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Antibiotic-Impregnated Cement Has Limited Cost Savings in Primary Total Hip Arthroplasty

Posted on: 03/25/2009
Total hip replacements (arthroplasties) are becoming much more common in North America than they ever have been. Although the percentage of complications haven't increased, the reality is because more people are having the surgery, more people are having problems. One serious problem associated with hip replacements is infection. A deep infection in a knee replacement can cause complications that end up requiring revision surgery to correct.

Doctors and researchers have been looking for ways to decrease the number of people who develop infections in their replacements, including giving antibiotics before the surgery. Another method uses, in conjunction with antibiotics beforehand, a bone cement that has an antibiotic inside. The idea is that this will further drop the risk of infection. Not all doctors agree that it should be used routinely however. They feel that the cost of the bone cement doesn't justify the few infections it may prevent. They also worry about antibiotic resistance, a real concern in today's world, and how the cement may affect the new joint.

The authors of this article wanted to study the issue to see if the cost of using the antibiotic-impregnated bone cement for total hip replacements is worth the cost. To do this, they reviewed revision rates, mortality rates, and the costs of the overall treatment. This includes the procedure and related acute-care hospital stay costs only. The researchers didn't include, surgeon fees, rehabilitation stay, or lost wages from work. The authors point out that the cost estimates are in US dollars with the 2002 value.

The estimated cost ranged from 12,846 dollars to 31,000 dollars for a primary total hip replacement. For the study's purposes, the cost was figured to be 21,654 dollars. Earlier studies have estimated that revision surgeries, compared to the original replacement ranged from 20 percent more to 60 percent more. For this study, the calculated amount was 34,866 dollars for revision surgery overall, but if the revision was due to an infection, this climbed dramatically to 96,166 dollars.This includes the use of intravenous antibiotics.

Using antibiotic-impregnated bone cement cost depends on the type of antibiotic used. Cement with gentamycin, for example, has been studied the most often and the estimated cost for one packet (40 grams) of the cement would be about 365 dollars and on average, two packets are used in surgery. This compares with 65 dollars for standard cement per pack, with two being needed most of the time.

After analyzing issues such as rate of revision, actual costs of procedures and equipment, as well as the success of the procedures, the results were looked at in two fashions: cost effectiveness of revisions done for any reason and cost effectiveness of revisions that were done because of deep infection. In the first case, using the antibiotic cement resulted in only a 200 dollar savings overall. However, if the revision was due to infection, the savings was higher, but it needed to be above 650 dollars worth of savings to be worthwhile or the patient had to be older than 71 years.

In this case, the researchers concluded that such a treated cement could have been useful in younger patients, however those who are younger tend to have replacements that don't need cement. So overall, as long as the cost remains high, treated cement doesn't appear to be a cost effective form of management.

Justin S. Cummins, MD, MS, et al. Cost-Effectiveness of Antibiotic-Impregnated Bone Cement Used in Primary Total Hip Arthroplasty. The Journal of Bone & Joint Surgery. March 2009. Vol. 91. No. 3. Pp. 633 to 641.

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