Aims

The aims of this study were to compare the use of resources, costs, and quality of life outcomes associated with subacromial decompression, arthroscopy only (placebo surgery), and no treatment for subacromial pain in the United Kingdom National Health Service (NHS), and to estimate their cost-effectiveness.

We report a cost-effectiveness analysis of Primary Total Ankle Replacements (TAR). In addition, we looked for factors that could be predictors of increased gain in Quality-Adjusted Life Years (QALYs). Pre-operative and six-month post-operative data for TAR was obtained over seven-and-a-half-years in NHS Lothian. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and Deprivation category. Continuous variables were assessed with Pearson correlation coefficients, Deprivation and BMI categories with Boxplots and gender with the Mann-Whitney U test. The 74-patient cohort [Mean age 68.03 (SD 8.61), 60.8% male] had 49% classed as obese or higher. Cost per QALY gained was £3841, rising to £9202 when annual 3.5% reduction in health gains and 1.9% revision rates were included. Lower pre-operative EQ-5D-3L index correlated significantly with increased QALYs gained (p <0.01), all other predictors returned insignificant results (p >0.05). Primary TAR has proven very cost-effective in treating end-stage ankle arthritis. Pre-operative EQ-5D-3L is the most promising predictor of QALYs gained identified

Aims

Prior cost-effectiveness analyses on osseointegrated prosthesis for transfemoral unilateral amputees have analyzed outcomes in non-USA countries using generic quality of life instruments, which may not be appropriate when evaluating disease-specific quality of life. These prior analyses have also focused only on patients who had failed a socket-based prosthesis. The aim of the current study is to use a disease-specific quality of life instrument, which can more accurately reflect a patient’s quality of life with this condition in order to evaluate cost-effectiveness, examining both treatment-naïve and socket refractory patients.

Aims

The aim of this study was to estimate the incremental use of resources, costs, and quality of life outcomes associated with surgical reconstruction compared to rehabilitation for long-standing anterior cruciate ligament (ACL) injury in the NHS, and to estimate its cost-effectiveness.

Aims

The aim of this trial was to assess the cost-effectiveness of a soft bandage and immediate discharge, compared with rigid immobilization, in children aged four to 15 years with a torus fracture of the distal radius.

Slipped capital femoral epiphysis (SCFE) is the most common pediatric hip disorder. The most devastating complication is development of avascular necrosis of the femoral head. In order to reduce the potential for this complication occurring following delayed contralateral SCFE, there has been consideration in the literature of prophylactic pinning of the contralateral hip. The objective of this study was to determine the cost-effectiveness of this treatment strategy. The outcome probabilities and utilities utilised in a decision analysis of prophylactic pinning of the contralateral hip in SCFE, reported by Kocher et al, were used in this study. Costing data, reported in 2005 Canadian dollars, was obtained from our institution. Using this data, an economic evaluation was performed. The time horizon was four years, so as to follow the adolescents to skeletal maturity. Discounting was performed at 3% per year. Sensitivity analyses were conducted to determine the effect of variation of the outcome probabilities and utilities. In all analyses, prophylactic pinning resulted in cost savings but lower utility, compared to the currently accepted strategy of observation of the contralateral hip. The results were most sensitive to an increase in the probability of a delayed contralateral SCFE to 27%. Using the base case analysis, the incremental cost-effectiveness ratio was $7856.12 per utility gained. Using the most sensitive probability of a delayed contralateral SCFE of 27%, the incremental cost-effectiveness ratio was $27,252.92 per utility gained. The results of this study demonstrated overall cost savings with prophylactic treatment, however the utility was lower than the standard treatment of observation. For both the base case and sensitivity analysis, the incremental cost-effectiveness ratio was less than the accepted threshold of $50,000 per quality adjusted life year gained. It should be noted that the use of a four year time horizon excluded consideration of the costs related to total hip arthroplasty for the sequelae of AVN. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment. On the basis of this cost-effectiveness analysis, prophylactic pinning of the contralateral hip in SCFE cannot be recommended. A prospective, randomised controlled trial, with an accompanying economic evaluation, is required to definitively answer the question of the cost-effectiveness of this treatment

Background and Purpose

The STarT Back approach comprises subgrouping of LBP patients according to risk of persistent LBP-related disability, and matches patients to appropriate treatments. In a clinical trial and implementation study, this stratified care approach was clinically and cost-effective compared to usual non-stratified care. However, the long-term cost- effectiveness is unknown, and could be established with decision modelling. A systematic review of model-based economic evaluations in LBP found shortcomings with existing models, including inadequate characterisation of the condition in health states and absence of long-term modelling. This study conceptualises the first decision model of this stratified care approach for LBP management, and assesses long-term cost-effectiveness.

There is ongoing debate regarding the optimal surgical treatment of complex proximal humeral fractures in elderly patients. The aim of this study was to evaluate the cost-effectiveness of reverse total shoulder arthroplasty (RTSA) compared to hemiarthroplasty (HA) in the management of these fractures.

A cost–utility analysis using decision tree and Markov modelling based on data from the published literature was conducted. A single-payer perspective with a lifetime time horizon was adopted. A willingness to pay threshold of CAD $50,000 was used. The incremental cost-effectiveness ratio (ICER) was used as the study's primary outcome measure.

In comparison to HA, the incremental cost per QALY gained for RTSA was $13,679. One-way sensitivity analysis revealed the model to be sensitive to the RTSA implant cost and the RTSA procedural costs. Two-way sensitivity analysis suggested RTSA could also be cost-effective within the first two years of surgery with an early complication rate as high as 25% (if RTSA implant cost was approximately $3,000); or conversely, RTSA implant cost could be as high as $8,500 if its early complication rates were 5%. The ICER of $13,679 is well below the WTP threshold of $50,000 and probabilistic sensitivity analysis demonstrated that 92.6% of model simulations favoured RTSA.

Our economic analysis found that RTSA for the treatment of complex proximal humeral fractures in the elderly is the preferred economic strategy when compared to HA. The ICER of RTSA is well-below standard willingness to pay thresholds, and its estimate of cost-effectiveness is similar to other highly successful orthopaedic strategies such as total hip arthroplasty for the treatment of hip arthritis.

Introduction and Aims: Practice standards vary considerably for prophylactic pinning the contralateral hip opposite a scfe. This work provides a data-driven framework with which to analyse the risks, benefits, and costs of two modes of treatment: prophylactic pinning the normal side contralateral to a scfe versus observation; and pinning of subsequent slips.

Method: A decision analysis model was constructed using the English language literature to estimate SCFE incidence and severity. The model framework assumes that if a hip is pinned prophylactically it will not slip. The benefits of prophylactic pinning are therefore determined by identifying the percentage of contralateral hips that will subsequently slip and then develop early osteoarthritis requiring total hip arthroplasty at a young age. In our cost analysis model, the cost of diagnosis, treatment, and follow-up was developed for the two treatment modes using actual hospital costs and standardised medicare reimbursement schedules for professional fees.

Results: If a hip is not pinned prophylactically, there is a 7% risk of requiring a total hip arthroplasty in the contralateral hip at an early age due to osteoarthritis. This 7% is a combination of patients whose contralateral femoral epiphysis slipped moderately or severely and was pinned in a non-anatomic position (1.5% of the initial population) and patients whose substantial slip was not detected (5.5%). The risk of prophylactic pinning appears to be associated with a 0.3% chance of developing avascular necrosis. Other risks would include chances of infection or chondrolysis, although these have not been reported to date.

If every patient is managed by the prophylactic pinning protocol, the total cost per patient, not including lost time at work or school, for pinning a slipped capital femoral epiphysis, prophylactically pinning the contra lateral side, and post-operative follow-up is $6266. Conversely, the total cost per patient for the second mode, pinning a slipped capital femoral epiphysis, post-operative follow-up and pinning of subsequent contralateral slips that are detected is $6864. Costs of later hip arthroplasty were not included. This analysis suggests that costs to a national health care system for treatment of SCFE would not increase by prophylactic contralateral pinning.

Conclusions: Prophylactic pinning of the contralateral side is merited on the basis of both risk/benefit and cost-effectiveness analyses. Ultimately, the decision must incorporate the physician’s assessment of patient risk factors including: age, weight, co-morbidities, sports activities, the likelihood and feasibility of regular follow-up, and the patient’s and parents’ acceptance of prophylactic surgery.

Aims

To estimate the potential cost-effectiveness of adalimumab compared with standard care alone for the treatment of early-stage Dupuytren’s disease (DD) and the value of further research from an NHS perspective.

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Aims

A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial.

Aims. The purpose was to compare operative treatment with a volar plate and nonoperative treatment of displaced distal radius fractures in patients aged 65 years and over in a cost-effectiveness analysis. Methods. A cost-utility analysis was performed alongside a randomized controlled trial. A total of 50 patients were randomized to each group. We prospectively collected data on resource use during the first year post-fracture, and estimated costs of initial treatment, further operations, physiotherapy, home nursing, and production loss. Health-related quality of life was based on the Euro-QoL five-dimension, five-level (EQ-5D-5L) utility index, and quality-adjusted life-years (QALYs) were calculated. Results. The mean QALYs were 0.05 higher in the operative group during the first 12 months (p = 0.260). The healthcare provider costs were €1,533 higher per patient in the operative group: €3,589 in the operative group and 2,056 in the nonoperative group. With a suggested willingness to pay of €27,500 per QALY there was a 45% chance for operative treatment to be cost-effective. For both groups, the main costs were related to the primary treatment. The primary surgery was the main driver of the difference between the groups. The costs related to loss of production were high in both groups, despite high rates of retirement. Retirement rate was unevenly distributed between the groups and was not included in the analysis. Conclusion. Surgical treatment was not cost-effective in patients aged 65 years and older compared to nonoperative treatment of displaced distal radius fractures in a healthcare perspective. Costs related to loss of production might change this in the future if the retirement age increases. Level of evidence: II. Cite this article: Bone Jt Open 2021;2(12):1027–1034

Introduction and Objective. Total knee arthroplasty (TKA) is a frequently and increasingly performed surgery in the treatment of disabling knee osteoarthritis. The rising number of procedures and related revisions pose an increasing economic burden on health care systems. In an attempt to lower the revision rate due to component malalignment and soft tissue imbalance in TKA, robotic assistance (RA) has been introduced in the operating theatre. The primary objective of this study is to provide the results of a theoretical, preliminary cost-effectiveness analysis of RA TKA. Materials and Methods. A Markov state-transition model was designed to model the health status of sixty-seven-year-old patients in need of TKA due to primary osteoarthritis over a twenty-year period following their knee joint replacement. Transitional probabilities and independent variables were extracted from existing literature. Patients’ state in the transition model was able to change on an annual basis. The main differences between the conventional and RA TKA were the outlier rate in the coronal plane and the cost of the procedure. In RA TKA, it was hypothesized that there were lower revision rates due to a lower outlier rate compared to conventional TKA. Results. The value attributed to the utility both for primary and revision surgery has the biggest impact on the ICER, followed by the rate of successful primary surgery and the cost of RA-technology. Only 2.18–2.34% of the samples yielded from the probabilistic sensitivity analysis proved to be cost-effective (threshold set at $50000/QALY). A calculated surgical volume of at least 191–253 cases per robot per year is needed to prove cost-effective taking the predetermined parameter values into account. Conclusions. Robot-assisted TKA might be a cost-effective procedure compared to conventional TKA if a minimum of 191 cases are performed on a yearly basis, depending on the cost of the robot. The cost-benefit of the robotic TKA surgery is mainly based on a decreased revision rate. This study is based on the assumption that alignment is a predictor of success in total knee arthroplasty. Until there is data confirming the assertion that alignment predicts success robot-assisted surgery cannot be recommended

Aims. To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. Methods. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. Results. The UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE) recommendations apply to post-primary hip and knee arthroplasty follow-up. The ten-year time point is based on a lack of robust evidence beyond ten years. The term 'complex cases' refers to individual patient and surgical factors that may increase the risk for arthroplasty failure. For Orthopaedic Data Evaluation Panel (ODEP) 10A* minimum implants, it is safe to disinvest in routine follow-up from one to ten years post-non-complex hip and knee arthroplasty provided there is rapid access to orthopaedic review. For ODEP 10A* minimum implants in complex cases, or non-ODEP 10A* minimum implants, periodic follow-up post-hip and knee arthroplasty may be required from one to ten years. At ten years post-hip and knee arthroplasty, clinical and radiological evaluation is recommended. After ten years post-hip and knee arthroplasty, frequency of further follow-up should be based on the ten-year assessment; ongoing rapid access to orthopaedic review is still required. Conclusion. Complex cases, implants not meeting the ODEP 10A* criteria, and follow-up after revision surgery are not covered by this recommendation. Cite this article: Bone Jt Open 2023;4(2):72–78

Aims. To assess how the cost-effectiveness of total hip arthroplasty (THA) and total knee arthroplasty (TKA) varies with age, sex, and preoperative Oxford Hip or Knee Score (OHS/OKS); and to identify the patient groups for whom THA/TKA is cost-effective. Methods. We conducted a cost-effectiveness analysis using a Markov model from a United Kingdom NHS perspective, informed by published analyses of patient-level data. We assessed the cost-effectiveness of THA and TKA in adults with hip or knee osteoarthritis compared with having no arthroplasty surgery during the ten-year time horizon. Results. THA and TKA cost < £7,000 per quality-adjusted life-year (QALY) gained at all preoperative scores below the absolute referral thresholds calculated previously (40 for OHS and 41 for OKS). Furthermore, THA cost < £20,000/QALY for patients with OHS of ≤ 45, while TKA was cost-effective for patients with OKS of ≤ 43, since the small improvements in quality of life outweighed the cost of surgery and any subsequent revisions. Probabilistic and one-way sensitivity analyses demonstrated that there is little uncertainty around the conclusions. Conclusion. If society is willing to pay £20,000 per QALY gained, THA and TKA are cost-effective for nearly all patients who currently undergo surgery, including all patients at and above our calculated absolute referral thresholds. Cite this article: Bone Joint J 2020;102-B(7):950–958

Background. The management of the patella during primary total knee arthroplasty (TKA) is controversial. Despite the majority of patients reporting excellent outcomes following TKA, a common complaint is anterior knee pain. Resurfacing of the patella at the time of initial surgery has been proposed as a means of preventing anterior knee pain, however current evidence, including four recent meta-analyses, has failed to show clear superiority of patellar resurfacing. Therefore, the purpose of this study was to estimate the cost-effectiveness of patellar resurfacing compared to non-resurfacing in TKA. Methods. We conducted a cost-effectiveness analysis using a decision analytic model to represent a hypothetical patient cohort undergoing primary TKA. Each patient will receive a TKA either with the Patella Resurfaced or Not Resurfaced. Following surgery, patients can transition to one of three chronic health states: 1) Well Post-operative, 2) Patellofemoral Pain (PFP), or 3) Serious Adverse Event (AE), which we have defined as any event requiring Revision TKA, including: loosening/lysis, infection, instability, or fracture (Figure 1). We obtained revision rates following TKA for both resurfaced and unresurfaced cohorts using data from the 2014 Australian Registry. This data was chosen due to similarities between Australian and North American practice patterns and patient demographics, as well as the availability of longer term follow up data, up to 14 years postoperative. Our effectiveness outcome for the model was the quality-adjusted life year (QALY). We used utility scores obtained from the literature to calculate QALYs for each health state. Direct procedure costs were obtained from our institution's case costing department, and the billing fees for each procedure. We estimated cost-effectiveness from a Canadian publicly funded health care system perspective. All costs and quality of life outcomes were discounted at a rate of 5%. All costs are presented in 2015 Canadian dollars. Results. Our cost-effectiveness analysis suggests that TKA with patella resurfacing is a dominant procedure. Patients who receive primary TKA with non-resurfaced patella had higher associated costs over the first 14 years postoperative ($16,182 vs $15,720), and slightly lower quality of life (5.37 QALYs vs 6.01 QALYs). The revision rate for patellar resurfacing was 1.3%. If the rate of secondary resurfacing procedures is 0.5% or less, there is no difference in costs between the two procedures. Discussion. Our results suggest that, up to 14 years postoperative, resurfacing the patella in primary TKA is cost-effective compared to primary TKA without patellar resurfacing, due to the higher revision rate in this cohort of patients for secondary resurfacing. Our sensitivity analysis suggests that, among surgical practices that do not routinely perform secondary resurfacing procedures (estimated rate at our institution is 0.3%) there is no significant difference in costs. Although our results suggest that patella resurfacing results in higher quality of life, our model is limited by the availability and validity of utility outcome estimates reported in the literature for the long term follow up of patients following TKA with or without patella resurfacing and secondary resurfacing procedures

To evaluate the cost-effectiveness IDET relative to circumferential lumbar fusion with femoral ring allograft (FRA). Cost-effectiveness analysis. Patient-level data were available for patients with discogenic low back pain treated with FRA (n=37) in a randomized trial of FRA vs. titanium cage, and for patients recruited to a separate study evaluating the use of IDET (n=85). Patients were followed-up for 24 months. Oswestry Disability Index, visual analogue scale, quality of life (SF-36), radiographic evaluations, and NHS resource use. Cost-effectiveness was measured by the incremental cost per quality-adjusted life year (QALY) gained. Both treatments produced statistically significant improvements in pain, disability and quality of life at the 24-month follow-up. Costs were significantly lower with IDET due to a shorter mean procedure time (377.4 minutes vs. 49.9 minutes) and length of stay (7 days vs. 1.2 days). The mean incremental cost of IDET was -£3,713 per patient; the mean incremental QALY gain was 0.03. At a threshold of £20,000 per QALY the probability that IDET is cost-effective is 1, and the net health benefit is 0.21 QALY per patient treated. Both treatments led to significant improvements in patient outcomes which were sustained for at least 24 months. Costs were lower with IDET, and for appropriate patients IDET is an effective and cost-effective treatment alternative. Ethics approval: Ethics committee COREC. This cost-effectiveness analysis was carried out by the York Health Economics Consortium at the University of York, and was funded by Smith & Nephew. Smith & Nephew had no financial or other involvement in the collection or analysis of the data on which the CEA is based

The primary aim of this study was to undertake a cost-effectiveness analysis (CEA) of acute fixation versus conservative management of displaced midshaft clavicle fractures. The secondary aim was to conduct a sensitivity analysis of patient characteristics that may influence a threshold of £20,000 per quality-adjusted life year gained (QALY). A CEA was conducted from a randomised control trial comparing conservative management (n=92) to acute plate fixation (n=86) of displaced midshaft clavicle fractures. The incremental cost effectiveness ratio (ICER) was used to express the cost per QALY. The short form 6-dimensional (SF-6D) score was the preference based index to calculate the cost per QALY. The 12-month SF-6D advantage of acute fixation over conservative management was 0.0085 (p=0.464) with a mean cost difference of £4,096.22 and resultant ICER of £481,908.24/QALY. For a threshold of £20,000/QALY the benefit of acute fixation would need to be present for 24.1 years. Linear regression analysis identified nonunion as the only independent factor to influence the SF-6D at 12-months (p<0.001). Conservatively managed fractures that resulted in a nonunion (n=16) had a significantly worse SF-6D compared to acute fixation (0.0723, p=0.001) with comparable healthcare cost at 12-months (£170.12 difference). Modelling the ICER of acute fixation against those complicated by a nonunion proved to be cost effective at £2,352.97/QALY at 12-months. Routine plate fixation of displaced midshaft clavicle fractures is not cost-effective. Patients with nonunion after conservative management have increased morbidity with comparable expense to those undergoing acute fixation which suggests targeting these patients is a more cost-effective strategy

Introduction. The number of medial unicompartmental knee replacements (UKR) performed for arthritis has increased and as such, revisions to total knee replacement (TKR) is increasing. Previous studies have investigated survivorship of UKR to TKR revision and functional outcomes compared to TKR to TKR revision, but have failed to detail the surgical considerations involved in these revisions. Our objectives are to investigate the detailed surgical considerations involved in UKR to TKR revisions. Methods. This study is a retrospective comparative analysis of a prospectively collected database. From 2005 to 2017, 61 revisions of UKR to TKR were completed at a single center. Our inclusion criteria included: revision of UKR to TKR or TKR to TKR with minimum 1 year follow-up. Our exclusion criteria include: single component and liner revisions and revision for infection. The 61 UKR to TKR revisions were matched 2:1 with respect to age, ASA and BMI to a group of 122 TKR to TKR revisions. The following data was collected: indication for and time to revision, operative skin to skin surgical time, the use of specialized equipment (augment size/location, stem use), intraoperative and postoperative complications, re-operations and outcome scores (WOMAC, Oxford 12, SF 12, satisfaction score). Results. There were no statistical differences between the demographic data from either group (age, BMI, ASA, sex and follow-up range). Progression of arthritis was the most common reason for revision in the UKR to TKR group (30/61, 49%, p < 0.001). Aseptic loosening was the most common reason for revision in the TKR to TKR group (73/122, 60%,) and was encountered more often than aseptic loosening in the UKR to TKR group (21/61, 35%, p=0.002). The operative time was longer in the TKR to TKR group (77 vs 112 min, p< 0.001). Femoral augmentation was required for one 1/61 (1.64%) UNI and 92/122 (75%) TKR revisions, respectively (p <0.001). Medial tibial augments were required in 9/61 (14.8%) of the UKR to TKR group while 12/122 (10%) and 10/122 (8%) of the TKR to TKR group required medial and full tibial augments, respectively (p=0.7). UKR to TKR revisions never required femoral stems while 120/122 (98%) of the TKR to TKR group did (p<0.001). Tibial stems were required in 19/61 (31%) and 122/122 (100%) of UKR to TKR and TKR to TKR groups, respectively (p<0.001). There was no statistical difference in the overall complication rate of either group (15% in the UKR to TKR group and 13% in the TKR to TKR group, p = 0.9). Stiffness was a common complication of UKR to TKR and TKR to TKR re-revisions at 2/61 (3%), and 6/122 (5%), respectively (P = 0.6). Aseptic loosening was also a common complication of in both groups at 2/61 (3%) and 4/122 (3%) in the UKR to TKR and TKR to TKR groups, respectively (p = 0.7). There was no statistical difference in the re-operation rate of either group (10% in the UKR to TKR group and 7% in the TKR to TKR group, P = 1). Stiffness was the most common indication for re-operation in the UKR to TKR group (2/61, 3%, p = 0.11) while aseptic loosening was the most common in the TKR to TKR group (4/122, 3.2%, p = 0.7). The survivorship in the UKR to TKR was 93% and 90% at 5 and 9 years, respectively. The survivorship in the TKR to TKR group was 95% and 94% at 5 and 9 years, respectively, which was not statistically different from the UKR group. Discussion. The most common reason for revision was different between the two groups (p < 0.001) while the skin to skin time was longer in the TKR to TKR group. In terms of revision components, femoral stems were never required in the UKR to TKR group while tibial stems were only required in 31%. Similarly, medial tibial augments were only required in 15% of the UKR to TKR group. While the surgeon must be prepared to use augmentation and stems in UKR to TKR revisions, they can often be completed with primary components and therefor will have an overall lower cost to the health care system. Furthermore, the survivorship and re-operation between the two groups was similar which supports previous literature. The results of this study will allow for a more in-depth cost-effectiveness analysis of UKR to TKR vs TKR to TKR in arthroplasty decision making. Unicompartmental knee replacements should be considered in appropriate patients to decrease the lifetime cost of arthroplasty intervention and potentially decrease the burden on the health care system. For figures, tables, or references, please contact authors directly