[Economic evaluation of porous metal cones in total knee arthroplasty]

INTRODUCTION

The use of porous metal cones (PMC) to fill bone loss during knee replacements is increasing, but these medical devices are not reimbursed in addition to diagnosis related tariffs (DRTs). The economic impact of PMC may be significant for hospitals.

MATERIAL AND METHODS

This multicenter observational study includes all patients who benefited of a total knee prosthesis, with reconstruction by PMC, between June 2014 and June 2019, in two French university hospitals. The costs of each diagnosis related group (DRG) was evaluated using the "étude nationale des coûts à méthodologie commune (ENC)". The PMC costs were compared with the amounts of DRG and with the fares perceived by the hospital from the French sickness fund (DRTs).

RESULTS

96 patients (103 stays) benefited from the implantation of 195 cones. The hospital incomes were 10,970±1401€ /stay. Spending associated with PMC represented 35% of DRGs and 44% of DRTs. The average additional cost related to the cones was 2709±1138€ /stay. If the reconstructions had been performed by allograft, the average gain for hospitals would have been 108€ /stay.

CONCLUSION

If PMC have clinical benefits for surgeons in reducing the incidence of revision, this study shows the inadequacy of the funding of these devices for French hospitals. This suggests the need to expand the possibilities of supporting innovative technologies.

One-stage versus two-stage prosthesis replacement for prosthetic knee infections

INTRODUCTION

Periprosthetic knee infection is a severe complication. Confirmed criteria are lacking to choose between one-stage or two-stage prosthesis replacement to treat the infection. The one-stage replacement could lead to a satisfactory control of the infection and to better functional results.

METHOD

Retrospective study conducted between January 1, 2009 and December 31, 2014. The objectives of this study were to compare the infection outcome and functional results between the one-stage and two-stage replacement procedures. Functional results were evaluated using the IKS score, KOOS score, and SF-12 quality of life score.

RESULTS

Forty-one patients underwent a two-stage replacement procedure and 21 patients a one-stage replacement. The average follow-up was 22 months after surgery. The infection was cured in 78% of patients who underwent a two-stage replacement and 90% of patients who underwent a one-stage replacement (P=0.3). The flexion range of motion was significantly better in the one-stage group than in the two-stage group (P=0.04). Results of the IKS score and of the KOOS score were better in the one-stage group. No difference was observed for the SF-12 score.

CONCLUSION

The one-stage replacement procedure for periprosthetic knee infection was associated with a similar healing frequency as the two-stage replacement procedure, and with better knee function.

[Review of patient-specific instrumentation for total knee prosthesis]

OBJECTIVES

Single use patient-specific instruments (PSI) for total knee prosthesis are introduced as a new alternative to conventional ancillaries and computer assisted surgery by improving implants positioning. An exhaustive review was carried out to identify their specific characteristics, with their advantages and disadvantages.

METHODS

Medical devices suppliers were consulted in 2015 for reviewing their PSI. Their technical, clinical and economic data were compared. The results had been submitted to an orthopaedics expert commission of our university hospital for clinical and financial opinion.

RESULTS

Ten companies have provided the documentation for the analysis. PSI are manufactured by suppliers using a three dimensional printing method based on CT scans or MRI images. PSI are produced according to the surgeon's preferences after a preliminary data check, which can be performed by the suppliers' engineers, the surgeon and automatic calculation. Five suppliers can produce sterile PSI with optional delivery of 3D bone models. According to the experts, the studies failed to demonstrate the superiority of a PSI or hospital economic gain. The prices listed remain high and operating room time is not always significantly reduced.

CONCLUSIONS

With the development of personalized medicine, the role of PSI grows in importance. They facilitate the surgeon's work by fully respecting the anatomy. These systems offer an interesting perspective in their technical and pedagogical aspects. But it seems premature to take them into routine use given the low number of high-level studies that were currently done.

[Perspective of the transition from reusable instruments to single use ancillary in orthopedic surgery]

OBJECTIVES

Since 2009, single-use (SU) ancillaries for total knee arthroplasty (TKA) and total hip arthroplasty (THA) have been marketed to replace reusable ancillaries. The concept is not innovative but their use in orthopedics is still uncommon. An assessment has been done for the use of SU ancillary in Assistance publique-hôpitaux de Paris with the consequences for the patient, the surgeon and the hospital.

METHODS

A technical and a clinical review has been done with those devices in 2015. The economic and organizational impacts were identified and submitted for opinion to committee experts in orthopedics.

RESULTS

Three SU ancillaries are commercialized. No clinical studies are currently available. There is no reimbursement for SU ancillaries whereas reusable ancillaries are included in prosthesis reimbursement price. Although SU ancillaries (TKA and THA) saving costs for sterilization, the annual additional budget estimated for their purchase would approximately be 2.5 times higher. Nevertheless, indirect savings could be also considered in the long-term period (global costs for sterilization, volume effect…). For the same quality, according to the experts, organizational impacts are low for the patient and the surgeon but potentially important for the hospital, the nursing and pharmaceutical staff, and logistical activities.

CONCLUSIONS

On logistic, clinical and financial aspects, SU ancillaries need more evaluation. The switch to SU ancillaries allows saving sterilization costs and time, and provided an immediate mobilization of the equipment but their interest must be demonstrated by clinical and economic data.

[Medical and economic impact of a haemostatic sealant on the rate of transfusion after total knee arthroplasty]

OBJECTIVES

Blood loss reduction in total knee arthroplasty (TKA) contributes to the prevention of morbidity and mortality and in the management of health care costs. Fibrin haemostatic sealant have controversial effectiveness in reducing postoperative blood loss and transfusion requirements. Our study evaluated the medical and economic benefits of this treatment with the assumption that it decreases the frequency of blood transfusion after TKA.

METHODS AND PATIENTS

Our single-center and randomized study included 60 patients pose unilateral primary TKA for osteoarthritis. Distribution was done in 2 groups of 30 patients each. Group 1 patients treated with a dose of 5 mL Evicel®, compared to untreated group 2. Were collected the number of patients transfused. The treatment cost was compared to the sealant cost.

RESULTS

Results are not statistically significant. Two patients were transfused in group 1 and 3 in group 2 (P=0.64). The treatment cost for 30 patients is 13,500 €, for a savings of cells packed at 187 €, an additional cost of 13,313 € in group 1.

CONCLUSION

The use of fibrin haemostatic sealant in TKA did not induce a significant difference in terms of blood or transfusion savings, with a significant cost. We do not recommend its routine use in TKA.