Primary hip and knee joint replacements in Canada have been estimated to cost over $1.4 billion dollars annually, with revision surgery costing $177 million. The most common cause of revision arthroplasty surgery in Canada is infection. Periprosthetic joint infections (PJIs) are a devastating though preventable complication following arthroplasty. Though variably used, antibiotic laden bone cement (ALBC) has been demonstrated to decrease PJIs following primary total knee arthroplasty (TKA). Unfortunately, ALBC is costlier than regular bone cement (RBC). Therefore, the aim of this study was to determine if the routine use of ALBC in primary TKA surgery is a cost-effective practice from the perspective of the Canadian healthcare system. A decision tree was constructed using a decision analysis software (TreeAge Software, Williamstown, Massachusetts) to a two-year time horizon comparing primary TKA with either ALBC or RBC from the perspective of a single-payer healthcare system. All costs were in 2020 Canadian dollars. Health utilities were in the form of quality adjusted life years (QALYs). Model inputs for cost were derived from regional and national databases. Health utilities and probability parameters were derived from the latest literature. One-way deterministic sensitivity analysis was performed on all model parameters. The primary outcome of this analysis was an incremental cost-effectiveness ratio (ICER) with a willingness-to-pay (WTP) threshold of $50,000 per QALY. Primary TKA with ALBC (TKA-ALBC) was found to be more cost-effective compared to primary TKA with RBC (TKA-RBC). More specifically, TKA-ALBC dominated TKA-RBC as it was less costly on the long term ($11,160 vs. $11,118), while providing the same QALY (1.66). The ICER of this cost-utility analysis (CUA) was $-11,049.72 per QALY, much less than the WTP threshold of $50,000 per QALY. The model was sensitive to costs of ALBC-TKA as well as the probability of PJI following ALBC-TKA and RBC-TKA. ALBC ceased to be cost effective once the cost of ALBC was greater than $223.08 CAD per bag of cement. The routine use of ALBC in primary TKA is a cost-effective practice in the context of the Canadian healthcare system as long as the cost of ALBC is maintained at a reasonable price and the published studies to-date keep supporting the efficacy of ALBC in decreasing PJI following primary TKA. Further, this analysis is very conservative, and ALBC is likely much more cost-effective than presented. This is due to this model's revision surgery cost parameter being based on the average cost of all revision TKA surgery in Canada, regardless of etiology. Considering many PJIs require two-stage revisions, the cost parameter used in this analysis for revision surgery is an underestimate of true cost. Ultimately, this is the first cost-effectiveness study evaluating this topic from the perspective of the Canadian healthcare system and can inform future national guidelines on the subject matter

Introduction

Postoperative dislocation remains a vexing problem for patients and surgeons following total hip arthroplasty (THA). It is the commonest reason for revision THA in the US. Dual mobility (DM) THA implants markedly decrease the risk of THA instability. However, DM implants are more expensive than those used for conventional THA. The purpose of this study was to perform a cost-effectiveness analysis of DM implants compared to conventional bearing couples for unilateral primary THA using a computer model-based evaluation.

The optimal approach to arthroscopic repair of the rotator cuff is controversial, and both single row and double row fixation methods are commonly used. Which construct yields the highest efficacy is not clear. Given the current era of increasing costs in which health care delivery models are aiming for improved efficiencies and optimal outcomes, a cost-effectiveness study was performed to inform the decision making process of the utilisation of single versus double row repair. The purpose of this study was to evaluate the cost-effectiveness of single row versus double row constructs in patients undergoing arthroscopic rotator cuff repair. A cost-utility analysis was performed. Health resource use and outcome data were obtained from a previous prospective randomised controlled trial in which 90 patients were randomised to two treatment arms, single row rotator cuff repair (n=48) and double row (n=42). The patients were followed over a two-year span from the time of initial surgery. Unit cost data were captured using case costs collected from the hospital database and the Ontario Schedule of Benefits. Utility values were derived from published literature. The incremental cost effectiveness ratio (ICER), defined as the difference in cost between the two types of rotator cuff fixation divided by the difference in quality adjusted life years (QALY), was determined. Double row fixation was more costly ($2,279.94 versus $1,587.37) but was more effective than the single row method (QALY of 4.073 versus 4.055). An incremental cost-effectiveness ratio was estimated to be $38,504.92 per QALY for double row fixation relative to single row. This is well below the commonly used willingness to pay threshold of $50,000/QALY. Subgroup analysis demonstrated that patients with larger rotator cuff tears (>3cm) had a lower ICER, suggesting that double-row fixation may be more cost-effective in more severe tears. Double row rotator cuff fixation is a cost-effective option compared to single row rotator cuff repair with an ICER of $38,504.92/QALY, well within the accepted willingness to pay threshold of $50,000/QALY. Furthermore, the ICER between single and double row fixation improved with larger rotator cuff tears (>3cm), suggesting an additional benefit of a double row construct in those cases

Purpose. Using utilities and other outcome data collected prospectively on all SPRINT patients and cost data collected from a sample of SPRINT patients, we compared reamed and unreamed intramedullary nailing using a cost-utility analysis. Method. Participants completed the Health Utility Index 3 (HUI) questionnaire at two weeks after hospital discharge, and three, six, and 12 months post-surgery. We calculated quality adjusted life years (QALYs) for each patient for the first 12 months following intramedullary nailing. A convenience sample of 235 SPRINT patients with similar baseline characteristics provided data on healthcare resource utilization. Costs associated with the healthcare resource utilization were obtained from the 2008 Physicians Schedule of Benefits and a Case Costing System. Results. We found small, non-significant differences in QALYs for patients treated with reamed compared with unreamed intramedullary nails in both closed and open fractures: −0.017 (95% CI −0.021, 0.058) and −0.002 (95% CI −0.060, 0.062) respectively. The incremental costs for reamed compared with unreamed intramedullary nailing were $51 CAN (95% CI −$2,298, $2,400) in closed tibial fractures and $2,546 CAN (95% CI −$1,773, $6,864) in open tibial fractures. Conclusion. Considering point estimates only, reamed intramedullary nailing was less effective and more costly when compared to unreamed intramedullary nailing for both closed and open tibial fractures. Bootstrap simulations revealed that unreamed nailing was more likely to be cost-effective for both open and closed tibial fractures at all decision-making thresholds. Confidence intervals around both cost and utility estimates were wide and neither approached conventional levels of statistical significance