It is with no surprise that management of prosthetic joint infection (PJI) represents a massive economic burden on health care systems, hospital and patients as well. There are only few papers available that address this issue in well developed countries but there is a need to evaluate the impact of management of prosthetic joint infection over patient economy in developing countries like Pakistan. To the best of our knowledge, this report is first from single centre of Karachi, Pakistan regarding the economic burden of prosthetic joint infection (PJI) following primary total knee replacement (TKR). The total financial burden of management of prosthetic joint infection (PJI) over patient economy is much more than the sum of all available data that can be objectively ascertained. In the current study, we only reported the in-hospital cost and we are unable to report the out-patient cost such as follow-up visits and rehabilitation cost. We are also unable to assess indirect cost as well such as productivity loss and absenteeism from work of patient and his caregivers. It is also very difficult to compare our economic burden after management of prosthetic joint infection (PJI) with other developing countries due to difference in the health-care system and economic standard of particular nation.
Kapadia et al  in his study compares 21 infected primary total knee replacement with 21 non-infected patients who underwent uneventful total knee replacements. He found that patients with prosthetic joint infection had significantly prolonged hospitalizations. The total cost for patients with prosthetic joint infection was $116,383 USD (range, $44,416 to $269,914) which was significantly more than uneventful primary knee arthroplasty $28,249 USD (range, $20,454 to $47,957). This study was conducted in Sinai Hospital which is one of the renowned private American hospitals. We are unable to compare our economic burden with the results presented by Kapadia et al in his study due to difference in health care system and economic standard between two countries. In our study, patients with prosthetic joint infection (PJI) had more prolonged stay as well considering both hospitalizations that actually impose a major impact on patients and his family economy ( P value < 0.05) as shown in Table 1 and Table 3. In our study, ICU care was decided on the basis of ASA score and post-operative evaluation in recovery room. 22 (81.4%) patients with prosthetic joint infection had ASA score of 3 and 4 and warrant ICU admission for further monitoring as per decided by anaesthesia team. Patients with uneventful arthroplasty had ASA score of 1 and 2 and didn’t require ICU admission post-operatively.
J.Garrido-Gomez et al  performs a descriptive analysis of economic cost of patients with prosthetic joint infection in public health system of Andalusia (Spain). They presented results of prosthetic joint infection on basis of occurrence. The mean cost per patient was 24,980 $ (19,270.80 €) for patients with early PJI and rise to 78,111 $ (60,257 €) for those with late PJI. Our study excludes those patients who present early and underwent DAIR (debridement, antibiotics and implant retention) procedure. He also concludes that hospital stay followed by cost of surgical implants puts major impact on patient economy. Fernandez-Fairen et al  performed a systematic review and found that revision knee arthroplasty was 2–4 times more expensive than uneventful primary knee arthroplasty. We found that management of prosthetic joint infection is 4.5 times more expensive than patient who underwent primary uneventful knee arthroplasty. We also observed that ward cost, diagnostic test, antibiotics, clinical materials including prosthesis and surgeon and anesthetist fees used during revision surgery have significant impact on economic status of patient presented with prosthetic joint infection (PJI) as shown in Table 3.
The economic burden of prosthetic joint infection (PJI) can be reduced by making health policies as well as implementation of preventive measures to attenuate the risk of prosthetic joint infection (PJI). Knowledge of the cost related to prosthetic joint infection is necessary to optimize existing health resources in developing countries like Pakistan. Although, there are treatment protocols and guideline exist to prevent the incidence of prosthetic joint infection (PJI) following joint replacement procedure, a more pro-active and individualized approach may be necessary to sort out this issue  . There is a need to identify high risk patients with proactive implementation of pre and post-operative protocols in order to prevent this devastating complication thereby reducing financial burden. Previous studies reported number of evidence based protocols that have proven to be effective in reducing prosthetic joint infection (PJI) such as use of prophylactic antibiotics and negative pressure wound therapy (NPWT) on surgical incisions  . According to data from OECD (organization for economic co-operation and development), the U.S. spent 17.8% of its gross domestic product (GDP) on health care, while the average spending level among all high-income countries is 11.5 percent of gross domestic product (GDP) . On other hand, the share of total public health expenditure in Pakistan as percentage of GDP (Gross domestic product) is only 0.7 percent. The current indicators of economic burden in Pakistan demonstrate the overall poor picture of expenditures on health. The increase in the expenditure as percentage of GDP on health besides other social expenditures should be strongly emphasized.
The major limitation of this study is that we mainly focused on in-hospital cost and exclude outpatient cost such as follow-up visits and rehabilitation cost so that exact economic burden can’t be determined. Although this small retrospective case-control study manifest some important conclusions. Another drawback is that this was a single centre study.