Aims

Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

Aims

The aim of this study was to perform the first population-based description of the epidemiological and health economic burden of fracture-related infection (FRI).

Prosthetic joint infections (PJI) are one of the most devastating complications of joint replacement surgery. They are associated with significant patient morbidity and carry a significant economic cost to treat. The management of PJI varies from antibiotic suppression, debridement, antibiotics, and implant retention (DAIR) procedures through to single/multiple stage revision procedures. Concerns have been raised recently in relation to the rising number of revision arthroplasty procedures that are being undertaken in relation to infection. This database aims to collect data on all PJIs that have been managed in the Australian Capital Territory (ACT) region. This will allow us to investigate the microbial trends, outcomes of surgical intervention and patient outcomes within our local population. This database will incorporate diagnostic, demographic, microbiological and treatment information in relation to local PJI cases. The data will be collated from the local infectious diseases database, hospital medical records, and where available the Australian Orthopaedic Association National Joint Replacement Registry Data. The first 100 cases of PJI were assessed. 76% were defined as being acute. 56% of the patients received antibiotics prior to their diagnosis however only 3% were culture negative. 89% were monomicrobial and 11% polymicrobial. The intended management strategy was a DAIR in 38% of patients and a 2-stage revision in 12% of cases. The intended management strategy was successful in 46% of the patients. The ACT is uniquely placed to analyze and create a local PJI database. This will allow us to guide further treatment and local guidelines in terms of management of these complex patients

Aims

The aim of this study was to investigate the relationship between the Orthopaedic Trauma Society (OTS) classification of open fractures and economic costs.

Aims

Minimally manipulated cells, such as autologous bone marrow concentrates (BMC), have been investigated in orthopaedics as both a primary therapeutic and augmentation to existing restoration procedures. However, the efficacy of BMC in combination with tissue engineering is still unclear. In this study, we aimed to determine whether the addition of BMC to an osteochondral scaffold is safe and can improve the repair of large osteochondral defects when compared to the scaffold alone.

Osteoarthritis (OA) is one of the most common causes of knee pain in the aging population and presents with higher odds with increased BMI. Total knee arthroplasty (TKA) has become the standard of care for the treatment of OA. Over “719,000 TKA's were performed in 2010 in the USA alone, with dramatic economic burden- costing 16,000 USD per TKA” (CDC 2012). Over the past two decades, this cost was compounded by the unknown increasing rate of primary TKA and cannot be explained by the expanding population or worldwide obesity epidemic. These facts raise two key questions: are patients' quality of life expectations higher and driving the TKA rate up, or have surgeons changed their indications and started to operate on less disabled people? Our study aimed to determine the average functional profile for patients undergoing TKA using patient reported Outcome Measure (SF-36), to document if preoperative SF-36 scores have changed over the past two decades, and lastly to asses if patient pre-operative SF-36 scores are lower in in the USA vs the rest of the world. A literature search of Medline, Embase and Cochrane databases was performed extracting data from publishing year 1966 to 2016 with a search date of Dec 12, 2016. Two independent reviewers revised the abstracts and excluded articles with: no TKA, revision TKA, no pre-op SF-36, no SF-36 reported, incomplete scores to calculate SF-36, duplicates, review article, meta-analysis, letter to the editor, conference proceeding or abstract, disagreements were resolved with a third reviewer. All languages were included to maximize the catchment of data. All remaining articles were independently read and excluded if they did not provide data required for our study. Included articles were analyzed for data including: for year of patient enrollment, location (USA vs. non-USA), pre-operative SF-36 mental (MCS) and physical (PCS) component summary, level of evidence. Recorded data was compared post completion to assess inter-observer accuracy as per PRISMA guidelines for meta-analysis. After applying all the exclusion criteria on 923 selected abstracts, a total of 136 articles of which 30 were randomized control trials, were completely reviewed and included in our study. A total of 56,713 patients' physical component scores were analyzed and revealed an overall pre-operative SF-36 physical component score 31.93. When stratifying the data, it was revealed that patients operated in the USA had an average score of 32.3 whereas Non-US countries were 31.7, with no statistical significance. No statistical difference between SF36 scores was seen over time amongst studies of all nations. Based on the results of this study, we have shown that orthopaedic surgeons are performing TKA universally at the same pre-operative scores, independent of country of origin or year of surgery. The indications thus have remained consistent for two decades regardless of the advances in technology. Functional profiles of patients appear similar among US and Non-US countries. Further, we infer that based on pre-operative SF-36 PCS scores, the optimal time to undergo a TKA is when PCS is 31.9 +/−3

Aims

The primary aim of the study was to perform an analysis to identify the cost per quality-adjusted life-year (QALY) of robot-assisted unicompartmental knee arthroplasty (rUKA) relative to manual total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) for patients with isolated medial compartment osteoarthritis (OA) of the knee. Secondary aims were to assess how case volume and length of hospital stay influenced the relative cost per QALY.

Aims

The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR).

Periprosthetic infection involving TKR has been projected to rise as the burden of implanted TKR continues to grow. A study by Kurtz et al. found a significant increase in the annual incidence of TKR infection, 2001 (2.05%) to 2.18% in 2009. Thus, deep prosthetic infection around a TKR remains a significant problem that has not been solved, even as technologies improve and the operation is more commonly performed. The economic hospital cost of periprosthetic TKR infection is approximately $100,000 US for a two-stage removal and reimplantation; by the year 2020, it is estimated that 48,000 of these operations will be necessary. The total annual hospital cost for PJI treatment is expected to be over $1 billion by 2020, and does not include the doctor, pharmacologic, and physical therapy fees. Many factors have been found to be associated with an increased risk of PJI. This lecture will focus upon the peri-, intra-, and post-operative factors that have been found historically to carry an increased or decreased risk of infection. Preoperative factors that have been found to affect the risk of infection include: perioperative administration of intravenous antibiotics, patient nutrition, weight, and hemoglobin A1C in diabetic patients. Intraoperative factors include the duration of surgery, the use of antibiotic impregnated cement, and the use of dilute povidone/iodine solution irrigation. Postoperatively, wound care with antimicrobial agents, and a resistance to transfusing blood seem to lower the risk of infection. Yang et al. found that diabetes mellitus carried a 1.6x greater risk of TKR infection, in a meta-analysis of 11 cohort studies. In a registry study of over 32,000 TKA, increasing BMI from 25 kg/m2 to 35 kg/m2 was found to be associated with a greater risk of wound infection in TKR patients, increasing from 3 to 4.1%. Preoperative colonization with MRSA has been found by several investigators to be a risk for surgical site infection, despite attempts at eradication. Operatively, a wash of the surgical site for 3 minutes with a dilute solution of betadine has been found by Brown et al. to have decreased the incidence of periprosthetic joint infection from 0.97% to 0.15%. Postoperatively, the type of dressing placed over the incision may play a role; Grosso et al. found a significantly reduced rate of PJI (0.33% vs. 1.58%) when a silver impregnated, antimicrobial, dressing was used as compared to standard xeroform gauze. Finally, patients who received an allogeneic blood transfusion were found to have a higher risk of PJI (1.67%) than those who did not (0.72%)

Osteoarthritis (OA) of the spine and diarthrodial joints is by far the most common cause of chronic disability in people over 50 years of age. The disease has a striking impact on quality of life and represents an enormous societal and economic cost, a burden that will increase greatly as populations age. OA is a complex condition with broad pathology. Damage to the articular cartilage is a consistent feature, accompanied by changes to the subchondral bone and synovium. Progression of the disease involves further degeneration of the articular cartilage, damage to the underlying bone and morphological changes that include subchondral bone thickening, development of cysts, osteophytes and inflammation of the synovium. Enhanced production of proinflammatory cytokines and matrix metalloproteinases accelerates degradation of the articular cartilage. It is striking that no approved pharmacological intervention, biological therapy or procedure prevents the progressive destruction of the OA joint. All current treatments, without exception, produce symptomatic rather than regenerative results. While there have been some exciting developments in the search for OA treatments in the last decade, including matrix metalloproteinase inhibitors, anti-TNF and anti-IL1 drugs for example, none of these has to date emerged as an effective medicinal product. There is thus an urgent and compelling need to identify, validate and test new biological therapeutics. Stromal cell therapy represents one such compelling approach. The results from several early clinical studies have indicated that this approach holds a great deal of promise for the treatment of OA. Most studies have involved direct intraarticular injection of a suspension of mesenchymal stromal cells (MSCs) for treatment of knee OA. Results from a number of controlled patient studies have suggested that this treatment results in an effective repair response. Although data regarding mechanism of action are limited, it appears that the cells have an anti-inflammatory effect, possibly targeting cells within the synovium, rather than a direct cartilage repair effect. Several recent reports have highlighted a dramatic and sustained response in patients receiving MSC treatment. For example, allogeneic expanded adipose-derived MSCs have been shown to be safe and effective in the treatment of complex perianal fistulas in Crohn's disease. Also, allogeneic bone marrow-derived MSCs has a been shown to have a positive effect in pediatric acute graft versus host disease. These observations point to a mechanism of action that involves host immunomodulation, but this needs further examination. Within the field of musculoskeletal disease effective translation of MSC technology has been hindered by a lack of randomized controlled patient studies, severe inconsistencies regarding the preparation and characterization of the cell product, and an incomplete understanding of the therapeutic mechanism. Direct to consumer clinics have flourished in some countries, providing cell treatments to OA patients. Most or all of these utilize unexpanded cell fractions from marrow or fat without even rudimentary product characterization and may report an exaggerated clinical outcome. Data from these clinics is not likely to yield information that will be useful. In fact, a recent systemic review of clinical trials involving MSC treatment in OA indicated that only a limited number of studies provided high quality evidence and long term follow up. Many suffered from a lack of consistency, including a diversity of methods for MSC preparation, and thus did not contribute to a supporting evidence base. There is a compelling need to provide clear and unambiguous clinical proof of concept relating to MSC treatment for OA. The ADIPOA2 study, currently active in Europe, will go some way towards achieving this. This is a 150 patient, phase 2b study designed to to assess the efficacy of a single injection of autologous adipose-derived MSCs in the treatment of mild to moderate OA of the knee, active and unresponsive to conservative therapy for at least 12 months

Aims

The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb.

Aims

To compare the early management and mortality of older patients sustaining major orthopaedic trauma with that of a younger population with similar injuries.

Chronic osteomyelitis is a challenging problem and a growing burden for the National Health Service. Conventional method of treatment is 2 stage surgery, with debridement and prolonged courses of antibiotics. Recently single stage treatment of chronic osteomyelitis is gaining popularity due decreased patient morbidity and cost effectiveness. Dead space management in single stage treatment is accomplished by either a muscle / myocutaneous or antibiotic loaded calcium sulphate beads. We analysed the cost effectiveness of two dead space management strategies in single stage treatment of osteomyelitis. Study is designed to analyse the health economics at 2 time points; 45 days post surgery and 2 years post surgery. We report preliminary results at 45 days post surgery. Setting – Level 1 trauma centre and university hospital. Approval – Ethics committee approved study. 10 patients in each group were retrospectively analysed through patient records. Each group was identified for standard demographics, duration of procedure, hospital stay, type and duration of postoperative antibiotics, number of out patient visits in first 45 days and recurrence of infection. Table attached details the results of both groups. In health technology assessment four quadrant model, CSB appears in quadrant II suggesting that it is more cost effective. Based on small data set and on assessment only evaluating cost, at 45 days assessment, antibiotic calcium sulphate beads from a Health Economic Cost Effectiveness Analysis offers a better economic outcome. This is holding constant the morbidity of the patients and effectiveness, assuming both treatments are standards of care, which is best evaluated at 24 months. Acknowledgements. Biocomposites for funding the cost of health economist

The December 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Vitamin E infusion helpful in polyethylene; Hip replacement in fracture and arthritis; Non-surgical treatment for arthritis; Cost and approach in hip surgery; Who does well in FAI surgery?; AAOS Thromboembolism guidelines; Thromboprophylaxis and periprosthetic joint infection; Fluid collections not limited to metal-on-metal THR