What is the cost-effectiveness profile of TJA performed with bone cement that contains antibiotics?
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Antibiotic-loaded cement may decrease costs
As infection remains the most devastating cause of failure and reoperation after total knee arthroplasty, antibiotic-loaded cement has been recommended for prophylaxis, but its efficacy and cost-effectiveness remain controversial. The Norwegian Arthroplasty Registry reported a decreased rate of infection with antibiotic-loaded cement (ABLC) in 22,700 THAs. Recent systematic reviews of its efficacy showed conflicting results, possibly due to the relatively low overall incidence of infection. ABLC is available as premixed commercial preparations or the surgeon may manually add a heat-stable antibiotic. At our institution, premixed ABLC costs about $140 more than plain cement per package, but vancomycin, tobramycin or cefuroxime powder can be added manually to it at a lower cost. One analysis suggested ABLC may decrease the costs of revision surgery by $200. Another study reported that manually mixed ABLC was more cost-effective than premixed preparations, but the price reported in the study for the premixed cement was three-times higher than it is at our institution. American Academy of Orthopaedic Surgeons clinical guidelines suggest ABLC should be used only for “high-risk” patients in cases of revision, prior joint infection or chronic immunosuppression. The senior author also uses ABLC in patients with multiple medical comorbidities associated with a higher risk of infection. Since most THAs now performed in the United States use cementless fixation, additional studies of the efficacy and cost-effectiveness of both surgeon-mixed and premixed ABLC in TKA are warranted before its routine use is recommended.
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Paul F. Lachiewicz, MD; and Johannes F. Plate, MD, are in the department of orthopedic surgery at Duke University in Durham, North Carolina.
Disclosures: Lachiewicz reports he receives royalties from Innomed; consulting fees from Guidepoint Global, Gerson Lehrman Group, Heron Therapeutics and Intellisphere; speaker fees from Mallinkrodt and Ceramtec; and research funds from Zimmer Biomet. Plate reports no relevant financial disclosures.
Downsides to antibiotic-loaded cement
Periprosthetic infection is a catastrophic event. It can seriously jeopardize the result of the arthroplasty and, in the worst circumstances, can significantly endanger the patient. Much has been done to reduce this complication: improved surgical technique, more expeditious surgery, techniques to reduce blood loss, reduced operative wound contamination and prophylactic parenteral antibiotics. In most centers, infection rates are now less than 1% and may be as low as 0.3%. Continued efforts to reduce periprosthetic infection have made the need for antibiotic-impregnated cement in routine arthroplasty not cost effective and with possible serious downsides.
As overwhelmingly total hip replacement in the United States is performed with non-cemented implants (more than 90%), there is no need for cement at all. Total knee replacement — where cemented implants are still predominant — is the main arthroplasty in which antibiotics might be used. The cost-effectiveness of routine use of antibiotics in cement is questionable and may cost, in total, $300 to $400 per case. In the United States alone, this could add $125,000 to $150,000 million dollars to health care costs. It would require reduction of the current 1% infection rate to an impossible 0.04% for use of ABLC to be cost neutral. In addition, there are a number of registry studies that have demonstrated no difference in infection rates with or without antibiotics used in bone cement.
A major detrimental effect of using ABLC is the potential for resistant organisms due to the use of antibiotic-impregnated cement. Studies have demonstrated there is rapid mutation of bacteria when confronted with antibiotics and this could lead to difficulty in eradicating infections due to resistant organisms, should they occur. Allergy to antibiotics used and alteration of mechanical properties of cement is also a concern when antibiotics are added to cement, but these are probably not major issues with the doses currently being used.
There is a role for use of antibiotics added to cement in high-risk patients who are on immunosuppressive medications or have diabetes or rheumatoid arthritis. In revision joint replacement, which has a higher risk of infection, use of antibiotics in bone cement is indicated. In summary, routine use of antibiotics in cement is not cost-effective, can lead to emergence of resistant bacteria, may not reduce infection rates at all, adds tremendous cost to health care and, therefore, is not recommended.
Thomas P. Sculco, MD, is surgeon-in-chief emeritus at Hospital for Special Surgery and professor of orthopedic surgery at Weill Cornell Medical College in New York.
Disclosure: Sculco reports he receives royalties through a sponsored research and collaboration agreement between Hospital for Special Surgery and Exactech Inc. for the design of the posterior-stabilized knee prosthesis and is a consultant for Lima Corporate.