Department of Orthopaedic Surgery, Tufts University Medical Center, Boston, Massachusetts, U.S.A.
Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A.
Arthroscopy. 2021 Oct;37(10):3152-3156. doi: 10.1016/j.arthro.2021.04.005. Epub 2021 Apr 19.
This study aimed to (1) determine whether intraoperative graft soaking with vancomycin is a cost-effective measure for preventing infection after arthroscopic anterior cruciate ligament (ACL) reconstruction and (2) provide an adaptable model for providers and institutions to determine the cost effectiveness of this strategy over a range of initial infection rates, infection-related care costs, and vancomycin costs.
Baseline postoperative infection rates and the costs of antibiotics and infection-related care were gathered from the literature. The cost of treating infection was determined for 2 alternative protocols-irrigation and debridement with revision ACL reconstruction or ACL graft retention. Using a break-even economic analysis, we developed an equation to determine the absolute risk reduction (ARR) in infection rate required for the use of vancomycin graft soaking to be deemed cost-effective. To provide a widely applicable robust model, multiple simulations were performed at varying unit costs, infection rates, and ACL reconstruction postoperative infection related care costs. The number needed to treat was calculated from the ARR.
Intraoperative vancomycin was determined to be cost-effective if it prevents 1 infection in 550 cases (ARR = 0.182%), given costs of $24,178 and $44/1,000 mg for revision ACL reconstruction and vancomycin, respectively. If the ACL graft is retained following infection, intraoperative vancomycin was considered cost-effective if it prevents 1 infection in 146 cases (ARR = 0.685%), given costs of $6,424 and $44/1,000 mg for arthroscopic debridement and vancomycin prophylaxis, respectively. For any specific cost of treating infection and cost of vancomycin, variation in baseline infection rates did not influence the economic viability of vancomycin graft soaking. This intervention remained economically viable over a wide range of unit costs of vancomycin.
Through break-even economic analysis, this study demonstrates that the use of intraoperative graft preparation with vancomycin is a highly cost-effective prophylactic measure for infection prevention in arthroscopic ACL reconstruction.
IV, economic analysis.
本研究旨在：（1）确定关节镜下前交叉韧带（ACL）重建术后术中关节内浸泡万古霉素是否是预防感染的一种具有成本效益的措施；（2）为提供者和机构提供一个适应性模型，以确定在一系列初始感染率、感染相关护理成本和万古霉素成本范围内，该策略的成本效益。
从文献中收集了基线术后感染率以及抗生素和感染相关护理的成本。确定了两种替代方案（冲洗和清创术伴 Revision ACL 重建或 ACL 移植物保留）治疗感染的成本。通过盈亏平衡经济分析，我们开发了一个方程，以确定使用万古霉素关节内浸泡以具有成本效益所需的感染率绝对风险降低（ARR）。为了提供一个广泛适用的稳健模型，在不同的单位成本、感染率和 ACL 重建术后感染相关护理成本下进行了多次模拟。从 ARR 计算出需要治疗的人数。
如果术中使用万古霉素可预防 550 例中的 1 例感染（ARR=0.182%），考虑到 Revision ACL 重建的成本为 24178 美元，万古霉素的单位成本为 44 美元/1000 毫克，则术中使用万古霉素具有成本效益。如果感染后保留 ACL 移植物，考虑到关节镜清创术和万古霉素预防的成本分别为 6424 美元和 44 美元/1000 毫克，如果术中使用万古霉素可预防 146 例感染（ARR=0.685%），则术中使用万古霉素具有成本效益。对于任何特定的感染治疗成本和万古霉素成本，基线感染率的变化都不会影响万古霉素关节内浸泡的经济可行性。在万古霉素单位成本的广泛范围内，这种干预措施仍然具有经济可行性。
通过盈亏平衡经济分析，本研究表明，关节镜 ACL 重建术中使用万古霉素进行关节内移植准备是一种预防感染的高度具有成本效益的措施。
IV，经济分析。
