Routine histopathology in total joint arthroplasty: clinical utility and economic evaluation from a tertiary care center

Routine histopathological evaluation of bone and synovium during total knee and hip arthroplasty (TKA and THA) is widely practiced in many institutions. However, its cost-effectiveness, particularly in resource-limited settings, remains unclear. This study aims to assess whether such routine analysis offers clinical value commensurate with its cost. We retrospectively analysed 1027 consecutive primary total joint arthroplasty (823 knees and 204 hips) and compared our presumed preoperative diagnosis with the histopathological diagnosis made by the pathologists. Intraoperatively, femoral head specimen and bone pieces along with synovium removed during taking bone cuts were collected for THA and TKA respectively. The specimen was fixed with 10% neutral buffer formalin, treated with paraffin and cut with microtome. Staining was done with standard hematoxylin and eosin red stains. The cases were then grouped as concordant (matching), discrepant (not matching but no change in patient management) and discordant (not matching and with change in patient management). The cost-effectiveness analysis was conducted using the incremental cost-utility ratio (ICUR) framework, where cost-effectiveness was defined as < INR 4,82,472 ($5,597) per QALY gained. Of the 1027 consecutive cases, 883 (86%) were concordant, 144 (14%) were discrepant and none were discordant. Total expenditure for histopathological analysis over 10 years amounted to Rs. 22,59,300 ($26,191) with 0 QALYs gained. No malignancies or unexpected diagnosis altered patient management. Routine histopathological analysis from primary TKA and THA did not yield clinically actionable findings and was not cost-effective in our setting. The findings support selective use of histopathology based on clinical suspicion.