Do More Expensive Total Knee Arthroplasty Prostheses Provide Greater Improvements in Outcomes Over Less Expensive Prostheses Sold by a Physician-owned Distributorship?

BACKGROUND: It is unknown whether more expensive total knee prostheses provide better improvements in patient-determined outcomes compared with less expensive prostheses. A physician-owned distributorship (POD) was created with a goal to provide lower cost implants to hospitals as an alternative to higher cost prostheses sold by the large orthopaedic implant companies. The hypothesis was that lower cost total knee prostheses would have equivalent outcomes, while resulting in lower costs to the hospitals purchasing them compared with higher cost industry-supplied knee prostheses. METHODS: From May 2013 until January 2015, a POD existed which included five surgeons that performed total knee arthroplasties and were willing to follow the outcomes to ensure quality. The POD sold two knee arthroplasty systems at a cost that was lower than that of the large industry companies. Surgeons were allowed to use either POD knees or industry knees at their own discretion. Patients were followed up prospectively to determine The Knee Injury and Osteoarthritis Outcome Score (KOOS) outcomes at 2 years and any incidence of knee complications that required surgery. RESULTS: Two hundred-nine knees (35.2%) had a POD knee implanted, and 385 knees had an industry knee implanted. Both POD knees and industry knees showed statistically significant improvements (P < 0.0001) for all subgroups of the KOOS. No statistically significant difference was observed in improvement in any subgroup of the KOOS between the groups. Knee complications requiring surgical intervention were similar (2.9% POD knees versus 3.6% industry knees; P = 0.58). Using lower cost POD knees saved $209,875.71. CONCLUSIONS: No difference was observed in improvements in outcomes or complications in the lower cost POD-supplied knees compared with the higher cost industry-supplied knees. Hospitals and surgeons may consider using lower cost prostheses because the increased cost of the prosthesis has not been correlated to improved outcomes. LEVEL OF EVIDENCE: Level II therapeutic prospective cohort study.

Surgical management for malignant tumors of the thumb.

BACKGROUND: Malignant tumors of the thumb can be treated surgically with either wide local excision with reconstruction or amputation. Local excision of tumors in the thumb and hand often requires closer resection margin than at other sites, and there is also a need for tissue transfer from a donor site for reconstruction. Primary thumb amputation allows local tumor control while avoiding donor-site morbidity, but comes at great functional cost. We conducted this retrospective case review to assess the outcomes of thumb-sparing wide excisions and primary thumb amputations for malignant thumb tumors. METHODS: We performed a retrospective review of 23 patients who were surgically treated for malignant tumors of the thumb at our center from 1996 to 2005. We reviewed patient demographics, tumor pathology, extent of resection, postoperative margin status, adjuvant therapy, recurrence, and survival. Functional outcomes were scored using the Muscular Skeletal Tumor Society (MSTS) rating system. RESULTS: Twenty-three patients underwent definitive surgery: 14 thumb-sparing wide excisions and 9 amputations (five at the interphalangeal joint, three at the metacarpophalangeal joint, and one at the forearm). Median follow-up was 58 months (range, 5-156 months). All patients had negative margins. One patient developed a local tumor recurrence (following below-elbow amputation for a soft tissue sarcoma) while three patients developed distant metastases and died from their disease (two patients had melanomas and one had a soft tissue sarcoma). The median MSTS functional score was 28 (IQR, 27-29) for the entire cohort. Two patients that underwent amputation at the metcarpophalangeal joint without reconstruction had the lowest scores of 11 and 17. CONCLUSION: There was a low incidence of local recurrence and distant metastasis in this study, and these events appeared to be related to the underlying disease rather than the surgery performed. Thumb-sparing wide excision and amputation at the interphalangeal joint both give acceptable functional outcomes, though reconstruction should be strongly considered for patients undergoing amputation at the metacarpophalangeal joint.