DUAL ANTIBIOTIC-LOADED BONE CEMENT IS MORE COST-EFFECTIVE THAN SINGLE ANTIBIOTIC-LOADED BONE CEMENT IN PATIENTS UNDERGOING ASEPTIC REVISION TOTAL KNEE ARTHROPLASTY

Aim Periprosthetic joint infection (PJI) remains one of the most serious and costly complications following revision total knee arthroplasty (TKA), particularly in aseptic revision cases where baseline infection risk is elevated. Antibiotic-loaded bone cement (ALBC) is commonly used to reduce infection risk; however, dual-antibiotic formulations carry higher upfront costs compared with single-antibiotic cement. The purpose of this study was to evaluate whether dual-antibiotic ALBC provides superior cost-effectiveness compared with single-antibiotic ALBC in patients undergoing aseptic revision TKA. Methods A state-transition Markov model was developed to simulate a cohort of patients undergoing aseptic revision TKA from a U.S. healthcare payer perspective. Patients entered the model in an infection-free postoperative state and were followed over a lifetime horizon with annual cycles. Health states included infection-free survival, acute PJI, successful treatment following debridement and implant retention, one-stage revision, two-stage revision, chronic suppressive therapy, amputation, and death. Transition probabilities were derived from published literature, with early postoperative PJI risk differing between dual and single ALBC strategies. Costs were obtained from U.S. reimbursement data, hospital cost analyses, and implant pricing. Health outcomes were measured in quality-adjusted life-years (QALYs), with both costs and QALYs discounted at 3% annually. Probabilistic sensitivity analysis using 1,000 parameter samples and 10,000 microsimulations was performed to assess uncertainty. Results Dual-antibiotic ALBC demonstrated lower mean lifetime costs compared with single-antibiotic ALBC ($80,398 vs $84,824), representing a cost reduction of $4,426 per patient. Dual ALBC also resulted in improved effectiveness, with mean QALYs of 7.99 compared with 7.92 for single ALBC. This corresponded to an incremental gain of 0.07 QALYs, establishing dual ALBC as the dominant strategy. At a willingness-to-pay threshold of $50,000 per QALY, the incremental net monetary benefit was $7,924 in favor of dual ALBC. Probabilistic sensitivity analysis showed that dual ALBC was the preferred strategy in 71.9% of simulations, with consistent cost-effectiveness across a wide range of willingness-to-pay thresholds. Conclusions Dual-antibiotic ALBC provides a cost-saving and more effective strategy compared with single-antibiotic cement in aseptic revision TKA. These findings are driven by reductions in early postoperative PJI and avoidance of costly downstream interventions. The results support the use of dual ALBC in revision arthroplasty within value-based care models, where prevention of complications is critical to improving outcomes and reducing healthcare expenditures.