While pre-soaking grafts in vancomycin has demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. The primary aim of this study was to determine the cost-effectiveness of vancomycin pre-soaking during primary ACLR to prevent post-operative joint infections. The secondary aims of the study were to establish the breakeven cost-effectiveness threshold of the technique. A Markov model was used to determine cost effectiveness and the incremental cost effectiveness ratio of additional vancomycin pre-soaking compared to intravenous antibiotic prophylaxis alone. A repeated meta-analysis of nine cohort studies (Level III evidence) was completed to determine the odds ratio of infection with vancomycin pre-soaking compared to intravenous antibiotics alone. Estimated costs and transitional probabilities for further surgery were obtained from the literature. Breakeven threshold analysis was performed. The vancomycin soaking technique provides an expected cost saving of $600AUD per patient. There was an improvement in the quality-adjusted life years of 0.007 compared to intravenous antibiotic prophylaxis alone (4.297 versus 4.290). If the infection rate is below 0.023% with intravenous antibiotics alone or the additional intervention cost more than $1000AUD, the vancomycin wrap would no longer be cost-effective. For $30AUD, the vancomycin soaking technique provides a $600AUD cost saving by both reducing the risk of ACLR related infection and economic burden of infection. Treating septic arthritis represents a mean cost per patient of 6 times compared to that of the primary surgery. There has been no previous cost-effectiveness study of the vancomycin wrap technique. The vancomycin pre-soaking technique is a highly cost-effective method to prevent post-operative septic arthritis following primary ACLR

There is ongoing debate regarding the optimal surgical treatment of complex proximal humeral fractures in elderly patients. The aim of this study was to evaluate the cost-effectiveness of reverse total shoulder arthroplasty (RTSA) compared to hemiarthroplasty (HA) in the management of these fractures. A cost–utility analysis using decision tree and Markov modelling based on data from the published literature was conducted. A single-payer perspective with a lifetime time horizon was adopted. A willingness to pay threshold of CAD $50,000 was used. The incremental cost-effectiveness ratio (ICER) was used as the study's primary outcome measure. In comparison to HA, the incremental cost per QALY gained for RTSA was $13,679. One-way sensitivity analysis revealed the model to be sensitive to the RTSA implant cost and the RTSA procedural costs. Two-way sensitivity analysis suggested RTSA could also be cost-effective within the first two years of surgery with an early complication rate as high as 25% (if RTSA implant cost was approximately $3,000); or conversely, RTSA implant cost could be as high as $8,500 if its early complication rates were 5%. The ICER of $13,679 is well below the WTP threshold of $50,000 and probabilistic sensitivity analysis demonstrated that 92.6% of model simulations favoured RTSA. Our economic analysis found that RTSA for the treatment of complex proximal humeral fractures in the elderly is the preferred economic strategy when compared to HA. The ICER of RTSA is well-below standard willingness to pay thresholds, and its estimate of cost-effectiveness is similar to other highly successful orthopaedic strategies such as total hip arthroplasty for the treatment of hip arthritis

Patient-specific instruments for total knee arthroplasty shift the bone landmark registration and implant positioning of computer navigation from intraoperative to the pre-operative setting. A preoperative MRI or CT scan is mandatory, with the specifications determined by the instrument manufacturer. Default implant sizing and alignment targets must be templated by the surgeon and mapped onto the virtual knee. The surgeon must also review and modify the preoperative computer plan to incorporate any clinical findings, such as flexion contracture or fixed deformity. The finalised preoperative plan is sent back to the implant vendor for fabrication of patient-specific cutting blocks in 4–6 weeks. The supposed advantages of these instruments include more accurate coronal alignment, fewer outliers, no instrumentation of intramedullary canal, decreased operative time, and decreased hospital costs to clean-sterilise instruments. There are many disadvantages of patient-specific instruments, including: cost, preoperative scheduling of imaging, the learning curve for the surgeon, and the uncalculated preoperative planning time. A set of conventional instruments should be available if the custom instruments do not fit properly. One study of 66 knees using PSI reported that frequent surgeon-directed changes were required, 2.4 per knee, implant sizes were changed in 77% of femurs and 53% of tibias, and tourniquet time was not improved. A Markov model study reported an increased cost of $4600 for 4.6 QALYs for patient-specific instruments and that the rate of revision must be reduced by 50% or more for these instruments to be cost-effective. There is little evidence to support the claims made by the manufacturers of these instruments. We advise against the widespread use of these instruments for total knee arthroplasty

Purpose. Patellofemoral arthroplasty (PFA) has experienced significant improvements in implant survivorship with second-generation designs. This has renewed interest in PFA as an alternative to total knee arthroplasty (TKA) for younger, active patients with isolated patellofemoral osteoarthritis (PF OA). The decision to select PFA over TKA balances the clinical benefits of sparing healthy knee compartments and ligaments against the risk of downstream conversion arthroplasty. We analyzed the cost-effectiveness of PFA versus TKA for the surgical management of isolated PF OA. Methods. We used a Markov transition-state model (Figure 1) to compare cost-effectiveness between PFA and TKA. Cohorts were aged 60 (base case) and 50 years. Lifetime costs (2015 USD), quality-adjusted life year (QALY) gains and incremental cost-effectiveness ratio (ICER) were calculated from a healthcare payer perspective. Annual revision rates were derived from the United Kingdom National Joint Registry and validated against the highest quality literature available. Deterministic and probabilistic sensitivity analysis was performed for all parameters against a $50,000/QALY willingness-to-pay. Results for the 50 year-old cohort were similar to those of the base case simulation. Results. PFA was more expensive ($49,811 versus $46,632) but more effective (14.3 QALYs versus 13.3 QALYs) over a lifetime horizon (Figures 2 and 3). The ICER associated with the additional effectiveness of PFA was $3,097. The model was mainly sensitive to utility values and implant survivorship, with PFA remaining cost-effective provided that its utility exceeds that of TKA by at least 1.0%. PFA achieved dominance (lower cost and higher utility) at an annual revision rate of 1.63%, representing a 24.5% decrease from baseline. The results were not sensitive to costs of rehabilitation, perioperative complications or inpatient hospitalization. Multivariate probabilistic sensitivity analysis showed PFA to be cost-effective from a healthcare payer perspective in 96.2% of simulations. Conclusions. Recent improvements in implant survivorship rates makes PFA an economically beneficial joint-preserving procedure in younger patients, potentially delaying TKA until implant failure or tibiofemoral OA progression. The present study quantifies the minimum required marginal benefit for PFA to be cost-effective compared to TKA (1.0%) and identifies survivorship targets for PFA to become both less expensive and more effective. These cost-effectiveness benchmarks may be used to assess clinical outcomes of PFA from an economic standpoint within the United States healthcare system as updated clinical data becomes available. For any figures or tables, please contact the authors directly