergoing elective hip and knee arthroplasty who also have a contraindication to chemoprophylaxis and/or known residual venous thromboembolic disease. Therefore, we are unable to recommend for or against the use of such filters. (Grade of Recommendation: Inconclusive)

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of osteochondritis dissecans of the knee. None of the 16 recommendations made by the work group is graded as strong; most are graded inconclusive; two are graded weak; and four are consensus statements. Both of the weak recommendations are related to imaging evaluation. For patients with knee symptoms, radiographs of the joint may be obtained to identify the lesion. For patients with radiographically apparent lesions, MRI may be used to further characterize the osteochondritis dissecans lesion or identify other knee pathology.

AAOS Guideline on The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee Summary of Recommendations The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly encouraged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will note that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility.This summary of recommendations is not intended to stand alone. Clinical decisions should be made in light of all circumstances presented by the patient. Procedures applicable to the individual patient rely on mutual communication between patient, physician, and other healthcare practitioners.1. In the absence of reliable evidence about risk stratification of patients with a potential periprosthetic joint infection, it is the opinion of the work group that testing strategies be planned …

This guideline supersedes a prior one from 2007 on a similar topic. The work group evaluated the available literature concerning various aspects of patient screening, risk factor assessment, and prophylactic treatment against venous thromboembolic disease (VTED), as well as the use of postoperative mobilization, neuraxial agents, and vena cava filters. The group recommended further assessment of patients who have had a previous venous thromboembolism but not for other potential risk factors. Patients should be assessed for known bleeding disorders, such as hemophilia, and for the presence of active liver disease. Patients who are not at elevated risk of VTED or for bleeding should receive pharmacologic prophylaxis and mechanical compressive devices for the prevention of VTED. The group did not recommend specific pharmacologic agents and/or mechanical devices. The work group recommends, by consensus opinion, early mobilization for patients following elective hip and knee arthroplasty. The use of neuraxial anesthesia can help limit blood loss but was not found to affect the occurrence of VTED. No clear evidence was established regarding whether inferior vena cava filters can prevent pulmonary embolism in patients who have a contraindication to chemoprophylaxis and/or known VTED.

Della Valle, Craig MD; Parvizi, Javad MD; Bauer, Thomas W. MD, PhD; DiCesare, Paul E. MD; Evans, Richard Parker MD; Segreti, John MD; Spangehl, Mark MD; Watters, William C. III MD; Keith, Michael MD; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Sluka, Patrick MPH; Hitchcock, Kristin MSI

Esses, Stephen I. MD; McGuire, Robert MD; Jenkins, John MD; Finkelstein, Joel MD; Woodard, Eric MD; Watters, William C. III MD; Goldberg, Michael J. MD; Keith, Michael MD; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Sluka, Patrick MPH; Boyer, Kevin M.; Hitchcock, Kristin MLS; Raymond, Laura MA

Izquierdo, Rolando MD; Voloshin, Ilya MD; Edwards, Sara MD; Freehill, Michael Q. MD; Stanwood, Walter MD; Wiater, J. Michael MD; Watters, William C. III MD; Goldberg, Michael J. MD; Keith, Michael MD; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Anderson, Sara MPH; Boyer, Kevin; Raymond, Laura MA; Sluka, Patrick MPH; Hitchcock, Kristin MSI

This clinical practice guideline is based on a series of systematic reviews of published studies on the treatment of symptomatic osteoporotic spinal compression fractures. Of 11 recommendations, one is strong; one, moderate; three, weak; and six, inconclusive. The strong recommendation is against the use of vertebroplasty to treat the fractures; the moderate recommendation is for the use of calcitonin for 4 weeks following the onset of fracture. The weak recommendations address the use of ibandronate and strontium ranelate to prevent additional symptomatic fractures, the use of L2 nerve root blocks to treat the pain associated with L3 or L4 fractures, and the use of kyphoplasty to treat symptomatic fractures in patients who are neurologically intact.

Of the 31 recommendations made by the work group, 19 were determined to be inconclusive because of the absence of definitive evidence. Of the remaining recommendations, four were classified as moderate grade, six as weak, and two as consensus statements of expert opinion. The four moderate-grade recommendations include suggestions that exercise and nonsteroidal anti-inflammatory drugs be used to manage rotator cuff symptoms in the absence of a full-thickness tear, that routine acromioplasty is not required at the time of rotator cuff repair, that non-cross-linked, porcine small intestine submucosal xenograft patches not be used to manage rotator cuff tears, and that surgeons can advise patients that workers' compensation status correlates with less favorable outcomes after rotator cuff surgery.

Acute Achilles Tendon Rupture Summary of Recommendations The following is a summary of the recommendations in the AAOS’ clinical practice guideline, The Diagnosis and Treatment of Acute Achilles Tendon Rupture. The scope of this guideline is specifically limited to acute Achilles tendon rupture. This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners. 1. In the absence of the reliable evidence, it is the …

This clinical practice guideline is based on a series of systematic reviews of published studies in the available literature on the diagnosis and treatment of acute Achilles tendon rupture. None of the 16 recommendations made by the work group was graded as strong; most are graded inconclusive; four are graded weak; two are graded as moderate strength; and two are consensus statements. The two moderate-strength recommendations include the suggestions for early postoperative protective weight bearing and for the use of protective devices that allow for postoperative mobilization.

Richmond, John MD; Hunter, David MBBS, MSc, PhD; Irrgang, James PT, PhD, ATC; Jones, Morgan H. MD; Snyder-Mackler, Lynn PT, ATC, SCS, ScD; Van Durme, Daniel MD; Rubin, Cheryl MD; Matzkin, Elizabeth G. MD; Marx, Robert G. MD; Levy, Bruce A. MD; Watters, William C. III MD; Goldberg, Michael J. MD; Keith, Michael MD; Haralson, Robert H. III MD, MBA; Turkelson, Charles M. PhD; Wies, Janet L. MPH; Anderson, Sara MPH; Boyer, Kevin; Sluka, Patrick MPH; St. Andre, Justin MS; McGowan, Richard MLS

This clinical practice guideline is based on a systematic review of published studies on the treatment of glenohumeral osteoarthritis in the adult patient population. Of the 16 recommendations addressed, nine are inconclusive. Two were reached by consensus-that physicians use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; total shoulder arthroplasty and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than two shoulder arthroplasties per year (to reduce the risk of immediate postoperative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of total shoulder arthroplasty rather than hemiarthroplasty. Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved.

No preferred test for diagnosis of periprosthetic joint infection exists, and the algorithm for the workup of patients suspected of infection remains unclear. The work group evaluated the available literature to determine the role of each diagnostic modality and devise a practical algorithm that allows physicians to reach diagnosis of periprosthetic joint infection. Ten of the 15 recommendations have strong or moderate evidence in support. These include matters involving erythrocyte sedimentation rate and C-reactive protein level testing, knee and hip aspiration, and stopping the use of antibiotics prior to obtaining intra-articular cultures. The group recommends against the use of intraoperative Gram stain but does recommend the use of frozen sections of peri-implant tissues in reoperation patients in whom infection has not been established, as well as multiple cultures in reoperation patients being assessed for infection. The group recommends against initiating antibiotic treatment in patients with suspected infection until after joint cultures have been obtained, but recommends that prophylactic preop-erative antibiotics not be withheld in patients at lower probability for infection.

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

Methods of treating pediatric diaphyseal femur fractures are dictated by patient age, fracture characteristics, and family social situation. The recent trend has been away from nonsurgical treatment and toward surgical stabilization. The clinical practice guideline on pediatric diaphyseal femur fractures was undertaken to determine the best evidence regarding a number of different options for surgical stabilization. The recommendations address treatments that include Pavlik harness, Spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, submuscular plating, and pain management. The guideline authors conclude that controversy and lack of conclusive evidence remain regarding the different treatment options for pediatric femur fractures and that the quality of scientific evidence could be improved for the revised guideline.