Reducing arthroplasty revisions: cutting costs and improving patient satisfaction
How the use of antibiotic-loaded bone cement significantly lowers revision rates in hip and knee arthroplasty
Infection is a burdensome complication of all types of surgery and especially following arthroplasty. Implant removal and revision arthroplasty have a considerable impact on the patient and are associated with substantially greater hospital and physician resource utilisation, resulting in significantly higher costs compared to primary total joint arthroplasty. The use of antibiotic-loaded bone cements is a widely practised method of reducing orthopaedic infections. The major appeal of incorporating antibiotics in bone cements is the higher local concentrations of antibiotic achievable when it is delivered in this way, compared with intravenous administration. PALACOS® R+G (Heraeus Medical), which includes gentamicin, has been in use for over 40 years.
At the annual meeting of the British Orthopaedic Association (Liverpool, September 2015), Heraeus Medical sponsored a satellite symposium to discuss “Infection in the high-risk arthroplasty patient”.
“We need to reduce arthroplasty revisions as a quality measure,” commented Mike Reed, consultant trauma and orthopaedic surgeon at Northumbria NHS Healthcare Foundation Trust, who spoke at the symposium. Mr Reed presented recent data from the National Joint Registry (NJR) of England, Wales and Northern Ireland (the largest arthroplasty registry worldwide) supporting the efficacy of antibiotic-loaded bone cements in the prevention of revision surgery. The data, spanning 2004–2015, comprised 717,339 cemented total knee and 421,604 cemented total hip arthroplasty procedures. Of those, 47 per cent and 59 per cent of primary hip and knee arthroplasties respectively were performed using PALACOS® R+G. Results showed a statistically significant reduction in the number of both hip and knee arthroplasty revisions when using antibiotic-loaded bone cement, specifically PALACOS® R+G, as compared to other bone cements.
Reed set up a randomised trial of 848 patients undergoing hip hemi-arthroplasties; a good proxy for high-risk arthroplasty patients due to the high infection rate observed in hip hemi-arthroplasty patients. Patients receiving high dose dual antibiotic cement (COPAL® G+C, containing gentamicin and clindamycin; Heraeus Medical) had significantly reduced surgical site infection rate compared to those receiving standard antibiotic-loaded cement. Mr Reed discussed how, in his institution, all lower limb joint replacements are carried out using antibiotic-loaded cement, using high dose dual antibiotic cement for patients with a hip fracture requiring joint replacement. Commenting on whether cost may be an issue, Reed said: “We’ve done a significant cost analysis and it shows that even though high dose dual antibiotic cement is more expensive, the cost to the hospital and the NHS is reduced, because of the infections prevented.”
Analysis of long-term data is vital to prove differences in outcomes with orthopaedic devices and techniques. The NJR data are consistent with reports from other joint registries, including the Norwegian Arthroplasty Register and the Swedish National Hip Arthroplasty Register, which demonstrate that PALACOS® (R+G) displays the lowest risk of an implant failure among all bone cements analysed.
To review the respective valid reports of the NJR Implant Summaries, please visit the Heraeus Medical website, www.herae.us/njr-data