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Hidden costs of first choice alternatives: A financial model of thromboprophylaxis and prosthetic joint infection prophylaxis in total knee arthroplasty
⁎Corresponding author: Victoria E. Bergstein. vbergst2@jhmi.edu
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Aspirin has been shown to be equally or more effective than factor Xa inhibitors for thromboprophylaxis following total knee arthroplasty (TKA). Cefazolin has been proven more effective than vancomycin in preventing prosthetic joint infection (PJI) after TKA. This study aimed to compare costs between different drug combinations for prevention of venous thromboembolism (VTE) and PJI following TKA, focusing on costs associated with PJI management.
We used published PJI rates for TKA patients treated with aspirin or factor Xa inhibitors for thromboprophylaxis, as well as for those who received prophylactic cefazolin or vancomycin. Unit prices for each drug and labor costs associated with vancomycin administration were obtained from our hospital's pharmacy service. The PJI cost model included the price of 2-stage septic TKA revision and national projections of future TKA volume.
The least expensive average per-patient cost resulted from the combination of aspirin and cefazolin, equating to $521.19 given a 0.8 % PJI rate. The most expensive average per-patient cost was the combination of a factor Xa inhibitor and vancomycin, equaling $5,714.96 given a 1.8 % PJI rate. This extrapolates to an annual cost burden of $19.5 billion by 2040.
The average per-patient cost of using a combination of a factor Xa inhibitor and vancomycin is 711 % greater than the combination of aspirin and cefazolin. In this era of value-based care, aspirin and cefazolin should be considered gold standards for TKA thromboprophylaxis and PJI prophylaxis, as they reduce costs and improve patient outcomes.
Keywords
Economics
Cost-effectiveness
Financial modeling
Arthroplasty
Total knee arthroplasty
Prosthetic joint infection
Thromboprophylaxis
1 Introduction
Prosthetic joint infection (PJI) is a devastating complication of total knee arthroplasty (TKA). Though PJI incidence is low, occurring in only 0.5 %–1.9 % of cases, septic revision TKAs are on the rise due to the upward trend in number of primary TKAs.1,2 In fact, the American Joint Replacement Registry recently named infection as the leading etiology for revision TKA.3 It is necessary for most patients with late PJI to undergo two-stage exchange arthroplasty; the first stage involves removal of all material and aggressive debridement of bone and soft tissue, and the second stage occurs after 4–6 weeks of antibiotic treatment, in which new components are implanted.1 Not only is PJI treatment a lengthy and invasive process, it incurs a tremendous economic burden on the healthcare system, with annual costs estimated to exceed $518 million given U.S. septic TKA revision volume in 2017.4 For these reasons, current research has aimed to optimize elements of the TKA perioperative approach to minimize PJI risk as much as possible.
One such element that has been well-studied in the literature is the use of perioperative antibiotics for PJI prophylaxis. The results of many studies have supported cefazolin as the gold standard antibiotic for this purpose, due to its effective coverage of the most common PJI-causing bacteria, including Staphylococcus aureus and Staphylococcus epidermidis.5,6 While cefazolin is the most common antibiotic prescribed for TKA PJI prophylaxis, vancomycin or other alternatives are often prescribed for patients with reported penicillin allergies, despite being associated with a higher PJI risk.6–8 However, some physicians have advised the administration of cefazolin even if the patient reports a penicillin allergy, in light of evidence that only 1 % of the population have a true IgE-mediated penicillin allergy, of which 80 % lose their sensitivity after 10 years.9 Further, unlike cefazolin, vancomycin must be infused over the course of 1 h prior to surgery, which creates delays that incur an immense time-cost for the employees involved.10–12
Another aspect of the TKA perioperative protocol that has been studied in terms of PJI optimization is venous thromboembolism (VTE) prophylaxis. VTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a serious postoperative complication associated with significant morbidity.13–15 For post-TKA thromboprophylaxis regimens, aspirin has been widely shown to be a safe and effective choice, even in high risk patient populations.16–19 Not only has aspirin been shown to prevent VTE at rates equal to or better than other antithrombotics such as rivaroxaban (brand name Xarelto) or apixaban (brand name Eliquis), but aspirin thromboprophylaxis has been associated with lower risk of developing postoperative PJI compared to other thromboprophylactic drugs used after TKA.20 Despite this evidence, a significant number of TKAs in the United States are still performed with alternatives to aspirin for VTE prophylaxis.21
When considering perioperative VTE and PJI prophylaxis for TKA, both medication regimens have options that are both more effective and more economical. As these costs are incurred over time, they may not be evident and considered by providers when making treatment decisions at the time of primary TKA. The purpose of this study was to analyze different combinations of medications for PJI and VTE prophylaxis to determine the difference in the associated financial burden. Given the importance of value-based healthcare, we aimed to determine a drug combination that is the most effective for PJI and VTE prevention, while translating into the greatest cost savings for the healthcare system and for patients.22
2 Methods
2.1 Patient sample
We built a national-scale model based on data collected from a single, large orthopaedic specialty hospital, which included all patients who underwent primary TKA from 2013 to 2019 and had a minimum 90-day follow-up. This cohort, described in Anil et al. and Buchalter et al., included 11,550 patients, each of whom were administered 1) either aspirin or a non-aspirin alternative for VTE thromboprophylaxis, and 2) either cefazolin or a non-cephalosporin alternative for PJI prophylaxis. Cases of PJI were identified using Centers for Disease Control and Prevention's National Healthcare Safety Network criteria.23 Because our data came from previously published work only, and no new patient data was collected, Institutional Review Board approval was not necessary.
2.2 Financial model
For VTE thromboprophylaxis, the cohorts included in our analysis were an aspirin-only group, consisting of patients who took 81 mg or 325 mg of aspirin, twice daily, and a factor Xa inhibitor consisting of patients who took 10 mg of Xarelto once daily or 2.5 mg of Eliquis twice daily. Unit prices for each drug were obtained from our hospital's pharmacy team. The average price of the aspirin-only drug category was the mean cost of 81 mg and 325 mg doses taken over a 28-day course, and the average price of the factor Xa inhibitor group was the mean cost of 10 mg Xarelto and 2.5 mg Eliquis 28-day regimens. These costs are summarized in Table 1. Other common thromboprophylactic drugs, such as enoxaparin and warfarin, were excluded as they are now used far less commonly due to challenges with their administration and monitoring. Enoxaparin is administered subcutaneously and warfarin requires interval INR monitoring, while Xarelto, Eliquis, and aspirin are taken orally and do not require monitoring or dose adjustments.
| Drug Name | Unit Price | Total Cost |
| Average Aspirin | $0.31 | $17.36 + |
| Aspirin (81 mg)a | $0.49 | $27.44 |
| Aspirin (325 mg)a | $0.13 | $7.48 |
| Average Factor Xa Inhibitor | $100.80 | $3,784.20 + |
| Xarelto (10 mg) | $132.90 | $3,721.20 |
| Eliquis (2.5 mg)a | $68.70 | $3,847.20 |
| Cefazolin (2 g) | $0.67 | $0.67 |
| Vancomycin (15–20 mg/kg) | $1.98 | $1.98 |
For PJI prophylaxis, the cohorts included in our analysis were a cefazolin group and a vancomycin group. Unit prices of cefazolin and vancomycin were obtained from our hospital system's investigational pharmacy team. These costs are detailed in Table 1.
While the costs discussed above represent cost to the payer, namely, Medicare, other insurance providers, or patients themselves, there is also a cost to the hospital to consider regarding Vancomycin infusion. Vancomycin must be administered over the course of an hour prior to surgery due to the risk of vancomycin flushing syndrome that results from overly rapid infusion.24 Vancomycin flushing syndrome is characterized by a pruritic, erythematous rash involving the face, neck, and upper torso, resulting in burning, itching, dizziness, headache, and generalized discomfort.24 Further, if infusion time is hastened and the full dose of vancomycin is not completely administered, PJI rates have been shown to increase in response.10 Because the requirement for slow vancomycin infusion creates inevitable delays in the surgical schedule, or at the very least, extra supervised time in the pre-operative holding area, associated staffing costs were added to the unit price of vancomycin. To calculate the associated financial burden, hourly wage figures from annualized salaries were obtained from the financial division of our hospital's decision support department. Salaries of employees in the preoperative holding room involved in vancomycin administration, and of employees on standby in the operating room were accounted for in this model. Accounting for an average of 2 certified nursing assistants (CNAs) and 1 unit assistant in the preoperative holding area, as well as an average of 2.5 CNAs, 2 physician assistants, and 1 surgical tech in the operating room, the hour of extra wages come out to $700 to care for a single patient requiring a vancomycin infusion. Cefazolin does not incur this added labor cost because it can be administered immediately prior to surgery.
The financial burden of PJI treatment was modeled based on data from Okafor et al. who estimated the cost of an index 2-stage septic TKA revision to be $92,502 in Australian dollars.25 To convert their projections from 2020 Australian dollars to 2023 U S. dollars, a conversion rate of AUS $1.00 = USD $0.68 was utilized. Therefore, the U.S. cost of 2-stage septic revision used in our analysis was $62,901.36. Our model does not include the cost of 1-stage septic revision due to its lower efficacy and utilization rates, nor does it account for unsuccessful 2-stage revisions that necessitate re-revision. It also does not account for the cost of follow-up treatment. We used projections obtained from the National Inpatient Sample, published by Singh et al., to make cost projections accounting for predicted future TKA volume.26
3 Results
3.1 Average per-patient cost analysis
For thromboprophylaxis, patients treated with aspirin were reported to have a PJI incidence rate of 0.3 %.20 The per-patient cost for this group included the cost of 2-stage septic revision and the cost of a 28-day aspirin regimen, equating to $62,918.72. For the 99.7 % of patients who took aspirin but did not develop PJI, the total cost of treatment was just the cost of the aspirin regimen, coming out to $17.36. After accounting for the differential PJI incidence between the two groups, the average per-patient cost was determined to be $206.06.
Patients treated with a factor Xa inhibitor for thromboprophylaxis were reported to have a PJI incidence rate of 0.8 %.20 The cost of treatment, including the cost of the medication and the 2-stage septic revision, for this group was $66,685.56. For the 99.2 % of patients who did not develop PJI, the cost of the factor Xa inhibitor thromboprophylactic regimen was $3,784.20. Weighting for the incidence of PJI rates produced an average per-patient cost of $4,287.41.
For PJI prophylaxis, patients treated with cefazolin had a reported PJI rate of 0.5 %, for which the associated cost of the medication and 2-stage septic revision was $62,902.03. The 99.25 % of patients who did not develop PJI only needed to pay the unit price of cefazolin, which is $0.67. After adjusting for the differences in PJI incidence, the average per-patient price equated to $351.18.
Patients treated with vancomycin were reported to have a PJI incidence of 1.0 %. The per-patient cost for this group included the cost of the medication and 2-stage septic revision, equating to $63,603.34. The cost associated with the 99 % of patients who did not develop PJI included the cost of the medication, and weighted together, the average per-patient cost for vancomycin equated to $637.99. These costs are detailed in Table 2.
| Drug Name | Cost of Treating an Uninfected Patient | Percentage of Patients without PJI | Cost of Treating an Infected Patient | Percentage of Patients with PJI | Average Per-Patient Cost |
| Aspirin | $17.36 | 99.7 % | $62,918.72 | 0.30 % | $206.06 |
| Factor Xa Inhibitor | $3,784.20 | 99.2 % | $66,685.56 | 0.80 % | $4,287.41 |
| Cefazolin | $0.67 | 99.5 % | $62,902.03 | 0.5 % | $351.18 |
| Vancomycin | $701.98 | 99.0 % | $63,603.34 | 1.00 % | $ 1,330 .99 |
3.2 Combination costs for thromboprophylaxis and PJI prophylaxis
In practice, patients undergoing TKA are prescribed medications for both thromboprophylaxis and PJI prophylaxis. To evaluate the combined cost for a patient who does not develop PJI, the unit prices of two given drugs, one antibiotic and one antithrombotic, were added together. The cost for a patient that develops PJI was determined by adding the combined unit price of an antibiotic, an antithrombotic, and the price of index 2-stage septic revision. For a given drug combination, the PJI rate was determined by adding together the PJI rates associated with each individual drug, representing the PJI rate associated with use of the antibiotic or the antithrombotic. The combined cost calculations are detailed in Table 3.
| Drug Combination | Cost of Treating an Uninfected Patient | Percentage of Patients without PJI | Cost of Treating an Infected Patient | Percentage of Patients with PJI | Average Per-Patient Cost |
| Aspirin + Cefazolin | $18.03 | 99.20 % | $62,913.62 | 0.80 % | $521.19 |
| Aspirin + Vancomycin | $719.34 | 98.70 % | $70,190.51 | 1.30 % | $1,622.47 |
| Factor Xa Inhibitor + Cefazolin | $3,784.87 | 98.70 % | $65,475.07 | 1.30 % | $4,586.84 |
| Factor Xa Inhibitor + Vancomycin | $4,486.18 | 98.20 % | $72,751.96 | 1.80 % | $5,714.96 |
3.3 Drug combination cost comparisons
The largest percent difference in average patient cost was between the aspirin + cefazolin and factor Xa inhibitor + vancomycin combinations, where the average per-patient cost of the latter was 711 % higher than the former. The smallest percent difference resulted from the average per-patient cost of the factor Xa inhibitor + vancomycin combination being 23 % higher than that of the factor Xa inhibitor + cefazolin combination. All percent differences in price between each combination of paired drugs is detailed in Table 4.
| Drug Combination | Comparison Drug Combination | Percent Difference in Average Per-Patient Drug Cost |
| Aspirin + Cefazolin | Factor Xa Inhibitor + Vancomycin | 711 % |
| Aspirin + Cefazolin | Factor Xa Inhibitor + Cefazolin | 558 % |
| Aspirin + Vancomycin | Factor Xa Inhibitor + Vancomycin | 220 % |
| Aspirin + Vancomycin | Factor Xa Inhibitor + Cefazolin | 160 % |
| Aspirin + Cefazolin | Aspirin + Vancomycin | 154 % |
| Factor Xa Inhibitor + Cefazolin | Factor Xa Inhibitor + Vancomycin | 23 % |
3.4 Projections of costs to the overall healthcare system
Projections from the National Inpatient Sample have estimated TKA volume to increase to 1,272,000, 1,921,000, and 3,416,000 annual procedures in the United States by 2025, 2030, and 2040, respectively.26 Our modeled cost projections are derived from the average per-patient cost associated with each drug combination, multiplied by annual projected TKA volume. For these projections, costs to the overall healthcare system were considered, rather than just costs to the payer. Therefore, these projections include the $700 cost associated with the 1-h infusion hold that is necessary with use of vancomycin.
By 2040, use of the aspirin + cefazolin, aspirin + vancomycin, factor Xa inhibitor + cefazolin, and factor Xa inhibitor + vancomycin drug combinations will cost the healthcare system roughly $1.8 billion, $5.5 billion, $15.7 billion, and $19.5 billion, respectively. These cost projections are recorded in Table 5 and visualized in Fig. 1.
| Year | Projected Number of Annual TKAs | Cost Associated with Aspirin + Cefazolin | Cost Associated with Aspirin + Vancomycin | Cost Associated with Factor Xa Inhibitor + Cefazolin | Cost Associated with Factor Xa Inhibitor + Vancomycin |
| 2025 | 1,272,000 | $662,959,684 | $2,063,775,747 | $5,834,463,787 | $7,269,434,259 |
| 2030 | 1,921,000 | $1,001,215,057 | $3,116,755,668 | $8,811,324,635 | $10,978,445,921 |
| 2040 | 3,416,000 | $1,780,401,164 | $5,542,341,157 | $15,668,654,322 | $19,522,317,161 |
4 Discussion
The primary focus of this study was to determine the drug combination for PJI and VTE prophylaxis associated with the greatest cost benefit for the healthcare system and for patients. To this end, we found that the average per-patient cost of using a combination of a factor Xa inhibitor and vancomycin is 711 % more expensive than the combination of aspirin and cefazolin. Given that this cost difference materializes into a projection ranging from $1.7 billion to $19.5 billion in annual cost savings by 2040, the findings of this study have far-reaching implications.
Comparing the percent differences between the different antibiotic and thromboprophylactic drug combinations, we can conclude that the most significant cost driver is the use of a factor Xa inhibitor for thromboprophylaxis. This finding confirms aspirin's cost effectiveness, an additional benefit along with its medical efficacy that has been broadly reported upon in the literature.16,17,19,20,27 Not only has aspirin been associated with a lower early PJI rate, it has also been reported to be as effective, if not more effective, in symptomatic VTE prevention than other thromboprophylactic agents such as Factor Xa inhibitors, warfarin, and enoxaparin.16,17,19,20,27 While the financial impact of aspirin use for thromboprophylaxis is still an area of active investigation, previous studies have shown that aspirin is an independent predictor of reduced cost of hospitalization and care charges, while saving more quality-adjusted life years than warfarin following TKA and total hip arthroplasty (THA).28,29
Behind factor Xa inhibitors, the next greatest contributor to increased costs was use of vancomycin for PJI prophylaxis. This is largely due to the time and labor costs associated with vancomycin's required hour-long administration, and the higher PJI rate.10–12 These findings contribute to a growing picture of vancomycin as a suboptimal choice for PJI prophylaxis, adding a financial perspective to the existing literature regarding vancomycin's efficacy. Several studies have shown vancomycin to be less effective than other antibiotic classes, including cephalosporins such as cefazolin, in preventing PJI following TKA.6,30–33 In fact, some studies advocate for use of cefazolin over vancomycin even if patients report penicillin allergies, due to cefazolin's higher efficacy and the low prevalence of true IgE-mediated penicillin hypersensitivities among those who report allergies.6,34,35 In light of the documented benefits of cefazolin use for PJI prophylaxis, the added advantage of financial savings make cefazolin a preferable choice over vancomycin in this era of high value care.6,22,31,35
The main impact our study aims to emphasize is that the upfront cost difference between aspirin and factor Xa inhibitors, and between cefazolin and vancomycin, is minimal enough to go unnoticed during the decision-making process. The manner in which surgeons and health systems are remunerated focuses on specific episodes of care, and thus, are not impacted by the cost of a future PJI. However, when considering the seemingly hidden financial impact of PJI, and the differential rates of PJI associated with each drug type, the cost difference is significant when applied to a healthcare system-wide level, which could be realized at the level of the individual surgeons and hospitals. With these findings, hospital systems may be able to develop more standardized recommendation protocols for cost-effective PJI and VTE prophylaxis, using cefazolin and aspirin, respectively. According to the value-based healthcare model popularized by Michael Porter, cefazolin and aspirin fit the model's best-case scenario as they reduce costs while simultaneously improving patient outcomes.22
It is important to analyze this study in the context of its limitations. We recognize that not every patient is a candidate for aspirin or cefazolin. We did not include non-factor Xa inhibitor thromboprophylactic agents, nor did we include less commonly used antibiotics such as clindamycin, which would have impacted the cost estimates. We used a 28-day medication regimen for modeling our thromboprophylactic drugs, in line with the standard of care at our institution, but some surgical centers may use a 14-day regimen, which would impact cost estimates. The reported costs associated with PJI are likely underestimates, as they do not account for the cost of follow-up, failed revisions and re-revisions, physical therapy, and other forms of long-term treatment. The cohort data on which our study was based was retrospectively collected, therefore we cannot make true causative associations.6,20 The cohort was also collected from a single institution, which may limit generalizability, especially given that the PJI rate was lower than the national average.3,6,20
5 Conclusion
The average per-patient cost of using a combination of a factor Xa inhibitor and vancomycin is 711 % greater than the combination of aspirin and cefazolin. In this era of value-based care, aspirin and cefazolin should be considered gold standards for TKA thromboprophylaxis and PJI prophylaxis, as they reduce costs and improve patient outcomes.
Guardian/Patient's consent
Not applicable, no identifiable human subjects.
Credit statement
Victoria Bergstein: Validation, formal analysis, investigation, resources, data curation, writing – original draft, writing – review & editing, visualization, Walter Taylor: Writing – review & editing, Aaron Weinblatt: Writing – review & editing, William Long: Conceptualization, methodology, supervision, project administration.
Ethics
This study was a financial analysis based on previously collected data by our research group. Because all of the accessed information was an aggregate of deidentified patient data, Institutional Review Board Approval was not necessary.
Financial statement
There was no funding of any kind received for any portion of the creation, development, execution, or writing of this study.
References
- The management of an infected total knee arthroplasty. Bone Jt J. 2015;97-B(10_Supple_A):20-29.
- [Google Scholar]
- Outcome of revision surgery for infection after total knee arthroplasty: results of 3 surgical strategies. JBJS Rev. 2019;7(6):e4.
- [Google Scholar]
- 2022
- [Google Scholar]
- Projected economic burden of periprosthetic joint infection of the hip and knee in the United States. J Arthroplasty. 2021;36(5):1484-1489.e3.
- [Google Scholar]
- Organism profile in periprosthetic joint infection: pathogens differ at two arthroplasty infection referral centers in Europe and in the United States. J Knee Surg 2014:399-406.
- [Google Scholar]
- Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty. Bone Jt Open. 2022;3(1):35-41.
- [Google Scholar]
- The AAHKS clinical research award: extended oral antibiotics prevent periprosthetic joint infection in high-risk cases: 3855 patients with 1-year follow-up. J Arthroplasty. 2021;36(7):S18-S25.
- [Google Scholar]
- John Charnley Award: increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin: the value of allergy testing for antibiotic prophylaxis. Bone Joint J. 2019;101-B(6_Supple_B):9-15.
- [Google Scholar]
- Incomplete administration of intravenous vancomycin prophylaxis is common and associated with increased infectious complications after primary total hip and knee arthroplasty. J Arthroplasty. 2021;36(8):2951-2956.
- [Google Scholar]
- Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2015;135(6):759-772.
- [Google Scholar]
- Venous thromboembolism risk and thromboprophylaxis assessment in surgical patients based on caprini risk assessment model. Risk Manag Healthc Pol. 2020;13:2545-2552.
- [Google Scholar]
- The risk of venous thromboembolism, myocardial infarction, stroke, major bleeding and death in patients undergoing total hip and knee replacement: a 15-year retrospective cohort study of routine clinical practice. Bone Jt J. 2014;96-B(4):479-485.
- [Google Scholar]
- Low-dose aspirin is safe and effective for venous thromboembolism prophylaxis following total knee arthroplasty. J Arthroplasty. 2018;33(7):S131-S135.
- [Google Scholar]
- Low-dose aspirin is safe and effective for venous thromboembolism prevention in patients undergoing revision total knee arthroplasty: a retrospective cohort study. J Knee Surg. 2022;35(5):553-559.
- [Google Scholar]
- American academy of orthopaedic surgeons clinical practice guideline on. J Bone Joint Surg Am. 2012;94(8):746-747.
- [Google Scholar]
- Aspirin use for venous thromboembolism prevention is safe and effective in overweight and obese patients undergoing revision total hip and knee arthroplasty. J Arthroplasty. 2021;36(7):S337-S344.
- [Google Scholar]
- Aspirin thromboprophylaxis following primary total knee arthroplasty is associated with a lower rate of early prosthetic joint infection compared with other agents. J Arthroplasty. 2023;38(6, Supplement):S345-S349.
- [Google Scholar]
- Trends in deep vein thrombosis prophylaxis after total knee arthroplasty: 2016 ro 2021. 2023
- [Google Scholar]
- Is 2-stage septic revision worth the money? A cost-utility analysis of a 1-stage versus 2-stage septic revision of total knee arthroplasty. J Arthroplasty. 2023;38(2):347-354.
- [Google Scholar]
- Rates of total joint replacement in the United States: future projections to 2020-2040 using the national inpatient Sample. J Rheumatol. 2019;46(9):1134-1140.
- [Google Scholar]
- Aspirin as a thromboprophylaxis agent after revision knee arthroplasty: a retrospective analysis. J Orthop. 2023;41:23-27.
- [Google Scholar]
- Cost-effective prophylaxis against venous thromboembolism after total joint arthroplasty: warfarin versus aspirin. J Arthroplasty. 2015;30(2):159-164.
- [Google Scholar]
- Direct costs of aspirin versus warfarin for venous thromboembolism prophylaxis after total knee or hip arthroplasty. J Arthroplasty. 2015;30(9, Supplement):36-38.
- [Google Scholar]
- Vancomycin prophylaxis for total joint arthroplasty: incorrectly dosed and has a higher rate of periprosthetic infection than cefazolin. Clin Orthop Relat Res. 2017;475(7):1767-1774.
- [Google Scholar]
- Increased rate of early periprosthetic joint infection in total hip arthroplasty with the use of alternatives to cefazolin despite additional gram-negative coverage. Arthroplasty Today. 2022;14:183-188.
- [Google Scholar]
- Does dual antibiotic prophylaxis better prevent surgical site infections in total joint arthroplasty? Clin Orthop Relat Res. 2012;470(10):2702-2707.
- [Google Scholar]
- Efficacy and safety of intrawound vancomycin in primary hip and knee arthroplasty. Bone Joint Res. 2020;9(11):778-788.
- [Google Scholar]
- Preoperative allergy testing for patients reporting penicillin and cephalosporin allergies is cost-effective in preventing infection after total knee and hip arthroplasty. J Arthroplasty. 2021;36(2):700-704.
- [Google Scholar]
- Documented penicillin allergies should not preclude use of preoperative cefazolin in hip and knee arthroplasty. J Am Acad Orthop Surg. 2023;31(2):e107-e117.
- [Google Scholar]