Aims. To establish the cost of primary hip (THR) and knee (TKR) arthroplasty in an elective orthopaedic centre in the UK and to compare it with current government reimbursement to NHS hospitals and the costs in North America. Methods. In 2004 an elective orthopaedic centre was set up in South West London which performs mainly primary lower limb arthroplasty. We used a retrospective analysis of financial statements from September 2004-June 2005 inclusive to establish operative costs (including implant), perioperative costs and post-operative costs until discharge. Results. A total of 691 THRs and 897 TKRs were performed during this period accounting for 76% of the workload. Average post-operative stay was 6.5 days for TKRs and 5.7 for THRs. Average cost for a TKR was £6651 and for a THR £5990. Costs are favourable compared with our American colleagues and similar to our Canadian colleagues. Reimbursement in the NHS was set up in 2003-4 by the DH in the form of national tariffs. Our costs are similar to these reimbursements. We question the ability of general NHS hospitals in the UK to perform at these levels and prices for three reasons. Firstly, our high volume of joint replacement activity has enabled us to negotiate the most favourable implant prices in the UK. Secondly, length of stay in our unit is approximately 60% of national average. Thirdly, our unit is run without many of the infrastructure costs of a general hospital as well as the cost incurred by training junior staff and research and development. Conclusion. Our elective-only orthopaedic centre provides a cost effective way of performing primary arthroplasty surgery while maintaining high standards of care and twenty-four hour intensive care cover. We believe this cost effectiveness may be unachievable in general NHS hospitals in the UK

Introduction. The number of revision hip arthroplasty procedures is rising annually with 7852 such operations performed in the UK in 2010. These are expensive procedures due to pre-operative investigation, surgical implants and instrumentation, protracted hospital stay, and pharmacological costs. There is a paucity of robust literature on the costs associated with the common indications for this surgery. Objective. We aim to quantify the cost of revision hip arthroplasty by indication and identify any short-fall in relation to the national tariff. Methods. Clinical, demographic and economic data were obtained for 305 consecutive revision total hip replacements in 286 patients performed at a tertiary referral centre between 1998 and 2008. These operations were categorised by indication into: aseptic loosening, dislocation, deep infection and peri-prosthetic fracture. Clinical data included length of stay, operative time, estimated blood loss, prosthesis and instrumentation required. Financial data was collected on cost of implants, materials and augmentation utilised at time of surgery, operating room costs, recovery, inpatient stay, physiotherapy, occupational therapy, pharmacy, radiographs and laboratory studies. Statistical analysis was undertaken using the SPSS version 16 (SPSS Inc. Chicago, Il). Non-parametric bootstrap samples were used to obtain consistent 95% confidence intervals. Analysis of variance between groups was performed (p < 0.05). Results. The mean total cost of revision surgery in aseptic cases (n=194) was £11897 +/− 4629, septic revision (n=76) £21937 +/− 10965, peri-prosthetic fractures (n=24) £18185 +/− 9124, and in dislocations (n=11) £10893 +/− 5476. Conclusion. Revision procedures for deep infection and peri-prosthetic fracture were associated with significantly longer operative time, increased blood loss and a higher number of complications compared with revisions for aseptic loosening. Total inpatient stay was also significantly greater p< 0.001. Our study shows that financial costs vary significantly between revision subtypes which is not reflected by current National Health Service tariff rates

To compare the costs of treatment and income received for treating patients with tibial osteomyelitis, comparing limb salvage with amputation. We derived direct hospital costs of care for ten consecutive patients treated with limb salvage procedures and five consecutive patients who underwent amputation, for tibial osteomyelitis. We recorded all factors which affect the cost of treatment. Financial data from the Patient-Level Information and Costing System (PLICS) allowed calculation of hospital costs and income received from payment under the UK National Tariff. Hospital payment is based on primary diagnosis, operation code, length of stay, patient co-morbidities and supplements for custom implants or external fixators. Our primary outcome measure was net income/loss for each in-patient episode. The mean age of patients undergoing limb salvage was 55 years (range 34–83 years) whereas for amputation this was 61 years (range 51–83 years). Both groups were similar in Cierny and Mader Staging, requirement for soft-tissue reconstruction, anaesthetic technique, diagnostics, drug administration and antibiotic therapy. In the limb salvage group, there were two infected non-unions requiring Ilizarov method and five free flaps. Mean hospital stay was 15 days (10–27). Mean direct cost of care was €16,718 and mean income was €9,105, resulting in an average net loss of €7,613 per patient. Patients undergoing segmental resection with Ilizarov bifocal reconstruction and those with the longest length of stay generated the greatest net loss. In the amputation group, there were 3 above knee and 2 below knee amputations for failed previous treatment of osteomyelitis or infected non-union. Mean hospital stay was 13 days (8–17). Mean direct cost of care was €18,441 and mean income was €15,707, resulting in an average net loss of €2,734 per patient. Length of stay was directly proportional to net loss. The UK National Tariff structure does not provide sufficient funding for treatment of osteomyelitis of the tibia by either reconstruction or amputation. Average income for a patient admitted for limb salvage is €6,602 less than that for amputation even though the surgery is frequently more technically demanding (often requiring complex bone reconstruction and free tissue transfer) and the length of hospital stay is longer. Although both are significantly loss-making, the net loss for limb salvage is more than double that for amputation. This makes treatment of tibial osteomyelitis in the UK National Health Service unsustainable in the long term

Independent sector treatment centres (ISTCs) were introduced in October 2003 in the United Kingdom in order to reduce waiting times for elective operations and to improve patient choice and experience. Many concerns have been voiced from several authorities over a number of issues related to these centres. One of these concerns was regarding the practice of ‘cherry-picking’. Trusts are paid according to ‘payment by results’ at national tariffs. The national tariff is an average of costs occurring in an average mix of patients. The assumption is that the higher the co-morbidities of the patients the more likely they are to consume a higher amount of resource and to require a longer length of stay. Cherry-picking may also affect the quality of training available to trainees. This audit was aimed at identifying if, and how much this practice occurs. It also identifies what affect this has on the case-load of patients left for the NHS hospitals. We looked at the number of co-morbidities amongst 198 consecutive patients undergoing hip and knee primary total arthroplasty at an ISTC, a district general hospital whose PCTs provide patient to the ISTC (Doncaster Royal Infirmary - DRI), and a district general hospital in the same area whose PCT did not provide choice at that time and who therefore did not send patients to the ISTC (Bassetlaw District General Hospital - BDGH). We found a statistically significant difference in the number of co-morbidities per patient at the ISTC compared with the DRI (1.23 vs. 2.05) and the ISTC compared with the BDGH (1.23 vs. 1.76). We were unable to show a statistically significant difference between the DRI and the BDGH. We conclude that cherry-picking does take place, and further work should be done to assess the impact on training and finance

Aims. The rate of dislocation when traditional single bearing implants are used in revision total hip arthroplasty (THA) has been reported to be between 8% and 10%. The use of dual mobility bearings can reduce this risk to between 0.5% and 2%. Dual mobility bearings are more expensive, and it is not clear if the additional clinical benefits constitute value for money for the payers. We aimed to estimate the cost-effectiveness of dual mobility compared with single bearings for patients undergoing revision THA. Methods. We developed a Markov model to estimate the expected cost and benefits of dual mobility compared with single bearing implants in patients undergoing revision THA. The rates of revision and further revision were calculated from the National Joint Registry of England and Wales, while rates of transition from one health state to another were estimated from the literature, and the data were stratified by sex and age. Implant and healthcare costs were estimated from local procurement prices and national tariffs. Quality-adjusted life-years (QALYs) were calculated using published utility estimates for patients undergoing THA. Results. At a minimum five-year follow-up, the use of dual mobility was cost-effective with an estimated incremental cost-effectiveness ratio (ICER) of between £3,006 and £18,745/QALY for patients aged < 55 years and between 64 and 75 years, respectively. For those aged > 75 years dual mobility was only cost-effective if the timeline was beyond seven years. The use of dual mobility bearings was cost-saving for patients aged < 75 years and cost-effective for those aged > 75 years if the time horizon was beyond ten years. Conclusion. The use of dual mobility bearings is cost-effective compared with single bearings in patients undergoing revision THA. The younger the patient is, the more likely it is that a dual mobility bearing can be more cost-effective and even cost-saving. The results are affected by the time horizon and cost of bearings for those aged > 75 years. For patients aged > 75 years, the surgeon must decide whether the use of a dual mobility bearing is a viable economic and clinical option. Cite this article: Bone Joint J 2020;102-B(9):1128–1135

Background. Prosthetic implants used in primary total hip replacements have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, metal-on-metal); head sizes (small <36mm, large 36mm+); and fixation techniques (cemented, uncemented, hybrid, reverse hybrid), which influence prosthesis survival, patient quality of life, and healthcare costs. This study compared the lifetime cost-effectiveness of implants to determine the optimal choice for patients of different age and gender profiles. Methods. In an economic decision Markov model, the probability that patients required one or more revision surgeries was estimated from analyses of UK and Swedish hip joint registries, for males and females aged <55, 55–64, 65–74, 75–84, and 85+ years. Implant and healthcare costs were estimated from hospital procurement prices, national tariffs, and the literature. Quality-adjusted life years were calculated using utility estimates, taken from Patient-Reported Outcome Measures data for hip procedures in the UK. Results. Optimal choices varied between traditionally used cemented metal-on-polyethylene and cemented ceramic-on-polyethylene implants. Small head cemented ceramic-on-polyethylene implants were optimal for males and females aged under 65. The optimal choice for adults aged 65 and older was small head cemented metal-on-polyethylene implants. Conclusions. The older the patient, the higher the probability that small head cemented metal-on-polyethylene implants are optimal. Small head cemented ceramic-on-polyethelyne implants are optimal for adults aged under 65. Our findings can influence NICE guidance, clinical practice, and commissioning of services. Funding. NIHR Research for Patient Benefit programme PB-PG-0613-31032

Background. The Arthroplasty Pain Experience (APEX) studies are two randomised controlled trials in primary total hip (THR) and knee replacement (TKR) at a large UK orthopaedics centre. APEX investigated the effect of local anaesthetic wound infiltration (LAI), administered before wound closure, in addition to standard analgesia, on pain severity at 12 months. This abstract reports results of the within-trial economic evaluations. Methods. Cost-effectiveness was assessed from the health and social care payer perspective in relation to quality adjusted life years (QALYs). Resource use was collected from hospital records and patient-completed postal questionnaires, and valued using unit cost estimates from local NHS Trust and national tariffs. Missing data were imputed using chained equations. Costs and outcomes were compared per trial arm and plotted in cost-effectiveness planes. The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves. One-way deterministic sensitivity analyses explored any methodological uncertainty. Results. In both trials, LAI was cost-saving and more effective than standard care. Using the £20,000 per QALY threshold, in THR, the INMB was £1,125 (95%BCI, £183 to £2,067) and the probability of being cost-effective was over 98%. In TKR, the INMB was £264 (95%BCI, −£710 to £1,238), with only 62% probability of being cost-effective. Considering an NHS perspective only, LAI was no longer dominant in THR, but still highly cost-effective, with an INMB of £961 (95%BCI, £50 to £1,873). Conclusions. Administering LAI is a cost-effective treatment option in THR and TKR surgeries. The evidence is stronger for THR, because of larger QALY gain. In TKR, there is more uncertainty around the economic result, and smaller QALY gains, but results point to LAI being cheaper than standard analgesia, which includes a femoral nerve block. Trial Registration. ISRCTN96095682, 29/04/2010. Funding. NIHR Programme Grant for Applied Research RP-PG-0407-10070

The present study was conducted to evaluate the cost of physiotherapy both for inpatient and outpatient services. Significant physiotherapy resources are required to rehabilitate patients with an Ilizarov or Taylor Spatial Frame (TSF). Within Hull and East Yorkshire Hospitals NHS Trust Physiotherapy department the average number of outpatient treatment sessions per routine patient is 6. In comparison, the average number of treatment sessions required for a patient with an ilizarov (or TSF) is 24 for a trauma patient and 33 for a patient undergoing an elective procedure. Seventy three (73) patients received physiotherapy treatment with an Ilizarov frame or a Taylor spatial frame between April 2008 and April 2010. Physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient (if the patient received their treatment within Hull and East Yorkshire NHS trust). Data collection was divided into either trauma or elective procedure for analytical purposes. The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an inpatient with an ilizarov frame is £121.82 per case (trauma) and £133.15 per case (elective). The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an outpatient for a trauma case was calculated as £404.65 and £521.41for an average elective case. This is in comparison to a routine patient costing the service £60.29 (when treated by a Band 7 physiotherapist). The present study gives valuable data for future business planning and assistance with the setting of local or national tariffs for the treatment of this patient group

Frozen shoulder is a common condition that affects the working population. The longevity and severity of symptoms often results in great economic burden to health services and absence from work. This prospective cohort study aimed to investigate whether early intervention with arthroscopic capsular release resulted in improvement of symptoms and any potential economic benefit to society. Patients were recruited prospectively. Data was gathered by way of questionnaire to ascertain demographics, previous primary care treatment and absence from work. Oxford Shoulder Score (OSS) was also calculated. Arthroscopic capsular release was performed and further data gathered at four week post-operative follow up. Economic impact of delay to treatment and cost of intervention was calculated using government data from the national tariff which costs different forms of treatment. Statistical analysis was then performed on the results. Twenty five patients enrolled. Mean pre-operative OSS: 37.4 (range 27–58, SD 7.4). Mean post-operative OSS: 15.9 (range 12–22, SD 2.3). P<0.01. Mean improvement in OSS: 21.5 (range 12–38, SD 7.1). The cost of non-operative treatment per patient was £3954. The cost of arthroscopic capsular release per patient was £1861, a difference of £2093. There were no complications. Arthroscopic capsular release improved shoulder function on OSS within four weeks. The cost of arthroscopic capsular release is significantly less than the cost of treating the patients non-operatively. Early surgical intervention may improve symptoms quickly and reduce economic burden of the disease. A randomised controlled trial comparing timings of intervention would further elucidate potential benefits

Aim: To investigate the magnitude of revenue lost by the Department of Trauma and Orthopaedics at Ports-mouth Hospitals NHS Trust in 2007 as a result of providing outpatient viscosupplementation joint injections. Methods: Data was collated on all outpatient intra-articular hyaluronic acid viscosupplementation performed by our department in 2007. Information on existing HRG tariffs for orthopaedic outpatient attendances as well as clinical coding of joint injections by our department was also gathered. Results: The 2007/2008 tariffs for orthopaedic outpatient first and follow-up appointments were £147 and £73 respectively for adults, and £157 and £85 respectively for children (under 17 years of age). No additional mandatory tariff currently exists for joint injections performed in the outpatient setting. During our study period, the cost of a dose of viscosuplementation (Hyaluronic acid 60mg/ 3 ml) varied between £213 and £248. A total of 812 doses of viscosupplementation were administered to outpatients by our department resulting in pharmaceutical costs of £175,126. Only 751 cases of outpatient appointment with joint injection (all types) were recorded and coded by the department. Conclusions:. As long as no mandatory DoH tariff exists for out-patient joint injections, outpatient viscosupplementation remains an expensive service for trusts to provide and may warrant rationalisation. Under Payment by Results it is imperative that the quality of data capture and clinical coding improve, if trusts are to maximise financial gains. Clinicians need to be made more aware of the processes and implications of Payment by Results. In order for trusts to receive fair remuneration it is essential that reasonable national tariffs be set for all types of procedure or service delivered

The introduction of new treatments needs to be both clinically effective and cost effective. Clinicians tend to be unaware of the importance of the latter, and how health economic assessments are undertaken, especially in a public health system where the inclusion of funded treatments is made on a national basis. The purpose of this study was to determine the cost savings from a societal perspective in the use of recombinant human Bone Morphogenetic Protein -2 (rhBMP-2) in grade III A and B open tibia fractures treated with a locked intramedullary nail and soft-tissue management in the UK, Germany, and France. Healthcare system (direct healthcare costs) and costs for productivity losses (indirect health-care costs) were calculated using the raw data from the Bone Morphogenetic Protein Evaluation Group in Surgery for Tibial Trauma “BESTT study”. Return-to-work time for estimation of productivity losses was assumed to correspond with the time of fracture healing. For calculation of secondary interventions costs and productivity losses the respective 2007/08 national tariffs for surgical procedures and average national wages for the UK, Germany, and France were used. From a societal perspective, overall savings per case of €7911 for the UK, €9270 for Germany, and €9291 were calculated. Those savings largely offset the upfront price of rhBMP-2 of €2266(£1,790) in the UK, €2970 in Germany, and €2950 in France. Total net savings can be estimated to be €9.6 million for the UK, €14.5 million for Germany, and €11.4 million for France. For all three countries reduced productivity losses are the key driver for the overall savings. In summary, despite the apparent high direct cost of rhBMP-2 in grade III A and B open tibia fractures, at a national level there are net cost-savings from a societal perspective for all three countries

Aims

The burden of revision total hip arthroplasty (rTHA) continues to grow. The surgery is complex and associated with significant costs. Regional rTHA networks have been proposed to improve outcomes and to reduce re-revisions, and therefore costs. The aim of this study was to accurately quantify the cost and reimbursement for a rTHA service, and to assess the financial impact of case complexity at a tertiary referral centre within the NHS.

Aim: Our aim was to determine the in-hospital costs of total hip replacement (THR) and total knee replacement (TKR), and compare them to their reimbursement under the national tariff system and to our North American colleagues. Methods: In 2004 an elective orthopaedic centre was set up in South West London which performs mainly primary lower limb arthroplasty. We used a retrospective analysis of financial statements from September 2004- December 2005 inclusive to establish operative costs (including implant), perioperative costs and post operative costs until discharge. Results: A consecutive series of 1538 primary TKR patients (mean age = 72.2) and 1118 primary THR patients (mean age = 70.8) was studied from September 2004 to December 2005 accounting for 88% of the workload. Average post operative stay was 6.5 days for TKRs and 5.7 for THRs and 66% of the patients were ASA grade III or over. The cost including implant of a THR was £6054, and for a TKR it was £6499. After adjustment to allow direct comparison to tariff, our THR cost is 2.3% less than and 1.0% more than the 2004/5 and 2005/6 tariffs respectively. Our adjusted TKR cost is 5.0 % and 4.2% less than the 2004/5 and 2005/6 tariffs respectively. Our cemented and uncemented THR costs are 8.0% less than and 6.6% more than their respective tariffs introduced for the first time in 2005/6. Overall there is no large discrepancy between our THR/TKR costs and tariff reimbursements. Discussion: Although in our unit our costs are similar to the re-imbursements used in the UK, we question the ability of general NHS hospitals in the UK to perform at these levels and prices for three reasons. Firstly, our high volume of joint replacement activity has enabled us to negotiate the most favourable implant prices in the UK. Secondly, length of stay in our unit is approximately 60% of national average. Thirdly, our unit is run without many of the infrastructure costs of a general hospital as well as the cost incurred by training junior staff and research and development. Costs were also found to be favourable compared with our American colleagues and similar to our Canadian colleagues. Conclusion: Our elective only orthopaedic centre provides a cost effect way of performing primary arthroplasty surgery while maintaining high standards of care and twenty-four hour intensive care cover. We believe this cost effectiveness may be unachievable in general NHS hospitals in the UK

Aims

The primary aim of this study is to quantify and compare outcomes following a dorsally displaced fracture of the distal radius in elderly patients (aged ≥ 65 years) who are managed conservatively versus with surgical fixation (open reduction and internal fixation). Secondary aims are to assess and compare upper limb-specific function, health-related quality of life, wrist pain, complications, grip strength, range of motion, radiological parameters, healthcare resource use, and cost-effectiveness between the groups.

Aims

To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA).

Aims

The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Aims

The purpose of this study was to evaluate the cost of reverse shoulder arthroplasty (RSA) for patients with a proximal humerus fracture, using time-driven activity based costing (TDABC), and to compare treatment costs with reimbursement under the Healthcare Resource Groups (HRGs).

Aims

The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers.

Objectives

To assess the clinical and cost-effectiveness of a virtual fracture clinic (VFC) model, and supplement the literature regarding this service as recommended by The National Institute for Health and Care Excellence (NICE) and the British Orthopaedic Association (BOA).