Abstract
Aims
Periprosthetic joint infections (PJIs) pose significant challenges to patients and healthcare systems worldwide. The aim of this study was to estimate the health-economic burden of reimbursement payment in Europe for PJIs following primary hip and knee arthroplasty.
Methods
The calculation was based on health-economic modelling using data on primary hip and knee arthroplasties for the year 2019 from the Statistical Office of the European Union (Eurostat) and published infection rates to estimate the total number of hip and knee PJIs in 30 European countries. Revision procedures were stratified into: 1) debridement, antibiotics, and implant retention (DAIR); 2) one-stage exchange; and 3) two-stage revision procedures. The cases were then multiplied by the respective healthcare system reimbursement payments. Payment data were acquired from a survey of 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK) and extrapolated for the remaining countries.
Results
In 2019, a total of 2,048,778 primary total joint replacements were performed (total hip arthroplasty (THA) = 1,147,316 and total knee arthroplasty (TKA) = 901,462), with an estimated 20,416 cases of PJIs (11,131 hip and 9,285 knee) in Europe. This results in an estimated total reimbursement burden of €346,262,026 for European healthcare systems. The breakdown for hip PJI reimbursement was €197,230,953 (€9,751,962 for DAIR procedures, €45,135,894 for one-stage revisions, and €142,343,097 for two-stage revisions). For knee PJIs, the analysis yielded a total reimbursement of €149,031,073 (€9,335,075 for DAIR procedures, €48,058,479 for one-stage revisions, and €91,637,518 for two-stage revisions).
Conclusion
This is the first study to evaluate the health-economic burden of PJIs in Europe, revealing a substantial impact on healthcare systems with an estimated case load of 20,414 cases and overall reimbursement of €346,262,026 for primary THAs and TKAs performed in 2019.
Cite this article: Bone Jt Open 2025;6(3):298–311.
Take home message
This is the first study to evaluate the health-economic burden of periprosthetic joint infections in Europe of primary arthroplasties of the hip and knee performed in 2019, revealing a substantial impact on healthcare systems with an estimated case load of 20,414 cases and overall reimbursement of €346,262,026.
Introduction
Periprosthetic joint infection (PJI) is a formidable and serious postoperative complication that may arise following total joint replacement, inclusive of total hip arthroplasty (THA) or total knee arthroplasty (TKA). Epidemiologically, the PJI incidence after primary arthroplasty in Europe is documented to range from 0.6% to 1.3%.1 The prevalence of PJI is demonstrating an upward trajectory, owing primarily to an ageing population and the ever-increasing caseload of joint arthroplasty surgeries.2,3 In Germany alone, it is projected that the number of primary implantations will further increase by 45% for TKA and 23% for THA by 2040.2
The management of PJI is inherently complex and financially burdensome, often necessitating multiple surgical interventions, prolonged antibiotic therapy, and extended hospitalization. The clinical sequelae can be severe, potentially leading to immobility, amputation, diminished quality of life, and considerable psychological distress4 with a reported 3.7-fold increased risk of death within the first two years of the diagnosis.5,6 Consequently, PJI imposes a considerable burden on both patients and the healthcare system, manifesting in substantial socioeconomic costs.7 Recent projections estimate that the combined annual hospital costs related to knee and hip PJI in the USA will reach $1.85 billion by 2030.8 Furthermore, other studies have estimated a base-case cost of $390,806 for each 65-year-old patient with an infected THA.9
While some studies offer insights into direct healthcare costs associated with PJI, there is a notable paucity of data regarding reimbursement payment from healthcare funders. Predominantly, these reports emanate from single-centre studies and typically focus on costs associated with specific treatment methods, such as debridement, antibiotics, and implant retention (DAIR),10 or two-stage revisions.11-16 Furthermore, these studies often feature limited sample sizes, ranging from eight to 61 patients.16,17 A comprehensive analysis focusing on Europe is lacking and is needed to facilitate detailed economic analyses and inform future medical and health-economic policymaking.18 Consequently, the primary objective of this study was to estimate the health-economic burden of reimbursement payments for PJI following primary hip and knee arthroplasty in Europe over a one-year period.
Methods
This paper reports the outcome of a project developed by the European Bone and Joint Infection Society (EBJIS). The study included 30 countries, listed alphabetically: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Hungary, Ireland, Italy, Lithuania, Luxembourg, Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, and the UK.
Health-economic modelling
The health-economic model was conducted from a healthcare payors’ perspective to evaluate the financial impact on healthcare systems across the 30 included countries. This analysis primarily focused on the reimbursement burden of public healthcare systems, which are predominant in Europe. Reimbursement from the public system was assumed to be similar for basic payments from the private sector as the used data from the Statistical Office of the European Union (Eurostat) do not distinguish between private and public healthcare sectors. This approach can be deemed conservative as private healthcare provision is normally associated with higher costs and higher reimbursement.
The model used a five-step calculation process (Figure 1) using data from Eurostat for the year 2019 on primary hip and knee arthroplasties and published infection rates to estimate the overall number of hip and knee PJIs for 30 European countries (Figure 1, equation 1).
Fig. 1
Equations used for the health-economic modelling. Calculations were done for hip and knee periprosthetic joint infection (PJI), respectively. #Number and costs of revision procedures were calculated for debridement, antibiotics, and implant retention (DAIR), one-stage, and two-stage PJI procedures, respectively.
Revision procedures were stratified into: 1) DAIR; 2) one-stage exchange; and 3) two-stage revision interventions for hip and knee PJIs based on published ratios (Figure 1, equation 2). These were then multiplied with the respective reimbursement payments of the healthcare funders (Figure 1, equation 3). Data on these payments were acquired through a survey conducted in 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK) and extrapolated to the other countries using gross domestic product (GDP) mean values. The expenses for the DAIR, one-stage, and two-stage procedures were then calculated and summarized for each country for hip and knee PJIs, respectively (Figure 1, equation 4). The sum of these payments yields the estimated overall financial burden for healthcare funders of the 30 European countries for hip and knee PJIs following primary hip arthroplasty in 2019 (Figure 1, equation 5).
Number of hip and knee PJIs in Europe after primary arthroplasty performed in 2019
To estimate the annual number of PJIs following primary hip and knee arthroplasty, data on the total number of primary arthroplasties were requested from the Statistical Office of the European Union (Eurostat),19 based on the Operation and Procedure Classification System (OPS) codes '5 to 820, Implantation of an endoprosthesis of the hip joint' and '5 to 822, Implantation of an endoprosthesis of the knee joint' (Figure 1, equation 1).
We adopted published infection rates of 1.03% following primary TKA and 0.97% following primary THA,1 to calculate the total number of hip and knee PJIs for each country and across Europe.
Estimation of DAIR, one-stage, and two-stage procedures per country
As reimbursement payments are contingent upon the type of treatment, PJI cases were subsequently stratified according to the treatment procedure into: 1) DAIR; 2) one-stage exchange; and 3) two-stage revision to facilitate a detailed health-economic analysis. The distribution of these three surgical strategies for knee revisions in Germany was calculated using OPS codes from the Federal Statistical Office of Germany (Destatis), as recently published.3 An analogous approach was employed for hip revision procedures using the OPS codes '5 to 821, Endoprosthetic joint and bone arthroplasty: revision, arthroplasty and removal of an endoprosthesis of the hip joint'. These ratios were used and multiplied with the total number of infections per country yielding the total number of treatment procedures per country (Figure 1, equation 2). The calculations were separately performed for knee and hip PJIs.
Calculation of reimbursement payments
In the next step, data on reimbursement payments for DAIR, one-stage, and two-stage procedures received by hospitals from public healthcare funders for PJI treatment were collected from 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK). These data were obtained through a survey conducted by the Country Delegates Group of the EBJIS.
For all other countries, clustering into higher- and lower-income European countries was performed based on the GDP per capita. Information on the GDP per capita was sourced from Eurostat.19 Data ranged from 42 GDP per capita in purchasing power standards (PPS) for North Macedonia to 261 GDP per capita in PPS for Luxembourg. The average GDP per capita in PPS for all European countries was 101, which served as the cut-off for this categorization (Table I).
Table I.
Extrapolation of reimbursement payments of different European healthcare systems for DAIR, one-, and two-stage procedures for hip and knee periprosthetic joint infection treatment, based on classification of lower versus higher income European country depending on the gross domestic product per capita.
| Country | Gross domestic product per capita in purchasing power standards in 2022 | Classification in higher-income or lower-income European country |
Hip | Knee | ||||
|---|---|---|---|---|---|---|---|---|
| Reimbursement per hip DAIR procedure (€) | Reimbursement per hip one-stage procedure (€) | Reimbursement per hip two-stage revision (€) | Reimbursement per knee DAIR procedure (€) | Reimbursement per knee one-stage procedure (€) | Reimbursement per knee two-stage revision (€) | |||
| Belgium | 120 | Higher | 13,885 | 15,209 | 29,456 | 12,814 | 16,944 | 30,737 |
| Bulgaria | 59 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Cyprus | 92 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Czechia | 91 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Denmark | 137 | Higher | 13,885 | 15,209 | 29,456 | 12,814 | 16,944 | 30,737 |
| Estonia | 87 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Finland | 109 | higher | 13,885 | 15,209 | 29,456 | 12,814 | 16,944 | 30,737 |
| Hungary | 77 | lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Ireland | 233 | Higher | 13,885 | 15,209 | 29,456 | 12,814 | 16,944 | 30,737 |
| Luxembourg | 261 | Higher | 13,885 | 15,209 | 29,456 | 12,814 | 16,944 | 30,737 |
| North Macedonia | 42 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Poland | 80 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Romania | 77 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Serbia | 44 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Slovakia | 68 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Spain | 85 | Lower | 6,240 | 6,986 | 11,207 | 4,753 | 5,325 | 9,774 |
| Sweden | 120 | Higher | 13,885 | 15,209 | 29,456 | 12,814 | 16,944 | 30,737 |
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DAIR, debridement, antibiotics, and implant retention.
The payments for DAIR, one-, and two-stage procedures, were then multiplied with the number of the respective interventions per country to calculate the payments for each procedure (Figure 1, equation 3). The sum of all payments for the three procedures per country yielded the overall payments per country for hip and knee PJIs (Figure 1, equation 4). In the final step, these payments were summed up to estimate the overall financial burden for healthcare payors across all 30 European countries (Figure 1, equation 5). Costs in currencies other than EUR were converted to EUR using the exchange rates on 26 May 2023.
It was assumed that reimbursement from the public healthcare systems would be similar to those from private health payors as separation of the two sectors was not possible. This approach was adopted for a conservative estimation in the model.
Results
Total number of hip and knee PJIs in Europe for primary arthroplasty performed in 2019
According to the data provided by Eurostat, the Statistical Office of the European Union for 2019, there were 901,462 primary TKAs and 1,147,316 primary THAs performed, with a combined total of 2,048,778 primary THA and TKA procedures in Europe. Most procedures were performed in Germany (THA: 261,675, TKA: 188,985, THA + TKA: 450,660), followed by France (THA: 169,458, TKA: 124,648, THA + TKA: 294,106), the UK (THA: 124,322, TKA: 98,651, THA + TKA: 222,973), and Italy (THA: 115,821, TKA: 82,067, THA + TKA: 197,888) (Table II).
Table II.
Number of primary total hip arthroplasties and total knee arthroplasties implanted in 2019 per country in Europe and the estimated number of resulting hip and knee periprosthetic joint infections from these primary implantations.
| Country | Number of primary THAs implanted in 2019 | Estimated number of hip PJIs of primary THAs implanted in 2019 | Number of primary TKAs implanted in 2019 | Estimated number of knee PJIs of primary TKAs implanted in 2019 |
|---|---|---|---|---|
| Austria | 26,183 | 254 | 20,296 | 209 |
| Belgium | 32,552 | 316 | 24,373 | 251 |
| Bulgaria | 9,241 | 90 | 2,525 | 26 |
| Croatia | 5,885 | 57 | 3,020 | 31 |
| Cyprus | 522 | 5 | 410 | 4 |
| Czechia | 22,136 | 215 | 15,942 | 164 |
| Denmark | 13,281 | 129 | 10,541 | 109 |
| Estonia | 2,241 | 22 | 1,458 | 15 |
| Finland | 16,075 | 156 | 13,721 | 141 |
| France | 169,458 | 1,644 | 124,648 | 1,284 |
| Germany | 261,675 | 2,538 | 188,985 | 1,947 |
| Hungary | 14,369 | 139 | 9,172 | 94 |
| Italy | 115,821 | 1,123 | 82,067 | 845 |
| Ireland | 6,165 | 60 | 2,426 | 25 |
| Lithuania | 5,474 | 53 | 3,652 | 38 |
| Luxembourg | 1,216 | 12 | 1,037 | 11 |
| Netherlands | 29,370 | 285 | 38,090 | 392 |
| North Macedonia | 1,417 | 14 | 400 | 4 |
| Norway | 14,303 | 139 | 6,279 | 65 |
| Poland | 68,021 | 660 | 28,508 | 294 |
| Portugal | 9,387 | 91 | 6,441 | 66 |
| Romania | 14,966 | 145 | 5,127 | 53 |
| Serbia | 10,272 | 100 | 2,693 | 28 |
| Slovenia | 4,164 | 40 | 2,865 | 30 |
| Slovakia | 6,965 | 68 | 5,472 | 56 |
| Spain | 60,501 | 587 | 65,316 | 673 |
| Sweden | 24,959 | 242 | 13,833 | 142 |
| Switzerland | 26,835 | 260 | 22,312 | 230 |
| Turkey | 49,540 | 481 | 101,202 | 1,042 |
| UK | 124,322 | 1,206 | 98,651 | 1,016 |
| Total | 1,147,316 | 11,131 | 901,462 | 9,285 |
| Total primary hip and knee arthroplasties implanted in 2019 | 2,048,778 | |||
| Estimated number of resulting hip and knee PJIs from these primary implantations. | 20,416 | |||
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PJI, periprosthetic joint infection; THA, total hip arthroplasty; TKA, total knee arthroplasty.
Assuming infection rates for TKA and THA of 1.03% and 0.97%, respectively, as reported by Springer et al1 in a review summarizing PJI incidence rates from various arthroplasty registries, the estimated total annual number of hip and knee PJIs is 20,416. This figure includes 11,131 hip PJI cases and 9,285 knee PJI cases, arising from primary THAs and TKAs performed in 2019 (Table II).
Estimation of DAIR, one-stage, and two-stage procedures per country
For an accurate allocation of surgical procedures for PJI treatment, the OPS codes provided by Destatis, Germany, were analyzed. This yielded a distribution of 11.4% for DAIR, 42.6% for one-stage, and 46.0% for two-stage procedures for knee revisions and 8.3% for DAIR, and 33.5% for one-stage and 58.2% for two-stage procedures for hip revisions. Based on these proportions, the number of DAIR, one-, and two-stage procedures per country were calculated and extrapolated to all other countries, resulting in an estimated total number of 925 DAIRs, 3,728 one-stage procedures, and 6,478 two-stage procedures for hip PJI treatment (Supplementary Table i). For knee PJI treatment, the estimates were 1,058 DAIRs, 3,955 one-stage, and 4,271 two-stage procedures (Supplementary Table ii).
Reimbursement payments for DAIR, one-stage, and two-stage PJI procedures per country
As previously reported, detailed information on reimbursement payments for DAIR, one-, and two-stage PJI procedures were obtained from 13 countries (Austria, Croatia, France, Germany, Italy, Lithuania, Netherlands, Norway, Portugal, Slovenia, Switzerland, Turkey, and the UK) (Table III). Generally, reimbursement was lowest for DAIR procedures, and highest for two-stage revisions. The lowest and highest reimbursement payments across all procedure types were observed in Turkey and Switzerland, respectively. For DAIR procedures, reimbursement rates ranged from €978 in Turkey to €32,698 in Switzerland. For one- and two-stage procedures, reimbursement rates were €3,467 and €5,266 in Turkey, and €45,899 and €78,597 in Switzerland, respectively.
Table III.
Reimbursement payments of different European healthcare systems for DAIR, one-stage, and two-stage procedures for hip and knee periprosthetic joint infection treatment, for which detailed information could be gathered in a survery. All values are presented in €.
| Country | Hip | Knee | ||||
|---|---|---|---|---|---|---|
| Reimbursement per hip DAIR procedure | Reimbursement per hip one-stage procedure | Reimbursement per hip two-stage revision | Reimbursement per knee DAIR procedure | Reimbursement per knee one-stage procedure | Reimbursement per knee two-stage revision | |
| Austria | 10,500 | 11,000 | 27,000 | 10,500 | 11,000 | 27,000 |
| Croatia | 7,949 | 10,073 | 10,073 | 7,949 | 11,267 | 11,267 |
| France | 11,545 | 11,545 | 19,596 | 11,545 | 11,545 | 19,596 |
| Germany | 13,918 | 14,893 | 28,936 | 11,203 | 16,047 | 29,050 |
| Italy | 8,215 | 11,932 | 16,605 | 8,215 | 11,932 | 16,605 |
| Lithuania | 3,667 | 3,667 | 3,667 | 3,580 | 3,580 | 3,580 |
| Netherlands | 18,113 | 17,985 | 36,097 | 14,720 | 18,050 | 34,013 |
| Norway | 10,534 | 10,534 | 21,068 | 8,715 | 8,715 | 17,430 |
| Portugal | 5,528 | 5,528 | 11,415 | 4,009 | 4,009 | 13,793 |
| Slovenia | 13,918 | 14,893 | 28,936 | 7,249 | 7,620 | 19,064 |
| Switzerland | 31,229 | 31,417 | 62,834 | 32,698 | 45,899 | 78,597 |
| Turkey | 1,331 | 4,089 | 5,266 | 978 | 3,467 | 4,483 |
| UK | 7,028 | 12,365 | 23,608 | 4,919 | 12,365 | 23,608 |
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DAIR, debridement, antibiotics, and implant retention.
To extrapolate reimbursement payments for the remaining countries without available billing data, these were classified as lower- or higher-income European countries based on their GDP per capita (Table I). Initially, mean values per procedure were estimated by averaging the available data from lower-income countries (Croatia, Lithuania, Portugal, Slovenia, and Turkey). This resulted in a mean amount of €6,240 for DAIR procedures (range: Turkey: €1,331 EUR to Slovenia: €13,918), €6,986 for one-stage exchanges (range: Lithuania: €3,667 EUR to Slovenia: €14,893), and €11,207 for two-stage treatment (range: Lithuania: €3,667 EUR to Slovenia: €28,936) for hip PJI treatment (Table I). For knee PJIs, mean values were €4,753 for DAIR procedures (range: Turkey: €978 EUR to Croatia: €7,949), €5,325 for one-stage exchanges (range: Turkey: €3,467 EUR to Croatia: €11,267), and €9,774 for two-stage revisions (range: Lithuania: €3,580 EUR to Slovenia: €19,064). Averaging the data from higher income countries yielded mean values of €12,814 for DAIR procedures (range: UK: €4,919 EUR to Switzerland: €32,698), €16,944 for one-stage exchanges (range: Norway: €8,715 EUR to Switzerland: €78,597), and €30,737 for two-stage revisions (range: Italy: €16,605 EUR to Switzerland: €45,899) with respect to knee PJIs. For hip PJIs, the average estimates were €13,885 for DAIR procedures (range: UK: €7,028 EUR to Switzerland: €31,229), €15,209 for one-stage exchanges (range: Norway: €10,534 EUR to Switzerland: €31,417), and €29,456 for two-stage revisions (range: Italy: €16,605 EUR to Switzerland: €62,834) (Table I).
Health-economic burden of PJI after primary THA and TKA performed in 2019 for Europe
For hip PJI treatment following primary arthroplasties performed in 2019, the total reimbursement payments across all European countries were estimated to be €197,230,953 (Table IV). The country-specific values ranged from €47,593 in Cyprus to €58,334,220 in Germany. For knee PJI treatment following primary TKA performed in 2019, the total anticipated reimbursement burden is €149,031,073, with values ranging from €30,102 in North Macedonia to €41,804,330 in Germany (Table V).
Table IV.
Reimbursement payments for DAIR, one-stage exchange, and two-stage revision procedures, per country for hip periprosthetic joint infection treatment for primary total hip arthroplasty implanted in 2019.
| Country | Number of DAIR procedures for hip PJI treatment of primary THA implanted in 2019 | Reimbursement per hip DAIR procedure (€) | Total reimbursement for hip DAIR procedures (€) | Number of one-stage procedures for hip PJI treatment of primary THA implanted in 2019 | Reimbursement per hip one-stage procedure (€) | Total reimbursement for hip one-stage procedures (€) | Number of two-stage procedures for hip PJI treatment of primary THA implanted in 2019 | Reimbursement per hip two-stage procedure (€) | Total reimbursement for hip two-stage procedures (€) | Total reimbursement for hip PJI treatment of primary THA implanted in 2019 |
|---|---|---|---|---|---|---|---|---|---|---|
| Austria | 21 | 10,500 | 220,500 | 85 | 11,000 | 935,000 | 148 | 27,000 | 3,996,000 | 5,515,000 |
| Belgium | 26 | 13,885 | 361,010 | 106 | 15,209 | 1,612,154 | 184 | 29,456 | 5,419,904 | 7,393,068 |
| Bulgaria | 7 | 6,240 | 43,680 | 30 | 6,986 | 209,580 | 53 | 11,207 | 593,971 | 847,231 |
| Croatia | 5 | 7,949 | 39,745 | 19 | 10,073 | 191,379 | 33 | 10,073 | 332,394 | 563,518 |
| Cyprus | 0 | 6,240 | 0 | 2 | 6,986 | 13,972 | 3 | 11,207 | 33,621 | 47,593 |
| Czechia | 18 | 6,240 | 112,320 | 72 | 6,986 | 502,992 | 125 | 11,207 | 1,400,875 | 2,016,187 |
| Denmark | 11 | 13,885 | 152,735 | 43 | 15,209 | 653,987 | 75 | 29,456 | 2,209,200 | 3,015,922 |
| Estonia | 2 | 6,240 | 12,480 | 7 | 6,986 | 48,902 | 13 | 11,207 | 145,691 | 207,073 |
| Finland | 13 | 13,885 | 180,505 | 52 | 15,209 | 790,868 | 91 | 29,456 | 2,680,496 | 3,651,869 |
| France | 136 | 11,545 | 1,570,120 | 551 | 11,545 | 6,361,295 | 957 | 19,596 | 18,753,372 | 26,684,787 |
| Germany | 211 | 13,918 | 2,936,698 | 850 | 14,893 | 12,659,050 | 1477 | 28,936 | 42,738,472 | 58,334,220 |
| Hungary | 12 | 6,240 | 74,880 | 46 | 6,986 | 321,356 | 81 | 11,207 | 907,767 | 1,304,003 |
| Italy | 93 | 8,215 | 763,995 | 376 | 11,932 | 4,486,432 | 654 | 16,605 | 10,859,670 | 16,110,097 |
| Ireland | 5 | 13,885 | 69,425 | 20 | 15,209 | 304,180 | 35 | 29,456 | 1,030,960 | 1,404,565 |
| Lithuania | 4 | 3,667 | 14,668 | 18 | 3,667 | 66,006 | 31 | 3,667 | 113,677 | 194,351 |
| Luxembourg | 1 | 13,885 | 13,885 | 4 | 15,209 | 60,836 | 7 | 29,456 | 208,649 | 283,370 |
| Netherlands | 24 | 18,113 | 434,712 | 95 | 17,985 | 1,708,575 | 166 | 36,097 | 5,992,102 | 8,135,389 |
| North Macedonia | 1 | 6,240 | 6,240 | 5 | 6,986 | 34,930 | 8 | 11,207 | 89,656 | 130,826 |
| Norway | 12 | 10,534 | 126,408 | 46 | 10,534 | 484,564 | 81 | 21,068 | 1,706,508 | 2,317,480 |
| Poland | 55 | 6,240 | 343,200 | 221 | 6,986 | 1,543,906 | 384 | 11,207 | 4,303,488 | 6,190,594 |
| Portugal | 8 | 5,528 | 44,224 | 31 | 6,986 | 216,566 | 52 | 11,415 | 593,580 | 854,370 |
| Romania | 12 | 6,240 | 74,880 | 49 | 6,986 | 342,314 | 84 | 11,207 | 941,388 | 1,358,582 |
| Serbia | 8 | 6,240 | 49,920 | 34 | 6,986 | 237,524 | 58 | 11,207 | 650,006 | 937,450 |
| Slovenia | 3 | 13,918 | 41,754 | 13 | 14,893 | 193,609 | 24 | 28,936 | 694,464 | 929,827 |
| Slovakia | 6 | 6,240 | 37,440 | 23 | 6,986 | 160,678 | 39 | 11,207 | 437,073 | 635,191 |
| Spain | 49 | 6,240 | 305,760 | 197 | 6,986 | 1,376,242 | 341 | 11,207 | 3,821,587 | 5,503,589 |
| Sweden | 20 | 13,885 | 277,700 | 81 | 15,209 | 1,231,929 | 141 | 29,456 | 4,153,296 | 5,662,925 |
| Switzerland | 22 | 31,229 | 687,038 | 87 | 31,417 | 2,733,279 | 151 | 62,834 | 9,487,934 | 12,908,251 |
| Turkey | 40 | 1,331 | 53,240 | 161 | 4,089 | 658,329 | 280 | 5,266 | 1,474,480 | 2,186,049 |
| UK | 100 | 7,028 | 702,800 | 404 | 12,365 | 4,995,460 | 702 | 23,608 | 16,572,816 | 22,271,076 |
| Total | 925 | 9,751,962 | 3,728 | 45,135,894 | 6,478 | 142,343,097 | 197,230,953 |
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DAIR, debridement, antibiotics, and implant retention; PJI, periprosthetic joint infection; THA, total hip arthroplasty.
Table V.
Reimbursement payments for DAIR, one-stage exchange, and two-stage revision procedures, per country for knee periprosthetic joint infection treatment for primary total knee arthroplasty implanted in 2019.
| Country | Number of DAIR procedures for knee PJI treatment of primary TKA implanted in 2019 | Reimbursement per knee DAIR procedure (€) | Total reimbursement for knee DAIR procedures (€) | Number of one-stage procedures for knee PJI treatment of primary TKA implanted in 2019 | Reimbursement per knee one-stage procedure (€) | Total reimbursement for knee one-stage procedures (€) | Number of two-stage procedures for knee PJI treatment of primary TKA implanted in 2019 | Reimbursement per knee two-stage procedure (€) | Total reimbursement for knee two-stage procedures (€) | Total reimbursement for knee PJI treatment of primary TKA implanted in 2019 |
|---|---|---|---|---|---|---|---|---|---|---|
| Austria | 24 | 10,500 | 250,231 | 89 | 11,000 | 979,603 | 96 | 27,000 | 2,596,386 | 3,826,220 |
| Belgium | 29 | 12,814 | 366,721 | 107 | 16,944 | 1,812,057 | 115 | 30,737 | 3,549,486 | 5,728,264 |
| Bulgaria | 3 | 4,753 | 14,092 | 11 | 5,325 | 58,997 | 12 | 9,774 | 116,931 | 190,019 |
| Croatia | 4 | 7,949 | 28,188 | 13 | 11,267 | 149,302 | 14 | 11,267 | 161,218 | 338,707 |
| Cyprus | 0 | 4,753 | 2,288 | 2 | 5,325 | 9,580 | 2 | 9,774 | 18,987 | 30,855 |
| Czechia | 19 | 4,753 | 88,972 | 70 | 5,325 | 372,485 | 76 | 9,774 | 738,261 | 1,199,719 |
| Denmark | 12 | 12,814 | 158,602 | 46 | 16,944 | 783,690 | 50 | 30,737 | 1,535,106 | 2,477,398 |
| Estonia | 2 | 4,753 | 8,137 | 6 | 5,325 | 34,066 | 7 | 9,774 | 67,519 | 109,722 |
| Finland | 16 | 12,814 | 206,449 | 60 | 16,944 | 1,020,114 | 65 | 30,737 | 1,998,215 | 3,224,778 |
| France | 146 | 11,545 | 1,689,746 | 547 | 11,545 | 6,314,313 | 591 | 19,596 | 11,573,049 | 19,577,107 |
| Germany | 222 | 11,203 | 2,486,015 | 829 | 16,047 | 13,306,628 | 895 | 29,050 | 26,011,688 | 41,804,330 |
| Hungary | 11 | 4,753 | 51,189 | 40 | 5,325 | 214,304 | 43 | 9,774 | 424,748 | 690,241 |
| Italy | 96 | 8,215 | 791,623 | 360 | 11,932 | 4,296,637 | 389 | 16,605 | 6,456,579 | 11,544,839 |
| Ireland | 3 | 12,814 | 36,502 | 11 | 16,944 | 180,366 | 11 | 30,737 | 353,303 | 570,171 |
| Lithuania | 4 | 3,580 | 15,352 | 16 | 3,580 | 57,367 | 17 | 3,580 | 61,945 | 134,664 |
| Luxembourg | 1 | 12,814 | 12,814 | 5 | 16,944 | 77,098 | 5 | 30,737 | 151,020 | 240,932 |
| Netherlands | 45 | 14,720 | 658,356 | 167 | 18,050 | 3,016,720 | 180 | 34,013 | 6,138,340 | 9,813,416 |
| North Macedonia | 0 | 4,753 | 2,232 | 2 | 5,325 | 9,346 | 2 | 9,774 | 18,524 | 30,102 |
| Norway | 7 | 8,715 | 64,254 | 28 | 8,715 | 240,107 | 30 | 17,430 | 518,541 | 822,902 |
| Poland | 33 | 4,753 | 159,102 | 125 | 5,325 | 666,090 | 135 | 9,774 | 1,320,183 | 2,145,376 |
| Portugal | 8 | 4,009 | 30,320 | 28 | 4,009 | 113,302 | 31 | 13,793 | 420,927 | 564,549 |
| Romania | 6 | 4,753 | 28,614 | 22 | 5,325 | 119,793 | 24 | 9,774 | 237,427 | 385,834 |
| Serbia | 3 | 4,753 | 15,030 | 12 | 5,325 | 62,922 | 13 | 9,774 | 124,711 | 202,662 |
| Slovenia | 3 | 7,249 | 24,386 | 13 | 7,620 | 95,791 | 14 | 19,064 | 258,782 | 378,959 |
| Slovakia | 6 | 4,753 | 30,539 | 24 | 5,325 | 127,853 | 26 | 9,774 | 253,404 | 411,797 |
| Spain | 77 | 4,753 | 364,527 | 287 | 5,325 | 1,526,111 | 309 | 9,774 | 3,024,732 | 4,915,370 |
| Sweden | 16 | 12,814 | 208,134 | 61 | 16,944 | 1,028,440 | 66 | 30,737 | 2,014,526 | 3,251,101 |
| Switzerland | 26 | 32,698 | 856,647 | 98 | 45,899 | 4,493,539 | 106 | 78,597 | 8,308,823 | 13,659,009 |
| Turkey | 119 | 978 | 116,217 | 444 | 3,467 | 1,539,536 | 479 | 4,483 | 2,149,576 | 3,805,329 |
| UK | 116 | 4,919 | 569,797 | 433 | 12,365 | 5,352,325 | 467 | 23,608 | 11,034,578 | 16,956,700 |
| Total | 1,058 | 9,335,075 | 3,955 | 48,058,479 | 4,271 | 91,637,518 | 149,031,073 |
-
DAIR, debridement, antibiotics, and implant retention; PJI, periprosthetic joint infection; TKA, total knee arthroplasty.
A major cost driver for both hip and knee PJI reimbursement is the two-stage exchange, as this is the most frequently performed and expensive treatment modality in all countries. Overall, European healthcare systems are expected to face a total reimbursement burden of approximately €197,230,953 + €149,031,073 = €346,262,026 for PJI treatment for primary hip and knee arthroplasties performed in 2019.
Discussion
This is the first study to comprehensively examine the economic burden of hip and knee PJI within European healthcare systems. Reimbursement for PJI treatment is a critical element in managing this complex condition. The data revealed an estimated total case load of 11,131 hip PJIs and 9,285 knee PJIs in 2019, resulting in a combined total of 20,416 PJI cases. The associated reimbursement expenses were significant, totaling €197,230,953 for hip PJI and €149,031,073 for knee PJI, with an overall financial burden in 2019 of €346,262,026.
The study was conducted from a healthcare payors’ perspective and focusing on infections following primary THA and TKA performed in 2019. It is important to note that this does not represent the annual revision cases performed for PJI. This delineation carries several rationales and implications. First, the goal of the study was to assess the overall burden of PJI across Europe based on available data from Eurostat. As this institution does not provide data on revision arthroplasty surgery, the study relied on information regarding primary implantations, which is available for 30 European countries from Eurostat. This design enabled the calculation of the disease burden that would arise from a single ‘primary arthroplasty year’ in Europe, assuming an overall infection rate of 0.97% for hip and 1.03% knee PJIs.1 Second, the focus from a healthcare funder’s perspective emphasizes the reimbursement burden on healthcare payors rather than the direct costs borne by hospitals for patient treatment. This perspective was selected to diminish heterogeneity and improve the generalizability of the model, as direct costs analyses often reflect the unique financial situation of an individual hospital. These costs can vary considerably between different hospitals within the same country. However, reimbursement rates within a country are relatively uniform across all healthcare facilities.
The analysis clearly demonstrated that countries with the highest case load for primary arthroplasties accounted for the highest reimbursement burden. Eurostat data revealed a total of 2,048,778 primary THA and TKA procedures conducted in 2019 in Europe. The highest numbers were reported in Germany (450,660 cases), France (294,106 cases), the UK (222,973 cases), and Italy (197,888 cases). Collectively, these four countries accounted for 1,165,627 primary hip and knee implantations in 2019, representing 56.9% of all primary arthroplasty procedures in the 30 European countries. This volume translates into a total of 11,603 PJI cases, comprising 6,511 hip and 5,092 knee PJIs, according to the current health-economic model. This represents 61.7% of all reimbursement payments for PJIs (hip PJI: 61.8%, knee PJI: 61.6%). The relatively higher reimbursement ratios compared with the number of PJIs in these four countries can be attributed to the higher reimbursement payments per procedure relative to most other European countries.
Most previous studies have focused on direct healthcare costs of PJIs, assessing the treatment expenses for hospitals. For instance, in the USA in 2012, direct healthcare costs for PJI were reported to be between $24,200 and $31,300.7 Further analysis of treatment expenses revealed that the costs associated with DAIR in septic TKA revisions amounted to $38,776. The costs for two-stage revisions were found to be $56,900.20 Similar health-economic studies have been conducted in Europe. For example, the cost of knee DAIR procedures in Spain was reported to be €19,270.10 A wide range of direct healthcare costs has been reported for two-stage knee revisions, with figures ranging from €11,282 to 18,383 in Germany14,21 to €20,577 in France,16 €23,113 in Ireland,11 and up to €60,257 in Spain10, and €66,684 in Switzerland.15 Similarly, the cost for hip two-stage revisions also shows considerable variation, with reported figures ranging from €14,379 to 27,551 in Germany13,21,22 to €22,152 in France,16 €60,394 in Italy12, and €79,715 in Switzerland.15 The direct cost for hip septic revision in the UK was reported to be €25,545.23 These direct hospital costs cannot be directly equated with the reimbursement payments of healthcare payors due to differing health-economic perspectives. Nevertheless, a comparison is of interest to identify potential disparities between the expenses borne by hospitals for PJI treatment and the remuneration received from healthcare funding systems. This issue has been highlighted in several studies. For example, Haenle et al24 reported a deficit of €6,355 for hip PJI management in Germany, Sabalić et al25 noted a shortfall of €1,695 in Croatia, and Sousa et al17 identified losses of €2,828 for DAIR and €6,247 for two-stage hip PJI revisions. Similarly, in the UK it was reported that the current NHS tariffs do not fully reimburse the costs of revision knee surgery.26 In Switzerland, the financial loss to the treating hospital for two-stage revisions for PJI after TKA and THA, was €36,684 and €44,715, respectively.15 In contrast, in the USA the projected annual cost is estimated to reach $1.85 billion by 2030, with an estimated base-case cost of $390,806 per 65-year-old patient with an infection, a figure significantly higher than those reported in this study for Europe.8,9
The present analysis also illustrates that absolute reimbursement payments vary across different countries, leading to potential disparities in access to care. It is evident that the reimbursement rates in higher-income countries, such as France, Germany, Italy, Switzerland, the Netherlands, and the UK differ markedly from those in lower-income countries, such as Croatia, Lithuania, and Turkey. Notably, there is a striking contrast between countries with reimbursement payments of €1,331 and €31,229 per hip DAIR procedure for Turkey and Switzerland, respectively, or €3,580 and €78,597 for two-stage knee revision for Lithuania and Switzerland, respectively. Such low reimbursement rates in certain countries may pose challenges for healthcare providers in delivering comprehensive and effective PJI treatment. These discrepancies could lead to unequal access to specialized services and potentially compromise patient outcomes. Addressing this critical issue necessitates collaboration among stakeholders, particularly in light of the increasing incidence of PJI.6,27,28 It is imperative for healthcare policymakers, insurance companies, healthcare providers, and professional societies to collaboratively establish reimbursement models that accurately reflect the true costs associated with PJI treatment and cover the entire spectrum of required services.
Moreover, research focusing on the economic impact of PJI treatment and the evaluation of cost-effectiveness can inform reimbursement policies and help optimize resource allocation. By conducting comprehensive cost analyses and comparative studies across different treatment methods and countries, policymakers may gain valuable insights into the financial implications of PJI treatment and make informed decisions to improve reimbursement practices.
The health-economic model employed in this study, incorporating five equations, is based on several assumptions, each with its unique strengths and weaknesses. One of the model’s strengths is the differentiation of treatment costs between DAIR, one-stage, and two-stage PJI treatment. This was undertaken to accurately reflect the varying treatment efforts and associated reimbursement payments for each treatment type. However, for this purpose, ratios for DAIR, one-stage, and two-stage knee revision procedures were used from previously published data for Germany based on OPS codes from the Federal Statistical Office of Germany (Destatis).3 A similar approach was employed for hip procedures, resulting in ratios of 8.3%, 33.5%, and 58.2% for DAIR, one-stage, and two-stage hip procedures, respectively, and 11.4%, 42.6%, and 46.0% for knee procedures. These ratios were then extrapolated to all other countries in the study, which represents a limitation; however, this was a necessary step due to the lack of comparable data from Eurostat. Despite this, we elected to use this approach, as the benefits of procedure stratification outweigh the drawbacks of extrapolation. Further, if we were to assume a ratio of 20% for one-stage procedures, the calculation would yield a total of €380,609,478 (hip €212,049,518 + knee €168,559,960), representing a deviation of €34,347,452 from the actual analysis. In comparison with the 17th Annual Report of the National Joint Registry (NJR) from 2020,29 which does include infection procedures from primary arthroplasties from 2019, our assumed ratios for the different revision procedures show a comparable distribution, particularly for the hip PJI revision interventions. Unfortunately, DAIR procedures are not shown separately in the NJR but are included in single-stage procedures. If our data for DAIR and one-stage are summarized as well, there is almost no difference for the hip revisions (our data: one-stage: 42%, two-stage: 58%; NJR: one-stage: 44%, two-stage: 56%) and a tolerable difference for the knee procedures (our data: one-stage: 54%, two-stage: 46%; NJR: one-stage: 60%, two-stage: 40%). This additional comparison with NJR data strengthens our assumption and our modelling for the revision procedures.
The decision to use data from 2019 for this analysis was strategically made to avoid the potential impact of the COVID-19 pandemic on the number of procedures performed. It is important to clarify that the choice of the year 2019 for primary arthroplasties does not directly correspond to the number of PJI revisions performed in the same year. This approach specifically targets PJIs resulting from primary arthroplasties implanted in 2019, which would manifest over time. A recent observational study on 100,674 primary THAs reported a cumulative incidence of PJI at 15 years of 1.44%, with 62% of PJI cases occurring within two years of the index surgical procedure and 98% occurring within ten years.30 These data are not only clinically relevant, suggesting that 98% of cases are expected to arise in the first ten years by 2029, but also hold relevance for considering inflation rates in this health-economic analysis. We chose to exclude deduction calculations to maintain the clarity and focus of the study, given its existing complexity. This choice is particularly justified considering that over 60% of PJI cases are projected to occur within the first two years following surgery. This approach ensures a more streamlined and manageable analysis, while still capturing the majority of PJI instances expected in the postoperative period. Another limitation of the study is the limited availability of reimbursement data, which were accessible for 12 of the 30 countries. Consequently, average reimbursement rates were extrapolated to the remaining 18 countries based on clustering of higher- and lower-income countries according to GDP per capita. Additionally, the analysis of reimbursement payments was conducted specifically for PJI cases without severe comorbidities. This approach was necessitated by the lack of available comprehensive data that included detailed information on patient comorbidities. In the context of the German Diagnosis-Related Group system, significant variances in remuneration reaching up to €13,148 per hip PJI case have been reported, contingent upon the comorbidities of the patient.22 In addition, the analysis suffers from the fact that only the number of PJI cases, but not the total number of surgical revisions for these cases, could be considered. For example, neither exchange revision PJI cases, which constitute up to 16.2% of the total cases after one- or two-exchange procedures,31 nor failed DAIR procedures with re-revision rates between 0% and 40%,32 were taken into account.
Consequently, the presented numbers are likely to underestimate the overall reimbursement burden. For instance, assuming higher infection rates such as 1.5% for THA and 2.5% for TKA, the total estimated cost would nearly double to a total of €666,700,226 (hip €304,967,551 + knee €361,732,674). This conservative estimation approach was deliberately chosen to ensure a cautious and restrained perspective on the topic, while acknowledging the potential for higher actual costs in practice.
In conclusion, this is the first study to quantify the health-economic burden of PJIs in Europe after primary hip and knee arthroplasty. It reveals a substantial socioeconomic challenge in Europe, with an estimated case load of 20,416 cases and a total reimbursement cost of €346,262,026 for healthcare payors from primary THA and TKA performed in 2019. The primary limitation of this study stems from the focus solely on PJIs following primary arthroplasty procedures conducted in 2019, without including subsequent infection revision surgeries. This approach suggests that the analysis presented may represent an underestimation of the comprehensive PJI burden.
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Author contributions
V. Alt: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing
D. Szymski: Data curation, Methodology
M. Rupp: Data curation, Methodology, Writing – original draft
A. Fontalis: Data curation, Writing – original draft
D. Vaznaisiene: Data curation, Validation
L. C. Marais: Conceptualization, Writing – original draft, Writing – review & editing
C. Wagner: Conceptualization, Supervision
N. Walter: Data curation, Formal analysis, Writing – original draft, Writing – review & editing
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article, other than the open access funding outlined below.
ICMJE COI statement
A. Fontalis reports an EFORT Robotic Fellowship supported by Stryker, which is unrelated to this manuscript. L. Marais declares a South African National Research Foundation grant (no. RA210211585669); honorarium for lectures from Smith & Nephew and Orthofix; and being immediate past-president and board member of the South African Orthopaedic Association, all of which are unrelated. D. Vaznaisiene discloses being President of the Lithuanian Society for Infectious Diseases, and country delegate of the European Bone and Joint Infection Society, both of which are also unrelated.
Data sharing
The data that support the findings for this study are available to other researchers from the corresponding author upon reasonable request.
Acknowledgements
*Delegates from the Country Delegates Group of the European Bone and Joint Infection Society
Volker Alt, Department of Trauma Surgery and Regensburg Center for Musculoskeletal Infection (RUCMI), University Hospital Regensburg, Germany.
Martin Clauss, Center for Muskuloskeletal infections (ZSMI) and Department of Orthopaedics and Trauma Surgery, University Hospital Basel, Switzerland.
Matteo Carlo Ferrari, Internal Medicine Unit, Istituto Clinico Città Studi, Milan, Italy.
Efthymia Giannitsioti, Department of Propaedeutic and Internal Medicine, Medical School National and Kapodistrian University of Athens, Greece.
Mathias Glehr, Department of Orthopedics and Trauma, Medical University Graz, Graz, Austria.
André Grenho, Department of Orthopaedics, Hospital de Curry Cabral, Unidade Local de Saúde de São José, Portugal.
Tomislav Madjarevic, University Hospital for Orthopaedic Surgery Lovran, Croatia
Dirk Jan Moojen, Department of Orthopedic and Trauma Surgery OLVG, Amsterdam, The Netherlands.
Huotari Kaisa, Department of Infectious Diseases, Inflammation Center, Helsinki. University Hospital and University of Helsinki, Helsinki, Finland.
Bedri Karaismailoglu, Istanbul University-Cerrahpasa, Department of Orthopaedics and Traumatology, Istanbul, Turkey.
Rik Osinga, Center for Musculoskeletal Infections (ZMSI) and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland.
Jeroen Neyt, Department of Orthopedic Surgery, University Hospitals Ghent, Ghent, Belgium.
Imre Sallai, Department of Orthopaedics, Semmelweis University, Budapest, Hungary.
Andrea Sambri, Orthopaedic and Traumatology Unit, IRCCS Azienda Ospedaliera Universitaria di Bologna, Bologna, Italy.
Pablo Sanz-Ruiz, Department of Orthopaedic Surgery and Traumatology and Hospital General Universitario Gregorio Marañón, Madrid, Spain.
Ricardo Sousa, Porto Bone Infection Group (GRIP), Orthopaedic Department, Centro Hospitalar Universitário do Porto, Porto, Portugal.
Anna Stefansdottir, Department of Clinical Sciences Lund, Lund University, Division of Orthopedics; Department of Orthopedics, Skåne University Hospital, Lund, Sweden.
Rihard Trebse, Orthopaedic Hospital Valdoltra, Ankaran, Slovenia.
Danguole Vaznaisiene, Department of Infectious Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania.
Marianne Westberg, Division of Orthopaedic Surgery, Oslo University Hospital, Norway.
Christof Wagner, Department of Trauma Surgery, Hospital Ingolstadt, Ingolstadt, Germany.
Open access funding
The open access fee for this manuscript was funded by the University of Regensburg, Germany.
Supplementary material
Tables showing the number of debridement, antibiotics, and implant retention (DAIR), one-stage exchange, and two-stage revision procedures, per country for hip periprosthetic joint infection (PJI) treatment for primary total hip arthroplasty implanted in 2019 assuming a rate of 8.3% for DAIR, 33.5% for one-stage, and 58.2% for two-stage procedures; and the number of DAIR, one-stage exchange, and two-stage revision procedures, per country for knee PJI treatment for primary total knee arthroplasty implanted in 2019 assuming a rate of 11.4% for DAIR, 42.6% for one-stage, and 46.0% for two-stage procedures.
© 2025 Alt et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
