The cost-effectiveness of an additional surgical scrub in reducing prosthetic joint infections in total hip and knee arthroplasty

Cooper Tye; Jad Lawand; Vincent Moretti

doi:10.18203/issn.2455-4510.IntJResOrthop20241696

Authors

Cooper Tye Department of Orthopaedic Surgery, John Peter Smith Hospital, Ft. Worth, TX, USA
Jad Lawand University of Texas Medical Branch, School of Medicine, Galveston, TX, USA
Vincent Moretti Department of Orthopaedic Surgery, John Peter Smith Hospital, Ft. Worth, TX, USA

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20241696

Keywords:

Total hip arthroplasty, Total knee arthroplasty, PJI, Revision arthroplasty, Cost-effectiveness

Abstract

Background: Surgical skin preparation prior to total knee and hip arthroplasty is an important step in infection prevention. Compared to a single application, repeat skin preparation after draping demonstrates greater efficacy in reducing the overall occurrence of surgical site infections in total joint arthroplasty. We sought to find if the addition of an extra surgical scrub after draping is a cost-effective means of decreasing prosthetic joint infection (PJI), and if so, under what conditions it would be most cost-effective.

Methods: We employed a model to assess the cost-effectiveness of repeat skin preparation in total knee and hip arthroplasty. This model determines a threshold at which the expenses associated with a new intervention is offset by its ability to reduce overall costs. Literature review and records from our institution were used to draw average expenses for treatment of PJI, as well as surgical prep scrubs, to evaluate at their cost-effectiveness. We also compared against hypothetical higher and lower costs and infection rates to gain further information on the additional surgical prep’s cost-effectiveness.

Results: Each of the surgical scrubs is cost-effective at our institution's cost when an absolute risk reduction (ARR) of 0.01% is achieved. The cost-effectiveness was also noted with hypothetically higher infection rates and scrub cost prices. Lower potential two-stage revision costs make the additional surgical scrub less cost-effective.

Conclusions: Our findings demonstrate that an extra surgical scrub can be cost-effective way of decreasing PJI across a variety of different surgical scrub prices, arthroplasty revision costs, and PJI rates.

Metrics

Metrics Loading ...

References

Wallace IJ, Worthington S, Felson DT, Robert DJ, Kimberly TW, Heli M, et al. Knee osteoarthritis has doubled in prevalence since the mid-20th century. Proc Natl Acad Sci U S A. 2017;114(35):9332-6.

Prieto-Alhambra D, Judge A, Javaid MK, Cooper C, Diez-Perez A, Arden NK. Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis: influences of age, gender and osteoarthritis affecting other joints. Ann Rheum Dis. 2014;73(9):1659-64.

Zhan C, Kaczmarek R, Loyo-Berrios N, Sangl J, Bright RA. Incidence and short-term outcomes of primary and revision hip replacement in the United States. J Bone Joint Surg Am. 2007;89(3):526-33.

Shichman I, Roof M, Askew N, Leo N, Joshua CR, Thorsten MS, et al. Projections and Epidemiology of Primary Hip and Knee Arthroplasty in Medicare Patients to 2040-2060. JBJS Open Access. 2023;8(1):e22.00112.

Springer BD, Cahue S, Etkin CD, Lewallen DG, McGrory BJ. Infection burden in total hip and knee arthroplasties: an international registry-based perspective. Arthroplast Today. 2017;3(2):137-40.

Natsuhara KM, Shelton TJ, Meehan JP, Lum ZC. Mortality During Total Hip Periprosthetic Joint Infection. J Arthroplasty. 2019;34(7S):S337-42.

Pansu N, Hamoui M, Manna F. Implant retention and high rate of treatment failure in hematogenous acute knee and hip prosthetic joint infections. Med Mal Infect. 2020;50(8):702-8.

Guren E, Figved W, Frihagen F, Watne LO, Westberg M. Prosthetic joint infection-a devastating complication of hemiarthroplasty for hip fracture. Acta Orthop. 2017;88(4):383-9.

Kurtz SM, Lau E, Watson H, Schmier JK, Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27(8):61-5.

Bozic KJ, Kurtz SM, Lau E, Kevin O, Vanessa C, Thomas PV, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468(1):45-51.

Fairclough JA, Johnson D, Mackie I. The prevention of wound contamination by skin organisms by the pre-operative application of an iodophor impregnated plastic adhesive drape. J Int Med Res. 1986;14(2):105-109.

Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Bacteria isolated from deep joint sepsis after operation for total hip or knee replacement and the sources of the infections with Staphylococcus aureus. J Hosp Infect. 1983;4(1):19-29.

Zywiel MG, Daley JA, Delanois RE, Naziri Q, Johnson AJ, Mont MA. Advance pre-operative chlorhexidine reduces the incidence of surgical site infections in knee arthroplasty. Int Orthop. 2011;35(7):1001-6.

Morrison TN, Chen AF, Taneja M, Küçükdurmaz F, Rothman RH, Parvizi J. Single vs Repeat Surgical Skin Preparations for Reducing Surgical Site Infection After Total Joint Arthroplasty: A Prospective, Randomized, Double-Blinded Study. J Arthroplasty. 2016;31(6):1289-94.

Hatch MD, Daniels SD, Glerum KM, Higgins LD. The cost effectiveness of vancomycin for preventing infections after shoulder arthroplasty: a break-even analysis. J Shoulder Elbow Surg. 2017;26(3):472-7.

Kurtz SM, Ong KL, Lau E, Bozic KJ, Berry D, Parvizi J. Prosthetic joint infection risk after TKA in the Medicare population. Clin Orthop Relat Res. 2010;468(1):52-6.

Pulido L, Ghanem E, Joshi A, Purtill JJ, Parvizi J. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res. 2008;466(7):1710-5.

Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty. 2008;23(7):984-91.

Ahmed SS, Haddad FS. Prosthetic joint infection. Bone Joint Res. 2019;8(11):570-72.

Urquhart DM, Hanna FS, Brennan SL, Anita EW, Karin L, Peter AC, et al. Incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. J Arthroplasty. 2010;25(8):1216-22.

Yao JJ, Hevesi M, Visscher SL, Jeanine ER, David GL, Daniel JB, et al. Direct Inpatient Medical Costs of Operative Treatment of Periprosthetic Hip and Knee Infections Are Twofold Higher Than Those of Aseptic Revisions. J Bone Joint Surg Am. 2021;103(4):312-8.

Premkumar A, Kolin DA, Farley KX. Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States. J Arthroplasty. 2021;36(5):1484-9.

Bosko T, Hawkins C. Evolving Physician Reimbursement Structures: Moving the Medical Group to Value-Based Success. J Health Manag. 2016;61(3):176-80.

Kapadia BH, Zhou PL, Jauregui JJ, Mont MA. Does Preadmission Cutaneous Chlorhexidine Preparation Reduce Surgical Site Infections After Total Knee Arthroplasty? Clin Orthop Relat Res. 2016;474(7):1592-8.