The manufacture of generic replicas of implants for arthroplasty of the hip and knee: is it regulated and will it save money?

Joint replacement of the hip and knee remain very satisfactory operations. They are, however, expensive. The actual manufacturing of the implant represents only 30% of the final cost, while sales and marketing represent 40%. Recently, the patents on many well established and successful implants have expired. Companies have started producing and distributing implants that purport to replicate existing implants with good long-term results. The aims of this paper are to assess the legality, the monitoring and cost saving implications of such generic implants. We also assess how this might affect the traditional orthopaedic implant companies. Cite this article: Bone Joint J 2016;98-B:892-900.

Cost of infection after surgery for intracapsular fracture of the femoral neck.

INTRODUCTION: We investigated the financial and human costs of postoperative infection for intracapsular fracture of the femoral neck at a district general hospital in the UK. METHODS: Data on postoperative infections after surgical treatment for intracapsular fracture of the femoral neck were collected prospectively from June 2005 to April 2009. Infected patients were pairwise-matched (1:2 ratio) with a non-infected group of patients from a database on hip fractures. Costs of additional surgery, duration of hospital stay, and opportunity costs were calculated using Primary Care Trust (PCT) tariffs and PCT-specific data. RESULTS: A total of 525 patients were treated with total hip replacement (n=110) or hip hemiarthroplasty (n=415). Seventeen patients (3.2%) were identified as having a surgical-site infection. Eight (1.5%) deep infections and nine (1.7%) superficial infections were documented. Compared with the non-infected group, duration of hospital stay and the prevalence of mortality doubled. Repeat surgery and the costs associated with hospital admission were increased significantly in the infected group. Mean financial loss associated with an infected patient was £7,726, whereas an uninfected patient brought £153 of profit to the hospital. When opportunity costs were considered, an infected patient represented £24,397 of lost income. CONCLUSIONS: Postoperative infection after surgical treatment for intracapsular fracture of the femoral neck has a significant negative impact on duration of hospital stay and financial costs, and demonstrates a trend towards an increase in the prevalence of mortality.

Cost savings of using a cemented total hip replacement: an analysis of the National Joint Registry data.

The debate whether to use cemented or uncemented components in primary total hip replacement (THR) has not yet been considered with reference to the cost implications to the National Health Service. We obtained the number of cemented and uncemented components implanted in 2009 from the National Joint Registry for England and Wales. The cost of each component was established. The initial financial saving if all were cemented was then calculated. Subsequently the five-year rates of revision for each type of component were reviewed and the predicted number of revisions at five years for the actual components used was compared with the predicted number of revisions for a cemented THR. This was then multiplied by the mean cost of revision surgery to provide an indication of the savings over the first five years if all primary THRs were cemented. The saving at primary THR was calculated to be £10 million with an additional saving during the first five years of between £5 million and £8.5 million. The use of cemented components in routine primary THR in the NHS as a whole can be justified on a financial level but we recognise individual patient factors must be considered when deciding which components to use.

Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis.

The rate and mode of early failure in 463 Birmingham hip resurfacings in a two-centre, multisurgeon series were examined. Of the 463 patients two have died and three were lost to follow-up. The mean radiological and clinical follow-up was for 43 months (6 to 90). We have revised 13 resurfacings (2.8%) including seven for pain, three for fracture, two for dislocation and another for sepsis. Of these, nine had macroscopic and histological evidence of metallosis. The survival at five years was 95.8% (95% confidence interval (CI) 94.1 to 96.8) for revision for all causes and 96.9% (95% CI 95.5 to 98.3) for metallosis. The rate of metallosis related revision was 3.1% at five years. Risk factors for metallosis were female gender, a small femoral component, a high abduction angle and obesity. We do not advocate the use of the Birmingham Hip resurfacing procedure in patients with these risk factors.

A novel system for the irrigation of open fractures.

It is accepted that a good washout of contaminated wounds with copious fluids reduces the rate of infection. We describe a simple method of rapidly irrigating wounds with high volumes of fluid.

The preoperative prevalence of deep vein thrombosis in patients with femoral neck fractures and delayed operation.

Out of 61 consecutive patients admitted for femoral neck fracture 21 patients had a delay to operation for more than 48 h from the time of injury. We studied these patients prospectively for the presence of deep-vein thrombosis (DVT). 13 (62%) had venographic evidence of thrombosis. All occurred in the broken limb. Five patients had bilateral thrombosis. The delay alone seems to be the major risk factor for thrombosis irrespective of age, fracture type, premorbid mobility and coexisting illness. The prevalence of preoperative DVT 48 h after injury approaches the reported postoperative incidence of DVT, which suggests that DVT will occur in a high proportion of patients regardless of treatment and prophylaxis. We recommend that those patients, in whom operation is delayed, should be routinely investigated for the presence of thrombosis preoperatively and a prophylactic vena cava filter should be considered when major deep vein thrombosis occurred.

Inner city gunshot wounds.

A retrospective survey was undertaken to establish the pattern and incidence of gunshot wounds seen at a South London hospital. Forty-two gunshot wounds were seen in 1993 and 1994. All the patients were under 39 years of age and 40 were male. All patients had low energy transfer injuries, having been shot with hand-guns (n = 36), seven of whom had multiple bullet or shotgun wounds (n = 6). Sixteen patients had head, neck or chest injuries, eight of whom died. Seven patients were wounded in the abdomen or pelvis and 31 had limb injuries. Thirty-six surviving patients had a total of 33 operations and a mean hospital stay of 7.65 days (range 0-105 days).

Blood transfusion in total hip replacement: is it always necessary?

Routine blood transfusion was prospectively withheld from 10 patients undergoing routine elective total hip arthroplasty who fulfilled specific criteria. A standard anaesthetic regimen was used. The mean perioperative fall in haemoglobin concentration was 1.9 g/dl, and only one patient required a postoperative blood transfusion. There were no postoperative complications. The need for routine peroperative blood transfusion of patients undergoing total hip arthroplasty is questioned.

Operating practices of and precautions taken by orthopaedic surgeons to avoid infection with HIV and hepatitis B virus during surgery.

OBJECTIVE: To assess the precautions being taken by orthopaedic surgeons to avoid becoming infected with HIV or hepatitis B virus by their patients during surgery. DESIGN: Pilot study of 50 surgeons selected at random followed by a postal questionnaire completed anonymously. SUBJECTS: All 1220 fellows and associates of the British Orthopaedic Association working in the United Kingdom. RESULTS: 800 (67%) Questionnaires were returned. 511 Surgeons has sustained a needlestick injury or had got body fluid in their eye within the past month despite 430 regularly wearing eye protection during major surgery. Seven had definitely and four possibly been infected with hepatitis B virus by a patient while operating, and 582 had been immunised against hepatitis B. Only 75 surgeons were satisfied with the present guidelines on testing patients for HIV antibodies. CONCLUSIONS: Although most surgeons who replied took some precautions when operating, most still exposed themselves to considerable risk from patients not known to be infected with HIV or hepatitis B virus.

Humeral rotation osteotomy for chronic posterior dislocation of the shoulder.

Delay in the diagnosis of posterior shoulder dislocation is common. We present two such cases treated satisfactorily by rotation osteotomy of the surgical neck of the humerus and discuss the indications for this procedure.

Thigh length versus knee length stockings in the prevention of deep vein thrombosis.

Above-knee graduated compression stockings are effective in preventing postoperative deep vein thrombosis, but are more expensive and less acceptable than below-knee stockings. One hundred and fourteen patients undergoing major abdominal surgery were randomly allocated to wear above-knee or below-knee graduated compression stockings. Deep vein thromboses were diagnosed by isotope uptake in three of 56 patients (5.4 per cent) in the above-knee group and one of 58 patients (1.7 per cent) in the below-knee group. These differences are not statistically significant. Results suggest that below-knee stockings are as effective as above-knee in the prevention of postoperative deep vein thrombosis.