Prosthetic joint infection (PJI) is a well-documented complication of total joint arthroplasty that imposes a significant morbidity and mortality burden on the person, as well as a cost to the healthcare system.
In the context of an aging population, where demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA) is expected to increase by 174% and 673%, respectively, by 2030, the burden of PJI is predicted to rise.
Pulsed lavage with 0.9% saline (PSL) is a widely used approach for PJI prevention [12]. PSL has shown significant success in lowering surgical site infection rates across different surgical subspecialties, compared to the previous usage of bulb syringe or gravity lavage . While the volume utilized in PSL varies based on the anatomy of interest and surgeon choice, a few studies show that 4 liters is ideal for TKA [20,21], but no particular volume recommendations exist for PJI.
At a cost of $38.28, an initial infection rate of 1.10% for TKA and 1.63% for THA, and a revision cost of $32,132 for TKA and $39,713 for THA, PSL would be cost-effective at an ARR of 0.12% for TKA and 0.10% for THA (Table 1). To be economically viable under these conditions, the protocol would need to prevent 1 case of PJI requiring revision of the 839 patients undergoing TKA and 1037 patients undergoing THA (Table 1). At the hypothetical most inexpensive cost of $20.00, to be cost-effective, the ARR would be 0.06% and 0.05% with a NNT of 1607 and 1986 for TKA and THA, respectively, (Table 1). At hypothetical upper limit of $150.00 for implementing PSL, the ARR required for cost-effectiveness would be 0.47% and 0.38% with NNTs of 214 and 265 for TKA and THA, respectively, (Table 1).
Pulsed lavage with 0.9% saline has been shown to be a safe and effective treatment, with some studies indicating that it outperforms normal bulb syringe or gravity lavage in terms of tissue and implant penetration, as well as infection prevention [12,[33], [34], [35]]. Several research in orthopedics have demonstrated the efficacy of PSL. In a prospective randomized trial of hip hemiarthroplasty for femoral neck fractures, a 2-liter PSL had a total infection rate of 5.5%, compared to 15.6% for a 2-liter normal-saline gravity or bulb syringe lavage (P =.002) [15]. In two investigations on spinal fusion procedures, the infection rate of PSL compared to bulb syringe lavage was 1.6% vs 10.1% (P =.046) and 2.5% vs 20% (P <.001). [13,14].
This break-even analysis shows that pulsed lavage with 0.9% saline is very cost-effective in preventing PJI after TJAs.
