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The cost-effectiveness of antibiotic-loaded bone cement versus plain bone cement following total and partial knee and hip arthroplasty
Journal Pre-proof The Cost-Effectiveness of Antibiotic-Loaded Bone Cement versus Plain Bone Cement Following Total and Partial Knee and Hip Arthroplasty Tyler Hoskins, Jay K. Shah, Jay Patel, Chris Mazzei, David Goyette, Eileen Poletick, Thomas Colella, II, James Wittig PII:
S0972-978X(20)30041-6
DOI:
https://doi.org/10.1016/j.jor.2020.01.029
Reference:
JOR 950
To appear in:
Journal of Orthopaedics
Received Date: 8 January 2020 Accepted Date: 24 January 2020
Please cite this article as: Hoskins T, Shah JK, Patel J, Mazzei C, Goyette D, Poletick E, Colella T II, Wittig J, The Cost-Effectiveness of Antibiotic-Loaded Bone Cement versus Plain Bone Cement Following Total and Partial Knee and Hip Arthroplasty, Journal of Orthopaedics, https://doi.org/10.1016/ j.jor.2020.01.029. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.
The Cost-Effectiveness of Antibiotic-Loaded Bone Cement versus Plain Bone Cement Following Total and Partial Knee and Hip Arthroplasty
Running Title: Antibiotic Cement versus Plain Cement
Tyler Hoskins BA1 [email protected], Jay K. Shah DO1,2 [email protected], Jay Patel DO1 [email protected], Chris Mazzei BS1 [email protected], David Goyette BS1 [email protected], Eileen Poletick DNP1 [email protected], Thomas Colella II BA1 [email protected], James Wittig MD1 [email protected]
1. Department of Orthopaedic Surgery Morristown Medical Center – Atlantic Health System Morristown, NJ 2. Department of Orthopaedic Surgery Jersey City Medical Center – RWJBarnabas Health Jersey City, NJ Corresponding Author: Tyler Hoskins BA1 [email protected] 100 Madison Avenue Morristown, NJ 07960 "Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article." Author Contributions: TH, JS, JP, and JW helped design the study and write the manuscript. CM, DG, EP, and TC II all assisted with data curation. All surgeries and data collection for this study were performed at Morristown Medical Center.
1
1
Abstract
2
Background
3
Postoperative infection is one of the most prevalent complications following total joint
4
arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop
5
new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons
6
have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in
7
primary hip and knee replacements due to its theoretical potential of lowering infection rates.
8
However, the cost-effectiveness of this intervention remains in question.
9
Questions/Purposes
10
To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as
11
compared to plain bone cement in hip and knee arthroplasty.
12
Patients and Methods
13
We reviewed 4,116 primary hip and knee arthroplasty cases performed between 2016 to 2018 at
14
Morristown Medical Center in New Jersey. Data regarding demographics, complications, and
15
any readmissions due to deep infection were collected retrospectively. During that time period
16
there were a total of 4,016 knee cases (423 ALBC, 3,593 PBC) and 123 hip cases (63 ALBC, 60
17
PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for
18
hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was
19
performed using Fisher’s exact test; the National Healthcare Safety Network (NHSN) surgical
20
site infection guidelines were used to distinguish between superficial and deep infections.
21
22
Results
2
23
Ten patients were readmitted due to deep infection, all of whom had undergone total knee
24
arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven
25
instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of
26
0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in
27
infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee
28
surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and
29
THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If
30
PBC had been used during all index procedures, it would have resulted in a total savings of
31
$231,509.28.
32
Conclusions
33
Antibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip
34
arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee
35
arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample
36
size and a randomized controlled trial would help confirm our findings and would provide
37
further information on the cost-effectiveness of ALBC cement versus PBC.
38
Significance/Clinical Relevance
39
In this review of cases performed from 2016 to 2018 there was no statistically significant
40
difference between the rate of infection and the need for revision surgeries for patients treated
41
with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment
42
model, it becomes imperative for providers to reduce any unnecessary costs in order to increase
43
quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by
44
using plain bone cement instead of antibiotic-loaded cement.
3
45
46
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
66 67 68 69
Keywords: joint arthroplasty, hip, knee, infection, cost-effectiveness
4
70 71
Introduction Periprosthetic joint infection (PJI) following hip and knee arthroplasty is a serious
72
complication. In order to decrease the incidence of infection following these procedures, new
73
prophylactic interventions and procedural modifications have been implemented. Antibiotic-
74
loaded bone cement (ALBC) was first introduced and used in lieu of plain bone cement (PBC)
75
by Buchholz and Englebrecht in 1970 [1, 2]. In a 1981 follow-up study, they reported a 77%
76
success rate among 583 patients undergoing total hip arthroplasty (THA). Success was defined as
77
no infection, no loosening of hardware, and useful function of the joint [3]. Subsequent studies
78
have investigated the efficacy of this intervention and have reported similar findings [2].
79
Although the use of ALBC in revision total joint surgery is well supported by the
80
literature, the regular use of this type of intervention in routine primary total joint arthroplasty
81
(TJA) remains controversial. Several potential adverse complications have emerged, including
82
the development of antibiotic-resistant strains of bacteria, antibiotic toxicity, a negative effect on
83
the mechanical properties of the cement, and the economic implications of the added cost.
84
Studies have reported that at high doses of antibiotics (>4.5 grams of antibiotic powder per 40
85
grams of cement), mechanical complications such as hardware loosening can occur much more
86
frequently [2, 4, 5, 6]. While the primary goal of ALBC is to deliver high, localized
87
concentrations of the antibiotic, the risk of systemic exposure and toxicity remain concerning. In
88
the past decade there have been a number of literature reports involving patients who received
89
ALBC during a total knee or hip arthroplasty and subsequently experienced acute renal failure
90
(ARF) [7-11].
91 92
The economic implications of this intervention also continue to be scrutinized. The price for one bag of ALBC can range from $200 to $500, while PBC costs under $100 [4, 12, 13].
5
93
Jiranek et al. reported an estimated increase of $117 million dollars to the annual healthcare costs
94
if ALBC is used in only half of the primary joint arthroplasty cases [4]. In order to justify the
95
incorporation of ALBC into routine primary joint arthroplasty, the cost savings must be greater
96
than if PBC was used alone. This is contingent upon preventing subsequent revision surgeries
97
due to deep infection. The goals of this study were to examine the cost-effectiveness and the rate
98
of deep infection using ALBC versus PBC for patients treated at our facility for either a total
99
knee arthroplasty (TKA), partial knee arthroplasty (UKA) or THA. Specifically, we aimed to
100
look at whether or not the additional cost of ALBC would be justified by the expected reduction
101
in deep infections.
102 103 104 105 106 107 108 109 110 111 112 113 114 115
6
116 117
Methods A retrospective review was conducted on all cemented total and partial hip and knee
118
arthroplasty cases performed between January 1, 2016 to December 31, 2018 at a large,
119
suburban, regional medical center. Patient demographics, comorbidities, and any readmissions
120
due to deep infection were extracted from patient charts. Data were also collected on patients
121
who were readmitted to outside facilities for deep infections after their index procedure was done
122
at our institution during the study period. For each procedure, either Stryker (Mahwah, NJ) or
123
Zimmer-Biomet (Parsippany, NJ) bone cement was used. Choice of cement was based on the
124
surgeon’s discretion. One surgeon in particular routinely utilized ALBC for all primary joint
125
replacements.
126
Inclusion criteria for the study were as follows: patients treated at our facility with a
127
cemented primary total or partial hip or knee arthroplasty. Exclusion criteria included: revision
128
arthroplasty patients and uncemented arthroplasty cases. A statistical analysis was performed
129
using Fisher’s exact test; the National Healthcare Safety Network (NHSN) surgical site infection
130
guidelines were used to distinguish between superficial and deep infections. Demographics such
131
as gender, age, body mass index (BMI), American Society of Anesthesiologists Score (ASA),
132
and LOS (length of stay) were included in our analysis. Medical comorbidities such as diabetes,
133
chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), renal disease,
134
and obesity were also identified for each cohort (Table 1).
135 136 137 138
7
139 140
Results During the study period there were a total of 4,016 cemented knee cases: 423 ALBC (408
141
TKA, 15 UKA) and 3,593 PBC (3,561 TKA, 32 UKA). There were also 123 cemented THA
142
cases: 63 ALBC and 60 PBC (Table 2). There were no cases of cemented hip hemiarthroplasty
143
during the study period. The average age was 67.92 (range, 36 to 94) with 39.94% of patients
144
being male and 60.06% being female. Average BMI, ASA, and LOS were 31.62 (range, 15 to
145
61.1), 2.32 (range, 1 to 4), and 2.28 days (range, 0 to 21), respectively. The large discrepancy in
146
case volume between hip and knee surgeries can be attributed to the general U.S. trend of
147
orthopedic surgeons using uncemented implants during routine THA.
148
Ten patients were readmitted due to deep infection, all of whom had undergone TKA. Of
149
the cases reported, PBC was used during the index procedure in 7 patients (0.19%) and ALBC
150
was used in 3 patients (0.62%). At our institution, the average cost for one bag of PBC is $72.14;
151
the average cost for one bag of ABLC is $336.42. The discrepancy in price is due to the pricing
152
differences between the two different brands of PBC and ALBC available at our institution. A
153
total of 778 bags of ALBC were used in 423 knee surgeries (TKA, UKA, bilateral TKA) and 98
154
bags of ALBC were used in 63 THA cases. The total cost for ALBC in TKA and THA
155
procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC
156
had been used during all index procedures, it would have resulted in a total savings of
157
$231,509.28. There were no infections in our UKA, bilateral TKA, and THA groups. There were
158
no statistically significant differences between the various comorbidities with respect to infection
159
rates between the PBC and ALBC cohorts (Table 3).
160
161
8
162
163
Discussion The most important finding of this study is that there was no statistically significant
164
difference between the rate of deep infection and the need for revision surgery in patients
165
undergoing either primary knee or hip arthroplasty who were treated with ALBC versus PBC.
166
The effectiveness of ALBC in primary hip and knee joint replacement remains a subject of
167
controversy in the literature. As hospital systems transition towards a bundled payment model,
168
the answer to this debate becomes even more essential, and may offer a significant avenue
169
towards cost savings while at the same time maintaining the quality of care rendered.
170
With regard to ALBC in primary THA, a majority of the support for its use comes from
171
early European registry data studies, where cemented THA is much more common than in the
172
United States [14, 15]. More recently, while there are no adequately powered randomized control
173
trials in the literature addressing ALBC for primary THA, systematic reviews continue to support
174
the use of ALBC to reduce the risk of deep periprosthetic infection in THA [16-18]. However,
175
the results of this paper directly contradict these findings, and did not demonstrate any
176
statistically significant reduction in deep infection rates in patients undergoing primary THA.
177
This is important, as most of the studies specifically looking at ALBC in primary THA are
178
almost a decade old and rely on national registry data that have the potential limitations of
179
selection bias due to incomplete data capture.
180
The authors of this paper also did not find a statistically significant difference in the rate
181
of deep infection and subsequent revision surgery between ALBC and PBC in primary TKA,
182
bilateral primary TKA or UKA. In the early 2000s, several authors, including Chiu et al. and
183
Eveillard et al., were the first to suggest that ALBC could reduce PJI rates in primary TKA [19,
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20]. However, these studies had several limitations, including borderline statistical significance
9
185
as well as the failure to address confounding comorbidities such as diabetes. The present study
186
demonstrated adequate control for confounding comorbidities (CHF, COPD, renal disease,
187
diabetes) and variables (age, gender, BMI) while still demonstrating a lack of efficacy of ALBC.
188
More recent studies, including a randomized control trial by Hinarejos et al. and other larger case
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series, corroborate the present study’s findings [17, 21, 22, 23]. They also failed to demonstrate a
190
decrease in infection rates when using ALBC versus PBC. More recent registry studies,
191
systematic reviews, and meta-analyses also have arrived at similar conclusions [13, 16, 24].
192
Several studies have commented on the idea of risk-stratified usage of ALBC, especially
193
in patients with diabetes and rheumatoid arthritis [19, 25]. However, a more recent study by
194
Qadir et al. found no advantage of ALBC over PBC in high-risk patients, such as those with
195
inflammatory arthropathies, diabetes, and immunosuppression [26]. This was supported by our
196
research, as there was no statistically significant difference between infection rates in the higher
197
risk patients defined by the medical comorbidities analyzed in our study.
198
The routine use of ALBC in TKA and THA leads to a significant increase in cost as
199
compared to PBC. Much of this is due to the relatively increased cost of ALBC in the United
200
States specifically. At our facility there was a nearly $300 difference in cost between ALBC and
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PBC, leading to a potential loss in savings of $231,509.28 over two years. Studies have
202
continued to fail to demonstrate its cost-effectiveness, specifically in the United States. Although
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certain models involving cheaper hand-mixed cement, younger patients, a higher overall
204
infection rate, and the inclusion of revisions for aseptic loosening have theoretically been able to
205
demonstrate the cost-effectiveness of ALBC, the same authors concluded that it would not be
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prudent to extrapolate this data to the current United States demographics and ALBC prices [12,
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27]. Arguably, any single episode of PJI carries a catastrophic increase in perioperative claims
10
208
costs. However, the 1% absolute risk reduction of PJI by ALBC that would be needed to justify
209
its cost, as described in the current literature, is already much higher than our institution’s
210
baseline PJI rate [23, 28]. Without any strong cost-effectiveness evidence indicating the role of
211
ALBC in reducing PJI in primary TKA, UKA and THA, the routine use of ALBC may not be
212
justified.
213
There were several limitations to our study. The lack of patient randomization to either
214
the PBC or ALBC cohorts and the retrospective nature of the study inherently make it difficult to
215
account for all confounding variables. Furthermore, this study included patients from multiple
216
surgeons, each with different surgical techniques and postoperative protocols. A more
217
standardized perioperative protocol could help decrease the confounding factors. However
218
subgroup statistical analysis was performed for certain demographics and comorbidities such as
219
diabetes, COPD, CHF, etc. which showed no significant difference in infection rates. No patients
220
were lost to follow up within the first 90 days. Patients who may have presented to outside
221
hospitals with their deep infections were still kept track of by our department of infection
222
control. Lastly, while our study included over 4,000 patients, the authors realize it may not be
223
sufficiently powered to detect the slight difference in PJI rates. In addition, the TJA infection rate
224
of 0.24% at our institution is eight times less than the national average of 2%. While this rate
225
may not be reproducible at all hospital settings, what can be reproduced is the cost-saving
226
benefits of using PBC. Despite these limitations, the authors feel that these results can be broadly
227
applied to all settings where hospitals have surgeons with varying training, protocols,
228
preferences, and techniques. Further studies with larger patient volumes, randomization, and
229
standardization of surgical and postsurgical protocols are needed to further validate the
230
conclusions of this study.
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232
Conclusion The use of ALBC in primary TKA varies by country. The percentage of surgeons who
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routinely use it in primary TKA is >90% in some countries, such as the United Kingdom,
234
Norway, and Sweden, compared with approximately 10% of surgeons in other countries such as
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the United States [3, 7, 14, 15]. The present study demonstrates that there was no statistically
236
significant difference in infection rates or in the need for revision surgery due to deep infection
237
for patients with primary TKA, UKA, and THA who were treated with ALBC as opposed to
238
PBC. The use of ALBC may add an unnecessary hospital expense in this setting. We estimate
239
that our hospital system could have saved nearly $120,000 per year if PBC was used in lieu of
240
ALBC for each index procedure. Given the rising necessity of hospitals to allocate funds
241
sparingly under bundled care models, it would be valuable to have randomized controlled trials
242
to confirm our findings and further evaluate the cost-effectiveness of ALBC versus PBC.
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Conflict of Interest
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'Declarations of interest: none'.
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Acknowledgements
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We would like to thank Paul Lombardi MD1, Robert Goldman MD1, Wayne Colizza MD1,
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Robert D’Agostini MD1, John Dundon MD1, and Aaron Forbes MD1 for performing the
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procedures included in this study and Stephanie Chiu MPH1 for analyzing the data.
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References
301 302 303 304 305
1. Buchholz HW, Engelbrecht H. Depot effects of various antibiotics mixed with Palacos resins. Chirurg. 1970;41:511–515. 2. Kleppel D, Stirton J, Liu J, Ebraheim NA. Antibiotic bone cement’s effect on infection
306
rates in primary and revision total knee arthroplasties. World J Orthop. 2017;8(12):946-
307
955.
308
3. Buchholz HW, Elson RA, Engelbrecht E, Lodenkämper H, Röttger J, Siegel A.
309
Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63-
310
B:342–353.
311
4. Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection
312
prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006;88:2487–2500.
313
5. Lautenschlager EP, Jacobs JJ, Marshall GW, Meyer PR Jr. Mechanical properties of bone
314
cements containing large doses of antibiotic powders. J Biomed Mater Res. 1976;10:929–
315
938.
316
6. Seldes RM, Winiarsky R, Jordan LC, Baldini T, Brause B, Zodda F, Sculco TP. Liquid
317
gentamicin in bone cement: a laboratory study of a potentially more cost-effective cement
318
spacer. J Bone Joint Surg Am. 2005;87:268–272.
319
7. Courtney PM, Melnic CM, Zimmer Z, Anari J, Lee GC. Addition of Vancomycin to
320
Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint
321
Arthroplasty. Clin Orthop Relat Res. 2015;473(7):2197-203.
322
8. Dovas S, Liakopoulos V, Papatheodorou L, et al. Acute renal failure after antibiotic-
323
impregnated bone cement treatment of an infected total knee arthroplasty. Clin Nephrol.
324
2008;69(3):207-12.
15
325 326
9. James A, Larson T. Acute renal failure after high-dose antibiotic bone cement: case report and review of the literature. Ren Fail. 2015;37(6):1061-6.
327
10. Luu A, Syed F, Raman G, et al. Two-stage arthroplasty for prosthetic joint infection: a
328
systematic review of acute kidney injury, systemic toxicity and infection control. J
329
Arthroplasty. 2013;28(9):1490-8.e1.
330
11. Patrick BN, Rivey MP, Allington DR. Acute renal failure associated with vancomycin-
331
and tobramycin-laden cement in total hip arthroplasty. Ann Pharmacother.
332
2006;40(11):2037-42.
333
12. Gutowski CJ, Zmistowski BM, Clyde CT, Parvizi J. The economics of using prophylactic
334
antibiotic-loaded bone cement in total knee replacement. Bone Joint J 2014;96-B:65e9.
335
13. King JD, Hamilton DH, Jacobs CA, Duncan ST. The hidden cost of commercial
336
antibiotic-loaded bone cement: a systematic review of clinical results and cost
337
implications following total knee arthroplasty. J Arthroplasty. 2018 ;33(12):3789-92.
338
Epub 2018 Aug 13.
339
14. Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic
340
prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in
341
bone cement on the revision rate of 22,170 primary hip replacements followed 0-14
342
years in the Norwegian Arthroplasty Register. Acta Orthop Scand. 2003;74:644-51.
343
15. Espehaug B, Engesaeter LB, Vollset SE, Havelin LI, Langeland N. Antibiotic
344
prophylaxis in total hip arthroplasty. Review of 10,905 primary cemented total hip
345
replacements reported to the Norwegian arthroplasty register, 1987 to 1995. J Bone Joint
346
Surg Br 1997;79:590e5.
16
347 348 349 350 351
16. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:61e65.e1. 17. Wang H, Qiu G-X, Lin J, Jin J, Qian W-W, Weng X-S. Antibiotic bone cement cannot reduce deep infection after primary total knee arthroplasty. Orthopedics 2015;38:e462e6. 18. Zheng H, Barnett AG, Merollini K, et al: Control strategies to prevent total hip
352
replacement-related infections: A systematic review and mixed treatment comparison.
353
BMJ Open 2014;4:e003978
354
19. Chiu F-Y, Chen C-M, Lin C-FJ, Lo W-H. Cefuroxime-impregnated cement in primary
355
total knee arthroplasty: a prospective, randomized study of three hundred and forty knees.
356
J Bone Joint Surg Am 2002;84-A:759e62.
357
20. Eveillard M, Mertl P, Tramier B, Eb F. Effectiveness of gentamicin-impregnated cement
358
in the prevention of deep wound infection after primary total knee arthroplasty. Infect
359
Control Hosp Epidemiol 2003;24:778e80.
360
21. Hinarejos P, Guirro P, Leal J, et al: The use of erythromycin and colistin-loaded cement
361
in total knee arthroplasty does not reduce the incidence of infection: A prospective
362
randomized study in 3000 knees. J Bone Joint Surg Am 2013;95:769-774.
363 364 365
22. Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty 2009;24:44e7. 23. Yayac M, Rondon AJ, Tan TL, Levy H, Parvizi J, Courtney PM. The Economics of
366
Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in
367
Infection Rates. J Arthroplasty. 2019 Apr 26.
17
368
24. Zhou Y, Li L, Zhou Q, Yuan S, Wu Y, Zhao H, et al. Lack of efficacy of prophylactic
369
application of antibiotic-loaded bone cement for prevention of infection in primary total
370
knee arthroplasty: results of a meta-analysis. Surg Infect 2015;16:183e7.
371
25. Yang Z, Liu H, Xie X, Tan Z, Qin T, Kang P: The influence of diabetes mellitus on the
372
post-operative outcome of elective primary total knee replacement: A systematic review
373
and meta-analysis. Bone Joint J 2014;96-B: 1637-1643.
374
26. Qadir, Rabah et al. Risk Stratified Usage of Antibiotic-Loaded Bone Cement for Primary
375
Total Knee Arthroplasty: Short Term Infection Outcomes With a Standardized Cement
376
Protocol. The Journal of Arthroplasty, Volume 29, Issue 8, 1622 – 1624
377
27. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesæter LB, Finlayson SR.
378
Costeffectiveness of antibiotic-impregnated bone cement used in primary total hip
379
arthroplasty. J Bone Joint Surg 2009;91:634e41.
380 381 382 383 384 385 386 387 388 389
28. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:61e65.e1.
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Table 1: Patient Comorbidities AntibioticLoaded Cement Hip 12
Plain Bone Cement Knee
Plain Bone Cement Hip
Totals
Diabetes
AntibioticLoaded Cement Knee 107
436
3
558
COPD
16
2
93
4
115
Renal Disease
16
2
78
1
97
CHF
8
4
48
2
62
Obesity
183
10
913
10
1116
Table 2- Total Cases Cases Total Knee Arthroplasty Bilateral Total Knee Arthroplasty Unicondylar Knee Arthroplasty Total Hip Arthroplasty Hip Resurfacing Bipolar Hip Hemiarthroplasty All Cases
Antibiotic-Loaded Cement 344
Plain Bone Cement 2677
Totals
40
665
705
39
251
290
12
34
46
24 27
10 16
34 43
486
3653
4139
3021
Table 3- Results Plain Bone Cement 7/3653
P-Values
All Cases
AntibioticLoaded Cement 3/486
All Knee Cases
3/423
7/3593
0.079
All Hip Cases
0/63
0/60
Total Knee Arthroplasty Bilateral Total Knee Arthroplasty Unicondylar Knee Arthroplasty Total Hip Arthroplasty Hip Resurfacing
3/344
7/2677
0.081
0/40
0/665
>0.999
0/39
0/251
>0.999
0/12
0/34
>0.999
0/24
0/10
>0.999
Bipolar Hip Hemiarthroplasty All Diabetic Patients
0/27
0/16
>0.999
1/119
0/439
0.213
All COPD Patients
0/18
0/97
>0.999
All CHF Patients
0/12
1/50
>0.999
All Renal Disease Patients All Obesity Cases
0/18
0/79
>0.999
3/193
6/923
0.192
0.103
>0.999
Conflict of Interest Statement "Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article."
S0972-978X(20)30041-6
DOI:
https://doi.org/10.1016/j.jor.2020.01.029
Reference:
JOR 950
To appear in:
Journal of Orthopaedics
Received Date: 8 January 2020 Accepted Date: 24 January 2020
Please cite this article as: Hoskins T, Shah JK, Patel J, Mazzei C, Goyette D, Poletick E, Colella T II, Wittig J, The Cost-Effectiveness of Antibiotic-Loaded Bone Cement versus Plain Bone Cement Following Total and Partial Knee and Hip Arthroplasty, Journal of Orthopaedics, https://doi.org/10.1016/ j.jor.2020.01.029. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.
The Cost-Effectiveness of Antibiotic-Loaded Bone Cement versus Plain Bone Cement Following Total and Partial Knee and Hip Arthroplasty
Running Title: Antibiotic Cement versus Plain Cement
Tyler Hoskins BA1 [email protected], Jay K. Shah DO1,2 [email protected], Jay Patel DO1 [email protected], Chris Mazzei BS1 [email protected], David Goyette BS1 [email protected], Eileen Poletick DNP1 [email protected], Thomas Colella II BA1 [email protected], James Wittig MD1 [email protected]
1. Department of Orthopaedic Surgery Morristown Medical Center – Atlantic Health System Morristown, NJ 2. Department of Orthopaedic Surgery Jersey City Medical Center – RWJBarnabas Health Jersey City, NJ Corresponding Author: Tyler Hoskins BA1 [email protected] 100 Madison Avenue Morristown, NJ 07960 "Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article." Author Contributions: TH, JS, JP, and JW helped design the study and write the manuscript. CM, DG, EP, and TC II all assisted with data curation. All surgeries and data collection for this study were performed at Morristown Medical Center.
1
1
Abstract
2
Background
3
Postoperative infection is one of the most prevalent complications following total joint
4
arthroplasty (TJA). As such procedures become more prevalent, it is imperative that we develop
5
new prophylactic methods to prevent the need for revision procedures. In recent years, surgeons
6
have opted to use antibiotic-loaded bone cement (ALBC) rather than plain bone cement (PBC) in
7
primary hip and knee replacements due to its theoretical potential of lowering infection rates.
8
However, the cost-effectiveness of this intervention remains in question.
9
Questions/Purposes
10
To determine the rate of infection and cost-effectiveness of antibiotic-loaded bone cement as
11
compared to plain bone cement in hip and knee arthroplasty.
12
Patients and Methods
13
We reviewed 4,116 primary hip and knee arthroplasty cases performed between 2016 to 2018 at
14
Morristown Medical Center in New Jersey. Data regarding demographics, complications, and
15
any readmissions due to deep infection were collected retrospectively. During that time period
16
there were a total of 4,016 knee cases (423 ALBC, 3,593 PBC) and 123 hip cases (63 ALBC, 60
17
PBC). The average cost for one bag of antibiotic-loaded bone cement and plain bone cement for
18
hip and knee arthroplasty was $336.42 and $72.14, respectively. A statistical analysis was
19
performed using Fisher’s exact test; the National Healthcare Safety Network (NHSN) surgical
20
site infection guidelines were used to distinguish between superficial and deep infections.
21
22
Results
2
23
Ten patients were readmitted due to deep infection, all of whom had undergone total knee
24
arthroplasty. Of those cases, plain bone cement was used for the index procedure in seven
25
instances and antibiotic-loaded cement was used in three. This resulted in an infection rate of
26
0.19% and 0.62%, respectively, p = 0.103. There was no statistically significant difference in
27
infection rates between the two groups. A total of 778 bags of ALBC were used in 423 knee
28
surgeries, and 98 bags of ALBC were used in 63 hip cases. The total cost for ALBC in TKA and
29
THA procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If
30
PBC had been used during all index procedures, it would have resulted in a total savings of
31
$231,509.28.
32
Conclusions
33
Antibiotic-loaded cement did not significantly reduce the rate of infection for either knee or hip
34
arthroplasty. Thus, the routine use of antibiotic-loaded cement in primary hip and knee
35
arthroplasty may be an unnecessary financial burden to the healthcare system. A larger sample
36
size and a randomized controlled trial would help confirm our findings and would provide
37
further information on the cost-effectiveness of ALBC cement versus PBC.
38
Significance/Clinical Relevance
39
In this review of cases performed from 2016 to 2018 there was no statistically significant
40
difference between the rate of infection and the need for revision surgeries for patients treated
41
with ALBC versus PBC. As hospital systems continue to transition towards a bundled payment
42
model, it becomes imperative for providers to reduce any unnecessary costs in order to increase
43
quality and efficiency. We estimate that our hospital system could save nearly $120,000/year by
44
using plain bone cement instead of antibiotic-loaded cement.
3
45
46
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
66 67 68 69
Keywords: joint arthroplasty, hip, knee, infection, cost-effectiveness
4
70 71
Introduction Periprosthetic joint infection (PJI) following hip and knee arthroplasty is a serious
72
complication. In order to decrease the incidence of infection following these procedures, new
73
prophylactic interventions and procedural modifications have been implemented. Antibiotic-
74
loaded bone cement (ALBC) was first introduced and used in lieu of plain bone cement (PBC)
75
by Buchholz and Englebrecht in 1970 [1, 2]. In a 1981 follow-up study, they reported a 77%
76
success rate among 583 patients undergoing total hip arthroplasty (THA). Success was defined as
77
no infection, no loosening of hardware, and useful function of the joint [3]. Subsequent studies
78
have investigated the efficacy of this intervention and have reported similar findings [2].
79
Although the use of ALBC in revision total joint surgery is well supported by the
80
literature, the regular use of this type of intervention in routine primary total joint arthroplasty
81
(TJA) remains controversial. Several potential adverse complications have emerged, including
82
the development of antibiotic-resistant strains of bacteria, antibiotic toxicity, a negative effect on
83
the mechanical properties of the cement, and the economic implications of the added cost.
84
Studies have reported that at high doses of antibiotics (>4.5 grams of antibiotic powder per 40
85
grams of cement), mechanical complications such as hardware loosening can occur much more
86
frequently [2, 4, 5, 6]. While the primary goal of ALBC is to deliver high, localized
87
concentrations of the antibiotic, the risk of systemic exposure and toxicity remain concerning. In
88
the past decade there have been a number of literature reports involving patients who received
89
ALBC during a total knee or hip arthroplasty and subsequently experienced acute renal failure
90
(ARF) [7-11].
91 92
The economic implications of this intervention also continue to be scrutinized. The price for one bag of ALBC can range from $200 to $500, while PBC costs under $100 [4, 12, 13].
5
93
Jiranek et al. reported an estimated increase of $117 million dollars to the annual healthcare costs
94
if ALBC is used in only half of the primary joint arthroplasty cases [4]. In order to justify the
95
incorporation of ALBC into routine primary joint arthroplasty, the cost savings must be greater
96
than if PBC was used alone. This is contingent upon preventing subsequent revision surgeries
97
due to deep infection. The goals of this study were to examine the cost-effectiveness and the rate
98
of deep infection using ALBC versus PBC for patients treated at our facility for either a total
99
knee arthroplasty (TKA), partial knee arthroplasty (UKA) or THA. Specifically, we aimed to
100
look at whether or not the additional cost of ALBC would be justified by the expected reduction
101
in deep infections.
102 103 104 105 106 107 108 109 110 111 112 113 114 115
6
116 117
Methods A retrospective review was conducted on all cemented total and partial hip and knee
118
arthroplasty cases performed between January 1, 2016 to December 31, 2018 at a large,
119
suburban, regional medical center. Patient demographics, comorbidities, and any readmissions
120
due to deep infection were extracted from patient charts. Data were also collected on patients
121
who were readmitted to outside facilities for deep infections after their index procedure was done
122
at our institution during the study period. For each procedure, either Stryker (Mahwah, NJ) or
123
Zimmer-Biomet (Parsippany, NJ) bone cement was used. Choice of cement was based on the
124
surgeon’s discretion. One surgeon in particular routinely utilized ALBC for all primary joint
125
replacements.
126
Inclusion criteria for the study were as follows: patients treated at our facility with a
127
cemented primary total or partial hip or knee arthroplasty. Exclusion criteria included: revision
128
arthroplasty patients and uncemented arthroplasty cases. A statistical analysis was performed
129
using Fisher’s exact test; the National Healthcare Safety Network (NHSN) surgical site infection
130
guidelines were used to distinguish between superficial and deep infections. Demographics such
131
as gender, age, body mass index (BMI), American Society of Anesthesiologists Score (ASA),
132
and LOS (length of stay) were included in our analysis. Medical comorbidities such as diabetes,
133
chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), renal disease,
134
and obesity were also identified for each cohort (Table 1).
135 136 137 138
7
139 140
Results During the study period there were a total of 4,016 cemented knee cases: 423 ALBC (408
141
TKA, 15 UKA) and 3,593 PBC (3,561 TKA, 32 UKA). There were also 123 cemented THA
142
cases: 63 ALBC and 60 PBC (Table 2). There were no cases of cemented hip hemiarthroplasty
143
during the study period. The average age was 67.92 (range, 36 to 94) with 39.94% of patients
144
being male and 60.06% being female. Average BMI, ASA, and LOS were 31.62 (range, 15 to
145
61.1), 2.32 (range, 1 to 4), and 2.28 days (range, 0 to 21), respectively. The large discrepancy in
146
case volume between hip and knee surgeries can be attributed to the general U.S. trend of
147
orthopedic surgeons using uncemented implants during routine THA.
148
Ten patients were readmitted due to deep infection, all of whom had undergone TKA. Of
149
the cases reported, PBC was used during the index procedure in 7 patients (0.19%) and ALBC
150
was used in 3 patients (0.62%). At our institution, the average cost for one bag of PBC is $72.14;
151
the average cost for one bag of ABLC is $336.42. The discrepancy in price is due to the pricing
152
differences between the two different brands of PBC and ALBC available at our institution. A
153
total of 778 bags of ALBC were used in 423 knee surgeries (TKA, UKA, bilateral TKA) and 98
154
bags of ALBC were used in 63 THA cases. The total cost for ALBC in TKA and THA
155
procedures was $261,734.76 (778*336.42) and $32,969.16 (98*336.42), respectively. If PBC
156
had been used during all index procedures, it would have resulted in a total savings of
157
$231,509.28. There were no infections in our UKA, bilateral TKA, and THA groups. There were
158
no statistically significant differences between the various comorbidities with respect to infection
159
rates between the PBC and ALBC cohorts (Table 3).
160
161
8
162
163
Discussion The most important finding of this study is that there was no statistically significant
164
difference between the rate of deep infection and the need for revision surgery in patients
165
undergoing either primary knee or hip arthroplasty who were treated with ALBC versus PBC.
166
The effectiveness of ALBC in primary hip and knee joint replacement remains a subject of
167
controversy in the literature. As hospital systems transition towards a bundled payment model,
168
the answer to this debate becomes even more essential, and may offer a significant avenue
169
towards cost savings while at the same time maintaining the quality of care rendered.
170
With regard to ALBC in primary THA, a majority of the support for its use comes from
171
early European registry data studies, where cemented THA is much more common than in the
172
United States [14, 15]. More recently, while there are no adequately powered randomized control
173
trials in the literature addressing ALBC for primary THA, systematic reviews continue to support
174
the use of ALBC to reduce the risk of deep periprosthetic infection in THA [16-18]. However,
175
the results of this paper directly contradict these findings, and did not demonstrate any
176
statistically significant reduction in deep infection rates in patients undergoing primary THA.
177
This is important, as most of the studies specifically looking at ALBC in primary THA are
178
almost a decade old and rely on national registry data that have the potential limitations of
179
selection bias due to incomplete data capture.
180
The authors of this paper also did not find a statistically significant difference in the rate
181
of deep infection and subsequent revision surgery between ALBC and PBC in primary TKA,
182
bilateral primary TKA or UKA. In the early 2000s, several authors, including Chiu et al. and
183
Eveillard et al., were the first to suggest that ALBC could reduce PJI rates in primary TKA [19,
184
20]. However, these studies had several limitations, including borderline statistical significance
9
185
as well as the failure to address confounding comorbidities such as diabetes. The present study
186
demonstrated adequate control for confounding comorbidities (CHF, COPD, renal disease,
187
diabetes) and variables (age, gender, BMI) while still demonstrating a lack of efficacy of ALBC.
188
More recent studies, including a randomized control trial by Hinarejos et al. and other larger case
189
series, corroborate the present study’s findings [17, 21, 22, 23]. They also failed to demonstrate a
190
decrease in infection rates when using ALBC versus PBC. More recent registry studies,
191
systematic reviews, and meta-analyses also have arrived at similar conclusions [13, 16, 24].
192
Several studies have commented on the idea of risk-stratified usage of ALBC, especially
193
in patients with diabetes and rheumatoid arthritis [19, 25]. However, a more recent study by
194
Qadir et al. found no advantage of ALBC over PBC in high-risk patients, such as those with
195
inflammatory arthropathies, diabetes, and immunosuppression [26]. This was supported by our
196
research, as there was no statistically significant difference between infection rates in the higher
197
risk patients defined by the medical comorbidities analyzed in our study.
198
The routine use of ALBC in TKA and THA leads to a significant increase in cost as
199
compared to PBC. Much of this is due to the relatively increased cost of ALBC in the United
200
States specifically. At our facility there was a nearly $300 difference in cost between ALBC and
201
PBC, leading to a potential loss in savings of $231,509.28 over two years. Studies have
202
continued to fail to demonstrate its cost-effectiveness, specifically in the United States. Although
203
certain models involving cheaper hand-mixed cement, younger patients, a higher overall
204
infection rate, and the inclusion of revisions for aseptic loosening have theoretically been able to
205
demonstrate the cost-effectiveness of ALBC, the same authors concluded that it would not be
206
prudent to extrapolate this data to the current United States demographics and ALBC prices [12,
207
27]. Arguably, any single episode of PJI carries a catastrophic increase in perioperative claims
10
208
costs. However, the 1% absolute risk reduction of PJI by ALBC that would be needed to justify
209
its cost, as described in the current literature, is already much higher than our institution’s
210
baseline PJI rate [23, 28]. Without any strong cost-effectiveness evidence indicating the role of
211
ALBC in reducing PJI in primary TKA, UKA and THA, the routine use of ALBC may not be
212
justified.
213
There were several limitations to our study. The lack of patient randomization to either
214
the PBC or ALBC cohorts and the retrospective nature of the study inherently make it difficult to
215
account for all confounding variables. Furthermore, this study included patients from multiple
216
surgeons, each with different surgical techniques and postoperative protocols. A more
217
standardized perioperative protocol could help decrease the confounding factors. However
218
subgroup statistical analysis was performed for certain demographics and comorbidities such as
219
diabetes, COPD, CHF, etc. which showed no significant difference in infection rates. No patients
220
were lost to follow up within the first 90 days. Patients who may have presented to outside
221
hospitals with their deep infections were still kept track of by our department of infection
222
control. Lastly, while our study included over 4,000 patients, the authors realize it may not be
223
sufficiently powered to detect the slight difference in PJI rates. In addition, the TJA infection rate
224
of 0.24% at our institution is eight times less than the national average of 2%. While this rate
225
may not be reproducible at all hospital settings, what can be reproduced is the cost-saving
226
benefits of using PBC. Despite these limitations, the authors feel that these results can be broadly
227
applied to all settings where hospitals have surgeons with varying training, protocols,
228
preferences, and techniques. Further studies with larger patient volumes, randomization, and
229
standardization of surgical and postsurgical protocols are needed to further validate the
230
conclusions of this study.
11
231
232
Conclusion The use of ALBC in primary TKA varies by country. The percentage of surgeons who
233
routinely use it in primary TKA is >90% in some countries, such as the United Kingdom,
234
Norway, and Sweden, compared with approximately 10% of surgeons in other countries such as
235
the United States [3, 7, 14, 15]. The present study demonstrates that there was no statistically
236
significant difference in infection rates or in the need for revision surgery due to deep infection
237
for patients with primary TKA, UKA, and THA who were treated with ALBC as opposed to
238
PBC. The use of ALBC may add an unnecessary hospital expense in this setting. We estimate
239
that our hospital system could have saved nearly $120,000 per year if PBC was used in lieu of
240
ALBC for each index procedure. Given the rising necessity of hospitals to allocate funds
241
sparingly under bundled care models, it would be valuable to have randomized controlled trials
242
to confirm our findings and further evaluate the cost-effectiveness of ALBC versus PBC.
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Conflict of Interest
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'Declarations of interest: none'.
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Acknowledgements
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We would like to thank Paul Lombardi MD1, Robert Goldman MD1, Wayne Colizza MD1,
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Robert D’Agostini MD1, John Dundon MD1, and Aaron Forbes MD1 for performing the
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procedures included in this study and Stephanie Chiu MPH1 for analyzing the data.
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References
301 302 303 304 305
1. Buchholz HW, Engelbrecht H. Depot effects of various antibiotics mixed with Palacos resins. Chirurg. 1970;41:511–515. 2. Kleppel D, Stirton J, Liu J, Ebraheim NA. Antibiotic bone cement’s effect on infection
306
rates in primary and revision total knee arthroplasties. World J Orthop. 2017;8(12):946-
307
955.
308
3. Buchholz HW, Elson RA, Engelbrecht E, Lodenkämper H, Röttger J, Siegel A.
309
Management of deep infection of total hip replacement. J Bone Joint Surg Br. 1981;63-
310
B:342–353.
311
4. Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection
312
prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006;88:2487–2500.
313
5. Lautenschlager EP, Jacobs JJ, Marshall GW, Meyer PR Jr. Mechanical properties of bone
314
cements containing large doses of antibiotic powders. J Biomed Mater Res. 1976;10:929–
315
938.
316
6. Seldes RM, Winiarsky R, Jordan LC, Baldini T, Brause B, Zodda F, Sculco TP. Liquid
317
gentamicin in bone cement: a laboratory study of a potentially more cost-effective cement
318
spacer. J Bone Joint Surg Am. 2005;87:268–272.
319
7. Courtney PM, Melnic CM, Zimmer Z, Anari J, Lee GC. Addition of Vancomycin to
320
Cefazolin Prophylaxis Is Associated With Acute Kidney Injury After Primary Joint
321
Arthroplasty. Clin Orthop Relat Res. 2015;473(7):2197-203.
322
8. Dovas S, Liakopoulos V, Papatheodorou L, et al. Acute renal failure after antibiotic-
323
impregnated bone cement treatment of an infected total knee arthroplasty. Clin Nephrol.
324
2008;69(3):207-12.
15
325 326
9. James A, Larson T. Acute renal failure after high-dose antibiotic bone cement: case report and review of the literature. Ren Fail. 2015;37(6):1061-6.
327
10. Luu A, Syed F, Raman G, et al. Two-stage arthroplasty for prosthetic joint infection: a
328
systematic review of acute kidney injury, systemic toxicity and infection control. J
329
Arthroplasty. 2013;28(9):1490-8.e1.
330
11. Patrick BN, Rivey MP, Allington DR. Acute renal failure associated with vancomycin-
331
and tobramycin-laden cement in total hip arthroplasty. Ann Pharmacother.
332
2006;40(11):2037-42.
333
12. Gutowski CJ, Zmistowski BM, Clyde CT, Parvizi J. The economics of using prophylactic
334
antibiotic-loaded bone cement in total knee replacement. Bone Joint J 2014;96-B:65e9.
335
13. King JD, Hamilton DH, Jacobs CA, Duncan ST. The hidden cost of commercial
336
antibiotic-loaded bone cement: a systematic review of clinical results and cost
337
implications following total knee arthroplasty. J Arthroplasty. 2018 ;33(12):3789-92.
338
Epub 2018 Aug 13.
339
14. Engesaeter LB, Lie SA, Espehaug B, Furnes O, Vollset SE, Havelin LI. Antibiotic
340
prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in
341
bone cement on the revision rate of 22,170 primary hip replacements followed 0-14
342
years in the Norwegian Arthroplasty Register. Acta Orthop Scand. 2003;74:644-51.
343
15. Espehaug B, Engesaeter LB, Vollset SE, Havelin LI, Langeland N. Antibiotic
344
prophylaxis in total hip arthroplasty. Review of 10,905 primary cemented total hip
345
replacements reported to the Norwegian arthroplasty register, 1987 to 1995. J Bone Joint
346
Surg Br 1997;79:590e5.
16
347 348 349 350 351
16. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:61e65.e1. 17. Wang H, Qiu G-X, Lin J, Jin J, Qian W-W, Weng X-S. Antibiotic bone cement cannot reduce deep infection after primary total knee arthroplasty. Orthopedics 2015;38:e462e6. 18. Zheng H, Barnett AG, Merollini K, et al: Control strategies to prevent total hip
352
replacement-related infections: A systematic review and mixed treatment comparison.
353
BMJ Open 2014;4:e003978
354
19. Chiu F-Y, Chen C-M, Lin C-FJ, Lo W-H. Cefuroxime-impregnated cement in primary
355
total knee arthroplasty: a prospective, randomized study of three hundred and forty knees.
356
J Bone Joint Surg Am 2002;84-A:759e62.
357
20. Eveillard M, Mertl P, Tramier B, Eb F. Effectiveness of gentamicin-impregnated cement
358
in the prevention of deep wound infection after primary total knee arthroplasty. Infect
359
Control Hosp Epidemiol 2003;24:778e80.
360
21. Hinarejos P, Guirro P, Leal J, et al: The use of erythromycin and colistin-loaded cement
361
in total knee arthroplasty does not reduce the incidence of infection: A prospective
362
randomized study in 3000 knees. J Bone Joint Surg Am 2013;95:769-774.
363 364 365
22. Namba RS, Chen Y, Paxton EW, Slipchenko T, Fithian DC. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty 2009;24:44e7. 23. Yayac M, Rondon AJ, Tan TL, Levy H, Parvizi J, Courtney PM. The Economics of
366
Antibiotic Cement in Total Knee Arthroplasty: Added Cost with No Reduction in
367
Infection Rates. J Arthroplasty. 2019 Apr 26.
17
368
24. Zhou Y, Li L, Zhou Q, Yuan S, Wu Y, Zhao H, et al. Lack of efficacy of prophylactic
369
application of antibiotic-loaded bone cement for prevention of infection in primary total
370
knee arthroplasty: results of a meta-analysis. Surg Infect 2015;16:183e7.
371
25. Yang Z, Liu H, Xie X, Tan Z, Qin T, Kang P: The influence of diabetes mellitus on the
372
post-operative outcome of elective primary total knee replacement: A systematic review
373
and meta-analysis. Bone Joint J 2014;96-B: 1637-1643.
374
26. Qadir, Rabah et al. Risk Stratified Usage of Antibiotic-Loaded Bone Cement for Primary
375
Total Knee Arthroplasty: Short Term Infection Outcomes With a Standardized Cement
376
Protocol. The Journal of Arthroplasty, Volume 29, Issue 8, 1622 – 1624
377
27. Cummins JS, Tomek IM, Kantor SR, Furnes O, Engesæter LB, Finlayson SR.
378
Costeffectiveness of antibiotic-impregnated bone cement used in primary total hip
379
arthroplasty. J Bone Joint Surg 2009;91:634e41.
380 381 382 383 384 385 386 387 388 389
28. Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty 2012;27:61e65.e1.
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390
Table 1: Patient Comorbidities AntibioticLoaded Cement Hip 12
Plain Bone Cement Knee
Plain Bone Cement Hip
Totals
Diabetes
AntibioticLoaded Cement Knee 107
436
3
558
COPD
16
2
93
4
115
Renal Disease
16
2
78
1
97
CHF
8
4
48
2
62
Obesity
183
10
913
10
1116
Table 2- Total Cases Cases Total Knee Arthroplasty Bilateral Total Knee Arthroplasty Unicondylar Knee Arthroplasty Total Hip Arthroplasty Hip Resurfacing Bipolar Hip Hemiarthroplasty All Cases
Antibiotic-Loaded Cement 344
Plain Bone Cement 2677
Totals
40
665
705
39
251
290
12
34
46
24 27
10 16
34 43
486
3653
4139
3021
Table 3- Results Plain Bone Cement 7/3653
P-Values
All Cases
AntibioticLoaded Cement 3/486
All Knee Cases
3/423
7/3593
0.079
All Hip Cases
0/63
0/60
Total Knee Arthroplasty Bilateral Total Knee Arthroplasty Unicondylar Knee Arthroplasty Total Hip Arthroplasty Hip Resurfacing
3/344
7/2677
0.081
0/40
0/665
>0.999
0/39
0/251
>0.999
0/12
0/34
>0.999
0/24
0/10
>0.999
Bipolar Hip Hemiarthroplasty All Diabetic Patients
0/27
0/16
>0.999
1/119
0/439
0.213
All COPD Patients
0/18
0/97
>0.999
All CHF Patients
0/12
1/50
>0.999
All Renal Disease Patients All Obesity Cases
0/18
0/79
>0.999
3/193
6/923
0.192
0.103
>0.999
Conflict of Interest Statement "Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article."