Cost-Effectiveness of Bone Cement With and Without Antibiotics: A Broader Perspective

Periprosthetic joint infections (PJIs) and periprosthetic femur fractures (PFFs) increase total costs of care. Retrospective registry/institutional studies with selection bias and underpowered meta-analyses have corrupted the evidence base regarding antibiotic-laden bone cement (ALBC) use in total knee arthroplasties (TKAs). Clinical practice guidelines (CPGs) recommend using cement fixation of femoral components in hip fracture patients to prevent PFFs, but have no recommendations regarding ALBC. Hip osteoarthritis CPGs have no bone cement recommendations regarding prevention of PJIs or PFFs. ALBC is potentially cost-effective by reducing PJIs, PFFs, and reducing implant costs. A systematic review was conducted to identify randomized controlled trials (RCTs), meta-analyses, and registry reports related to the efficacy of ALBC in reducing PJIs and cemented femoral fixation in reducing PFFs. Numbers needed to treat (NNT) are calculated. Cost-effectiveness margins per case are calculated. A pooled analysis of four TKA RCTs found ALBC reduces PJI by 0.94% (p=0.027), NNT 106. A total hip arthroplasty (THA) meta-analysis found ALBC reduces PJI by 0.58% (p<0.0001), NNT 172. A hip hemiarthroplasty (HH) RCT found high-dose dual-antibiotic ALBC reduces PJI by 2.35% (p=0.0474), NNT 43. A THA registry report found that cemented fixation compared to ingrowth fixation reduced PFFs by 0.44% (p<0.0001), NNT 229. A pooled analysis of three HH RCTs found that cemented femoral stem fixation reduced PFFs by 5.09% (p-0.0099), NNT 20. Mean PJI treatment costs are $80,000. Mean PFF treatment costs are $27,596. Mean HH cemented femoral stem cost reduction: $685. Using ALBC: TKA margin/case is $755; THA margin/case is $586; and HH margin/case is $3,925. Using plain bone cement: TKA margin/case is $0; THA margin/case is $121; and HH margin/case is $2,065. A broader perspective demonstrates that ALBC provides significant financial margins in TKAs, THAs, and hip hemiarthroplasties. ALBC is cost-effective when including the additional costs of using ALBC in TKAs, THAs, and hip hemiarthroplasties. Hand-mixed ALBC is more cost-effective than pre-mixed ALBC in all scenarios.