a significant amount of time. Indeed, the treatment of inflammatory periodontal disease requires a minimum of 4 to 6 weeks, and should include intensive patient education to maintain the health of the periodontal tissues. Except for cases of trauma, joint replacement surgery is generally an elective procedure and can usually be delayed until the patient has consulted with a dentist and/or periodontist and completed the treatment required to establish an oral cavity free of infection and inflammation. After completion of periodontal therapy, the dentist/periodon-tist should document the patient’s oral health, including any potential problems, and consult with the orthopedic surgeon before joint replacement surgery is scheduled.

 

Once joint replacement surgery is approved and scheduled, responsibility then shifts to the surgical staff to prevent surgery-related infection. Guidelines promoted by the Patient Safety Committee of the American Academy of Orthopedic Surgeons⁵⁰ have been organized in an “ out-side-to-in” concept of environmental control that includes the operating room environment, the patient environment, and the wound environment.

ment includes monitoring and maintenance of normal glycemia, normothermia, and administration of antimicrobial prophylaxis. ⁵⁰ The initial dose of the appropriate antimicrobial should be given within 1 hour preceding incision, and repeated during surgery as needed to maintain blood levels. Antimicrobial prophylaxis should be ceased within 24 hours, even if catheters or drains are still in place. Protection of the wound environment includes hair removal with an electric shaver or depilatory (not a safety razor) just prior to surgery, and proper skin preparation of the surgical field with alcohol, povidones, iodophors, or chlorhexidine gluconate. As much as possible, operative time should be minimized, tissue handled gently, and dead space and tissue eradicated. Whether to drain to reduce the risk of hematoma is questionable, because it raises concern regarding tract drainage, creates a potential passageway for infection, and increases transfusion requirements. There is no evidence that antibiotic irrigation is effective in prophylaxis for infection in orthopedic procedures.

 

Antibiotic prophylaxis and treatment in patients with joint prostheses Dentistry has successfully implemented, and accepted as the standard of care, the recommendations of the American Heart Association⁵¹ that antibiotic prophylaxis be provided for those patients at risk of developing adverse systemic problems as a result of bacteremia caused by oral tissue manipulation. In at-risk heart patients, the low incidence of complications from dental procedure-related bacteremia is the result of good communication among patients, cardiologists, and dentists.

Guidelines for the operating room environment include maintaining positive air pressure in the conventional operating room, with more than 15 volume exchanges per hour. ⁵⁰ Despite decades of experience with clean-air operating rooms, no uniform methods for efficiently preventing infections have been developed. However, laminar flow statistically reduces airborne contamination, and body exhaust suits, in combination with other infection control measures, also appear to improve infection rates. Use of scrubs, masks, and gloves and sterilization of all surgical instruments should Figure 1 follow published guidelines. Ethylene oxide has been classified as a carcinogen and is being replaced by H₂O₂ sterilization procedures. Operating room doors should remain closed and needless traffic, activity, and personnel eliminated. Strict adherence to operating room discipline and Universal Precautions should be maintained. Hand washing with soap and water is highly effective in preventing nosocomial spread of organisms. Newer alcohol and chlorhexidine gluconate-based hand lotions appear to provide more effective antisepsis than standard scrub and are recommended in the absence of visible soiling. In addition,

Severe infection of a hip prosthesis

healthcare personnel are more likely to
occurring several years after place-
comply with hand hygiene procedures if
ment as a result of bacteremia.
surgeons, senior medical staff, and peers
Based on patient’s dental history,
are seen to be compliant.
the bacteremia had a high prob-
ability of oral origin.

Maintaining the optimal patient environ-

The problem of antimicrobial prophylaxis in orthopedic implant surgery will become increasingly important and complex as the general population ages and requires more arthroplasty procedures. Given the low rate of prosthetic joint infection from bacteremia of oral origin and the fact that such bacteremia is transient and, for most dental procedures, of low magnitude, ¹⁹ one must conclude that the prescribing of prophylactic antibiotics for patients with an existing joint prosthesis is based on anecdotal, historical, and legal concerns. However, infection, should it occur, can be devastating to the patient and require additional surgeries, lengthy recovery time, and additional medical expenses (Figure 1). Despite this, some authors have proposed that the risk of adverse reaction to the antibiotic prophylaxis is greater than the risk of infection. ^{39, 52-55} Statistically, it has been estimated that 30 of every 100,000 patients