Does Single Stage Surgery of Long Bone Infection Using Gentamicin-Eluting Bone-Graft Substitutes Result in Decreased Cost and Improved Quality of Life Compared to Traditional Approaches?

OBJECTIVES: To determine if single-stage protocols using absorbable gentamicin-eluting bone graft substitutes (gBGS) provide lower costs and improved quality of life compared to other strategies in the treatment of chronic osteomyelitis (cOM).

METHODS: A Markov microsimulation model compared healthcare costs and quality-adjusted life years (QALYs) of a cohort of 1 million hypothetical patients using monthly cycles. The model simulated individuals over a 2-year time horizon with health states of cOM (femur or tibia), wound cured/healed, of dead, amputation, or cured/non-union. Reinfection could place the individual back in the starting health state. The strategies of antibiotic-loaded polymethyl methacrylate (PMMA) beads plus SOC (standard of care) or other mainstream two-stage procedures were compared to gBGS plus SOC. Clinical data were provided through a review of published studies from 1990 through 2020. The perspective of the study was the third-party payer and costs were calculated in 2021 U.S dollars in the setting of hospitals, and hospital outpatient wound care provider-based departments (PBDs). One-way, multiple ways, and probabilistic sensitivity analyses were conducted to account for variable and parameter uncertainties.

RESULTS: In all scenarios, the gBGS strategy resulted in substantial cost savings and a very small increase in QALYs. One-way and multiple-way sensitivity analysis showed that cost-effectiveness was mostly influenced by changing patient utilities values, although the gBGS strategy still dominated. Probabilistic sensitivity analysis showed that the gBGS strategy lowered cost 96.8% and 98% of the time against both groups.

CONCLUSIONS: The results of our model suggest that treating cOM of the tibia and femur in a single-stage approach with absorbable gBGS results in reduced cost and a very small higher quality of life compared to traditional two-stage or multi-stage approaches. The cost reduction is due to less surgeries and less intra- and post-surgical complications. Prospective investigations are warranted to confirm this finding.