Implant wastage in orthopaedic trauma: a UK experience

Abstract

Introduction

Implant wastage is an under-reported issue in orthopaedics, yet it has been shown to have a significant cost burden on healthcare budgets. In a background of a perilous financial climate in the UK health service, our aim was to define the frequency and costs of implant wastage in orthopaedic trauma.

Materials and methods

The trauma theatre’s implant logbook was retrospectively analysed between April 2017 and April 2018. Wasted implants were identified by the study authors independently. Patient demographics, implant details and costs were among the data collected. Product codes of wasted implants were used to identify implant costs through the manufacturer.

Results

Implant wastage occurred in 25.1% of trauma procedures during the study period. Most wasted implants (91%) were screws. The total cost of implant wastage was £8,377.25 during the 12-month period, accounting for 2% of the total implant budget. Wasted intramedullary nails accounted for almost 50% of the total cost. More than 51% of affected procedures involved a trainee as the primary operator.

Discussion

We report the first study of implant wastage in orthopaedics from the UK. Total implant wastage was higher than reported in most of the published literature, although it represented a small portion of the budget. Implant wastage is attributable to surgeons or operating theatre staff in most cases and is compounded by surgeons’ limited understanding of implant costs. Initiatives to reduce implant wastage should include raising awareness of costs and departmental wastage to surgeons and operating theatre staff as well as employing preoperative planning techniques.

Introduction

Implants have wide-ranging uses in orthopaedic surgery and are necessary tools in fracture management. However, their cost is a significant burden to healthcare providers across the globe. In the United States, spending on medical devices totalled US$173 billion in 2016, accounting for 5.2% of all national health expenditures,¹ while in the UK around £3 billion was spent annually on high-value medical devices.² Implant costs represent an important proportion of the total expenditure in orthopaedic surgery, with one study attributing up to 87% of the total cost in hip and knee replacements to the implants themselves.³

Implant wastage, however, is a common yet underreported issue in orthopaedics. Payne et al reported implant wastage in 12% of procedures undertaken in their department over a 12-month period.⁴ Other studies have shown lower wastage rates in arthroplasty surgery (hip, knee or shoulder), ranging from 2–5.7% of surgeries.^5–7 Only one study has focused on orthopaedic trauma and these authors reported wastage in 0.6% of procedures.⁸ In spinal surgery, Soroceanu et al reported wastage occurring in 20% of procedures, although this included ancillary materials (eg sutures, bone grafts).⁹ Costs incurred from wastage have been reported to range from US$27,653⁸ to a staggering US$634,668.⁴ Extrapolating from their data, Zywiel et al estimated that hospitals in the United States spent over US$36 million annually on the cost of wasted hip and knee arthroplasty implants.⁵

In the UK, the NHS has been under severe financial pressure over the past few years,¹⁰ with nearly half of hospital trusts in financial deficit.¹¹ National initiatives, such as the ‘Getting it Right First Time’ project,¹² have identified a wide variation in implant cost at different hospital trusts¹³ and, as such, implant-related savings have emerged as a priority for hospital trusts to reduce budget deficits. Reducing implant wastage would certainly be part of this effort. However, to date, there has been no study assessing implant wastage in orthopaedics from the UK.

Our aims were to identify the frequency of implant wastage in orthopaedic trauma procedures and the cost incurred to the hospital therein, over a one-year period at a large district general hospital.

Materials and methods

Study setting

The study was conducted at a busy district general hospital with 460 beds, including two orthopaedic wards and four orthopaedic theatres, one of which is a dedicated trauma theatre.

Study design

A one-year retrospective analysis between April 2017 and April 2018, inclusive, of the trauma theatre’s implant logbook was undertaken. The implant logbook lists each procedure in the trauma theatre and includes product labels for each implant opened in that particular operation. Implants that were wasted were identified as such on the implant record by theatre staff. Two of the study authors independently reviewed the logbook for the study duration to identify relevant cases.

Data collection and analysis

Patient demographics, procedure type, region operated, operator grade and number of discarded implants per procedure were recorded. Product codes for each discarded implant were recorded from the logbook. Where discarded implants were not identified by theatre staff, any discrepancies between the procedure and number of implants opened were noted (for example, if a four-hole plate was used but five screws opened). Intra- or postoperative radiographs and the operative notes were then reviewed to correlate for wasted implants, although detailed product identification was not possible using this method. Product codes of wasted implants were used to identify implant costs on the NHS Supply Chain catalogue website (https://my.supplychain.nhs.uk/catalogue). Implants are offered at up to 50% discount by the single manufacturer to the hospital. Total implant costs for the trust were identified through budget review. Data analysis was performed using Microsoft Excel (2016).

Results

Implant wastage

A total of 565 trauma procedures were performed during the study period. In 142 (25.1%) of these procedures one or more implants were wasted. Overall, a total of 227 implants were wasted in these procedures, with the vast majority (206; 91%) consisting of screws (Fig 1). Nearly two-thirds of procedures (65%) where an implant was wasted were in lower-limb trauma operations (Fig 1). More than half of cases involved a trainee as the primary operator (51%) with a significant portion (40%) were led by consultants.

Figure 1.

(A) The different types of implant wasted during the study period. (B) The operated regions where implants were commonly wasted.

Costs

Overall, total cost of implant wastage was £8,377.25 during the study period. Intramedullary nails accounted for nearly half (47.6%) of the total cost, despite being the implant least frequently wasted (Fig 2). Table 1 lists the high-value implants wasted during the study period.

Figure 2.

The wasted implant costs per implant type.

Table 1.

Discarded high-value implants.

Implant	Wasted (n)	Cost per implant (£)
Intramedullary nails:
Femoral nail	4	607.00
Humeral nail	1	607.00
Tibial nail	2	301.46
Forearm elastic nail	3	82.02
Plates:
Distal humerus plate	2	539.57
Superior clavicle plate	1	495.88
Screws:
Dynamic hip screw	2	53.02
Cannulated hip screw	1	53.02
Locking screw (various)	6	61.63

Discussion

This is the first study to assess implant wastage in orthopaedics at a UK institution. The overall cost of implant wastage over a 12-month period at Sandwell General Hospital was £8,377.25, which represented 2% of the total implant budget. Although a small proportion of the budget, it is of significance in the context of financial pressures across the NHS. High-value implants, such as intramedullary nails, were a small proportion of implants wasted but represented a greater proportion of the total cost. Implants were wasted in 25.1% of trauma cases, which was significantly higher than Zywiel et al’s series (0.6%),⁸ although in Payne et al’s study, 30% of trauma cases had a wasted implant.⁴

In the literature, implant wastage has been attributed to the fault of the surgeon or operating theatre staff in 66–95% of cases and, in the remaining cases, to the vendor representative.^5,8 Some of the possible explanations include contamination or damage, opening the incorrect implant (wrong size or side) change in the operative plan or opening incompatible implants from different vendors.^7,9 Technical errors, such as inaccurate measurements of screws or nails, are also key considerations.

It is also quite evident that orthopaedic surgeons have a limited understanding of implant costs. Studies have shown that both orthopaedic residents and attending surgeons are largely inaccurate when estimating implant costs.^14–18 Familiarity with the implant did improve accuracy.¹⁴ Rohman et al noted that there was a tendency to overestimate the costs of frequently used implants and vice versa.¹⁶

Price awareness is an important issue, as surgeons who were aware of implant costs were more likely to choose cheaper implants.^19,20 Although it is not evident that price awareness might reduce implant wastage, it is not unreasonable to assume that knowledge of implant costs, especially high-value implants, would raise second thoughts in the surgeon’s mind when discarding an implant.

Initiatives to reduce implant wastage have been tried with some success. Soroceanu et al assessed the effect of an educational programme to raise awareness of departmental wastage and reported an impressive reduction in wastage rates from 20.2% to 10.3%.⁹ Pfefferle et al similarly raised awareness of implant wastage by posting the cost of implants wasted by each surgeon in the surgery suite; these authors noted a non-significant reduction in wastage from hip, knee and shoulder arthroplasty procedures.⁶ Ast et al introduced a computer-based implant labelling system to aid standardisation and reduce the likelihood of opening incompatible implants.⁷ Over a six-month period, they noted a reduction in total knee arthroplasty implant wastage from 5.7% to 0.8%, which translated to annualised cost savings of more than US$75,000. The use of trial implants and digital or physical templates for implants can greatly assist with surgical planning.⁶ Preoperative planning software using two- or three-dimensional images is also of relevance in reducing implant wastage by accurately predicting the implants required so that the risk of opening incorrect implants and, therefore, wastage is reduced.²¹

The limitations of this study include its single-centre and retrospective nature. Implant records also failed to identify all wasted implants that were subsequently crosschecked on imaging; the accuracy of this checking was dependent on the quality of the x-rays available. Cost of the implants identified through this means were estimated by comparison with similar implants.

Conclusion

In a challenging financial climate for the NHS, cost-saving measures are necessary for hospitals to be able to balance their books effectively. This report on the wastage of implants in orthopaedic trauma at a busy hospital in the UK serves to emphasise an underrecognised source of loss to the department. High-value implants form a greater proportion of the total loss compared with more commonly wasted implants. Initiatives to reduce implant wastage should include raising awareness of implant costs and departmental wastage to surgeons and operating theatre staff as well as preoperative planning techniques.