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. Methods. A total of 316 patients were recruited and randomly assigned to either surgical reconstruction or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment). Healthcare resource use and health-related quality of life data (EuroQol five-dimension five-level health questionnaire) were collected in the trial at six, 12, and 18 months using self-reported questionnaires and medical records. Using intention-to-treat analysis, differences in costs, and quality-adjusted life years (QALYs) between treatment arms were estimated adjusting for baseline differences and following multiple imputation of missing data. The incremental cost-effectiveness ratio (ICER) was estimated as the difference in costs divided by the difference in QALYs between reconstruction and rehabilitation. Results. At 18 months, patients in the surgical reconstruction arm reported higher QALYs (0.052 (95% confidence interval (CI) -0.012 to 0.117); p = 0.177) and higher NHS costs (£1,017 (95% CI 557 to 1,476); p < 0.001) compared to rehabilitation. This resulted in an ICER of £19,346 per QALY with the probability of surgical reconstruction being cost-effective of 51% and 72% at a willingness-to-pay threshold of £20,000 and £30,000 per QALY, respectively. Conclusion. Surgical reconstruction as a management strategy for patients with long-standing ACL injury is more effective, but more expensive, at 18 months compared to rehabilitation management. In the UK setting, surgical reconstruction is cost-effective. Cite this article: Bone Joint J 2024;106-B(1):38–45

Aims. This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists. Methods. All hip, knee, and shoulder arthroplasties (2014 to 2020) from the Dutch Arthroplasty Register, and hip and knee arthroplasties from the Danish Hip and Knee Arthroplasty Registries, were included. The expected number of arthroplasties per month in 2020 was estimated using Poisson regression, taking into account changes in age and sex distribution of the general Dutch/Danish population over time, calculating observed/expected (O/E) ratios. Country-specific proportions of patient characteristics and hospital type were calculated per indication category (osteoarthritis/other elective/acute). Waiting list outcomes including QALYs were estimated by modelling virtual waiting lists including 0%, 5% and 10% extra capacity. Results. During COVID-period, fewer arthroplasties were performed than expected (Netherlands: 20%; Denmark: 5%), with the lowest O/E in April. In the Netherlands, more acute indications were prioritized, resulting in more American Society of Anesthesiologists grade III to IV patients receiving surgery. In both countries, no other patient prioritization was present. Relatively more arthroplasties were performed in private hospitals. There were no clinically relevant differences in revision arthroplasties between pre-COVID and COVID-period. Estimated total health loss depending on extra capacity ranged from: 19,800 to 29,400 QALYs (Netherlands): 1,700 to 2,400 QALYs (Denmark). With no extra capacity it will take > 30 years to deplete the waiting lists. Conclusion. The COVID-19 pandemic had an enormous negative effect on arthroplasty rates, but more in the Netherlands than Denmark. In the Netherlands, hip and shoulder patients with acute indications were prioritized. Private hospitals filled in part of the capacity gap. QALY loss due to postponed arthroplasty surgeries is considerable. Cite this article: Bone Jt Open 2022;3(12):977–990

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.

Aims. This study aims to estimate economic outcomes associated with 30-day deep surgical site infection (SSI) from closed surgical wounds in patients with lower limb fractures following major trauma. Methods. Data from the Wound Healing in Surgery for Trauma (WHiST) trial, which collected outcomes from 1,547 adult participants using self-completed questionnaires over a six-month period following major trauma, was used as the basis of this empirical investigation. Associations between deep SSI and NHS and personal social services (PSS) costs (£, 2017 to 2018 prices), and between deep SSI and quality-adjusted life years (QALYs), were estimated using descriptive and multivariable analyses. Sensitivity analyses assessed the impact of uncertainty surrounding components of the economic analyses. Results. Compared to participants without deep SSI, those with deep SSI had higher mean adjusted total NHS and PSS costs (adjusted mean difference £1,577 (95% confidence interval (CI) -951 to 4,105); p = 0.222), and lower mean adjusted QALYs (adjusted mean difference -0.015 (95% CI -0.032 to 0.002); p = 0.092) over six months post-injury, but this difference was not statistically significant. The results were robust to the sensitivity analyses performed. Conclusion. This study found worse economic outcomes during the first six months post-injury in participants who experience deep SSI following orthopaedic surgery for major trauma to the lower limb. However, the increase in cost associated with deep SSI was less than previously reported in the orthopaedic trauma literature. Cite this article: Bone Jt Open 2022;3(5):398–403

Aims. To perform an incremental cost-utility analysis and assess the impact of differential costs and case volume on the cost-effectiveness of robotic arm-assisted unicompartmental knee arthroplasty (rUKA) compared to manual (mUKA). Methods. This was a five-year follow-up study of patients who were randomized to rUKA (n = 64) or mUKA (n = 65). Patients completed the EuroQol five-dimension questionnaire (EQ-5D) preoperatively, and at three months and one, two, and five years postoperatively, which was used to calculate quality-adjusted life years (QALYs) gained. Costs for the primary and additional surgery and healthcare costs were calculated. Results. rUKA was associated with a relative 0.012 QALY gain at five years, which was associated with an incremental cost per QALY of £13,078 for a unit undertaking 400 cases per year. A cost per QALY of less than £20,000 was achieved when ≥ 300 cases were performed per year. However, on removal of the cost for a revision for presumed infection (mUKA group, n = 1) the cost per QALY was greater than £38,000, which was in part due to the increased intraoperative consumable costs associated with rUKA (£626 per patient). When the absolute cost difference (operative and revision costs) was less than £240, a cost per QALY of less than £20,000 was achieved. On removing the cost of the revision for infection, rUKA was cost-neutral when more than 900 cases per year were undertaken and when the consumable costs were zero. Conclusion. rUKA was a cost-effective intervention with an incremental cost per QALY of £13,078 at five years, however when removing the revision for presumed infection, which was arguably a random event, this was no longer the case. The absolute cost difference had to be less than £240 to be cost-effective, which could be achieved by reducing the perioperative costs of rUKA or if there were increased revision costs associated with mUKA with longer follow-up. Cite this article: Bone Jt Open 2023;4(11):889–898

While pre-soaking grafts in vancomycin has demonstrated to be effective in observational studies for anterior cruciate ligament reconstruction (ACLR) infection prevention, the economic benefit of the technique is uncertain. The primary aim of this study was to determine the cost-effectiveness of vancomycin pre-soaking during primary ACLR to prevent post-operative joint infections. The secondary aims of the study were to establish the breakeven cost-effectiveness threshold of the technique. A Markov model was used to determine cost effectiveness and the incremental cost effectiveness ratio of additional vancomycin pre-soaking compared to intravenous antibiotic prophylaxis alone. A repeated meta-analysis of nine cohort studies (Level III evidence) was completed to determine the odds ratio of infection with vancomycin pre-soaking compared to intravenous antibiotics alone. Estimated costs and transitional probabilities for further surgery were obtained from the literature. Breakeven threshold analysis was performed. The vancomycin soaking technique provides an expected cost saving of $600AUD per patient. There was an improvement in the quality-adjusted life years of 0.007 compared to intravenous antibiotic prophylaxis alone (4.297 versus 4.290). If the infection rate is below 0.023% with intravenous antibiotics alone or the additional intervention cost more than $1000AUD, the vancomycin wrap would no longer be cost-effective. For $30AUD, the vancomycin soaking technique provides a $600AUD cost saving by both reducing the risk of ACLR related infection and economic burden of infection. Treating septic arthritis represents a mean cost per patient of 6 times compared to that of the primary surgery. There has been no previous cost-effectiveness study of the vancomycin wrap technique. The vancomycin pre-soaking technique is a highly cost-effective method to prevent post-operative septic arthritis following primary ACLR

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. Patients and Methods. Using data from 273 patients, healthcare-related use of resources, costs and quality-adjusted life years (QALYs) were estimated at 12 months and 24 months after surgery on an intention-to-treat basis with adjustment for covariates. Uncertainty about the incremental cost-effectiveness ratio for arthroscopic versus open management at 24 months of follow-up was incorporated using bootstrapping. Multiple imputation methods were used to deal with missing data. Results. There were no significant differences between the arthroscopic and open groups in terms of total mean use and cost of resources or QALYs at any time post-operatively. Open management dominated arthroscopic management in 59.8% of bootstrapped cost and effect differences. The probability that arthroscopic management was cost-effective compared with open management at a willingness-to-pay threshold of £20 000 per QALY gained was 20.9%. Conclusion. There was no significant overall difference in the use or cost of resources or quality of life between arthroscopic and open management in the trial. There was uncertainty about which strategy was most cost-effective. Cite this article: Bone Joint J 2016;98-B:1648–55

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

Introduction and Aims: Treatment of the displaced intra-articular calcaneal fracture (DIACF) has long been a source of uncertainty in orthopaedic surgery. To evaluate the cost-effectiveness of operative versus non-operative management of this fracture, a model was constructed based on a randomised clinical trial. Model outputs were costs and quality-adjusted life years (QALYs). Method: A decision tree was constructed to model the effect on costs and quality-adjusted life years (QALYs) of operative versus non-operative management for DIACFs. Complication rate, fusion rate, survival data, productivity losses and patient utilities were estimated from a recent prospective randomised control trial. Four-year costs were estimated from the centre treating 73% of the patients. A societal perspective was used in the primary analysis. Future costs and benefits were discounted at 5% and reported in 2002 Canadian dollars. One-way sensitivity analysis and a multi-way Monte Carlo simulation were performed incorporating all ranges of values for the utilities, costs and probabilities. Results: When productivity losses were included, operative management was less costly ($13,000 cost saving) and had an incremental gain of .06 QALYs, based on improvements in health-related quality of life, thus, making it the dominant strategy compared to non-operative treatment. The cost-effectiveness was most sensitive to the estimates of the productivity losses. When productivity losses were excluded, the increase in cost of operative treatment was $2700 for an incremental gain of .06 QALYs, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. The outcome of the analysis remained stable with the remainder of the one-way and multi-way sensitivity analysis. Of the 2000 iterations, with Monte Carlo simulation when productivity losses were included, 80% resulted in cost-effectiveness ratios less than $50,000 per QALY gained for operative treatment. When productivity losses were excluded, 53% of the 2000 iterations resulted in cost-effectiveness ratios less than $50,000. Conclusion: The treatment of the DIACF has long been a source of uncertainty in orthopaedic surgery. The cost-effectiveness of operative management indicates that it is a moderately economically attractive treatment (a CU ratio of < $50,000). Further exploration of the impact of productivity losses is required

To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFS), a model was constructed based on a randomized clinical trial. Model outputs were costs and quality-adjusted life years (QALYs). When a societal perspective was taken (i.e. productivity losses were included), operative management was less costly and more effective than non-operative care. Sensitivity analysis revealed that cost-effectiveness was highly dependent on the estimates of productivity losses. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for an incremental gain of .06 QALYs, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. To evaluate the cost-effectiveness of operative versus non-operative management of displaced intra-articular calcaneal fractures (DIACFs). A decision tree was constructed to model the effect on costs and quality-adjusted life years (QALYs) of operative versus non-operative management for DIACFs. Complication rate, fusion rate, patient survival and utilities, and productivity losses were estimated from a recent prospective randomized control trial. Four-year costs were estimated from the center treating 73% of the patients in the trial. A societal perspective was used. Future costs and benefits were discounted at 5% and reported in 2002 Canadian Dollars. One-way and multi-way sensitivity analysis was performed on all variables using plausible ranges. When productivity losses were included, operative management was less costly ($13,000 saving) and had a gain of .06 QALYs (based on improvements in health related quality of life), making it the dominant strategy compared to non-operative treatment. The cost-effectiveness was most sensitive to the return to work estimates. When productivity losses were excluded, the increase in cost of operative treatment was $2,700 for a .06 QALY gain, giving an incremental cost-utility (CU) ratio of $44,000 per QALY gained. The treatment of the DIACF has long a source of uncertainty in orthopedic surgery. A recent prospective, randomized, trial concluded that operative management provided no improvement over non-operative care. The cost-effectiveness of operative management indicates that it is a moderately economically attractive treatment (a CU ratio of < $50,000). Further exploration of the impact of productivity losses is required. Funding: Dr. Brauer is supported by a grant from Alberta Heritage Foundation

Follow-up of arthroplasty varies widely across the UK. The aim of this NIHR-funded study was to employ a mixed-methods approach to examine the requirements for arthroplasty follow-up and produce evidence-based and consensus-based recommendations. It has been supported by BHS, BASK, BOA, ODEP and NJR. Four interconnected work packages have recently been completed: (1) a systematic literature review; (2a) analysis of routinely collected National Health Service data from four national data sets to understand when and which patients present for revision surgery; (2b) prospective data regarding how patients currently present for revision surgery; (3) economic modelling to simulate long-term costs and quality-adjusted life years associated with different follow-up care models and (4) a Delphi-consensus process, involving all stakeholders, to develop a policy document to guide appropriate follow-up care after primary hip and knee arthroplasty. We will present the following Recommendations:. For ODEP10A∗ minimum implants, it is safe to disinvest in routine follow-up from 1 to 10 years post non-complex hip and knee replacement provided there is rapid access to orthopaedic review. For ODEP10A∗ minimum implants in complex cases, or non-ODEP10A∗ minimum implants, periodic follow-up post hip and knee replacement may be required from 1 to 10 years. At 10 years post hip and knee replacement, we recommend clinical, which may be virtual, and radiographic evaluation. After 10 years post hip and knee replacement, frequency of further follow-up should be based on the 10-year assessment; ongoing rapid access to orthopaedic review is still required. Overarching statements. These recommendations apply to post primary hip and knee replacement follow-up. The 10-year time point in these recommendations is based on a lack of robust evidence beyond ten years. The term complex cases refer to individual patient and surgical factors that may increase the risk for replacement failure

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. Methods. A cost-utility analysis from the NHS perspective compared stratified care with usual care, in patients consulting in primary care with non-specific LBP. A Markov state-transition model was constructed where long-term patient prognosis over ten years was dependent upon physical function achieved at twelve months. Consultation with experts helped define condition health states, inform the long-term modelling, and choice of sensitivity analyses. Results. Preliminary base-case results indicate this model of stratified care is cost-effective over a ten-year time horizon, delivering 0.10 additional quality-adjusted life years (QALYs) at a cost-saving of £100.27 per patient. Sensitivity analyses indicate the approach is likely to be cost-effective in all scenarios, and cost-saving in most, although sensitive to assumptions regarding long-term patient prognosis. Analysis from the societal perspective improved the associated cost-savings. Conclusion. It is likely that implementation of this stratified care model will help reduce unnecessary healthcare usage, whilst improving patient quality of life. No conflicts of interest. Funding: Research stipend for JAH by the Institute for Primary Care & Health Sciences, Keele University

Background. Prosthetic implants used in primary total hip replacements have a range of bearing surface combinations (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, metal-on-metal); head sizes (small <36mm, large 36mm+); and fixation techniques (cemented, uncemented, hybrid, reverse hybrid), which influence prosthesis survival, patient quality of life, and healthcare costs. This study compared the lifetime cost-effectiveness of implants to determine the optimal choice for patients of different age and gender profiles. Methods. In an economic decision Markov model, the probability that patients required one or more revision surgeries was estimated from analyses of UK and Swedish hip joint registries, for males and females aged <55, 55–64, 65–74, 75–84, and 85+ years. Implant and healthcare costs were estimated from hospital procurement prices, national tariffs, and the literature. Quality-adjusted life years were calculated using utility estimates, taken from Patient-Reported Outcome Measures data for hip procedures in the UK. Results. Optimal choices varied between traditionally used cemented metal-on-polyethylene and cemented ceramic-on-polyethylene implants. Small head cemented ceramic-on-polyethylene implants were optimal for males and females aged under 65. The optimal choice for adults aged 65 and older was small head cemented metal-on-polyethylene implants. Conclusions. The older the patient, the higher the probability that small head cemented metal-on-polyethylene implants are optimal. Small head cemented ceramic-on-polyethelyne implants are optimal for adults aged under 65. Our findings can influence NICE guidance, clinical practice, and commissioning of services. Funding. NIHR Research for Patient Benefit programme PB-PG-0613-31032

Introduction. Postoperative dislocation remains a vexing problem for patients and surgeons following total hip arthroplasty (THA). It is the commonest reason for revision THA in the US. Dual mobility (DM) THA implants markedly decrease the risk of THA instability. However, DM implants are more expensive than those used for conventional THA. The purpose of this study was to perform a cost-effectiveness analysis of DM implants compared to conventional bearing couples for unilateral primary THA using a computer model-based evaluation. Methods. A state-transition Markov computer simulation model was developed to compare the cost-utility of dual mobility versus conventional THA for hip osteoarthritis from a societal perspective (Figure 1). The model was populated with health outcomes and probabilities from registry and published data. Health outcomes were expressed as quality-adjusted life years (QALYs). Direct costs were derived from the literature and from administrative claims data, and indirect costs reflected estimated lost wages. All costs were expressed in 2013 US dollars. Health and cost outcomes were discounted by 3% annually. The base case modeled a 65-year-old patient undergoing THA for unilateral hip osteoarthritis. A lifetime time horizon was analyzed. The primary outcome was the incremental cost-effectiveness ratio (ICER). The willingness-to-pay threshold was set at $100,000/QALY. Threshold, one-way, two-way, and probabilistic sensitivity analyses were performed to assess model uncertainty. Results. DM THA exhibited absolute dominance over conventional THA with lower accrued costs (US$45,960 versus $47,103) and higher accrued utility (12.08 QALY versus 11.84 QALY). The ICER was -$4,771/QALY, suggesting that DM THA is cost-saving compared to conventional THA. The cost threshold at which dual mobility implants were cost-ineffective was $25,000 (Figure 2), and the threshold at which DM implants ceased being cost-saving was $12,845. Sensitivity analyses demonstrated that the probability of intraprosthetic dislocation, primary THA utility, and age at index THA most influenced model results. In the probabilistic sensitivity analysis, 90% of model iterations resulted in cost savings for DM THA (Figure 3). Discussion. Dual mobility components showed clear cost-utility advantages over conventional THA components, and DM implants are cost-saving for primary unilateral THA from a societal perspecitve. Model results suggest that DM THA need not be limited to only high-risk patients, although patient age and risk of dislocation are important determinants of its cost-utility

Study design. Economic evaluation alongside a prospective, randomised, controlled trial from a two-year National Health Service (NHS) perspective. Objective. To determine the cost-effectiveness of Titanium Cages (TC) compared to Femoral Ring Allografts (FRA) in circumferential lumbar spinal fusion. Summary of background data. A randomised controlled trial has shown the use of TC to be clinically inferior to the established practice of using FRA in circumferential lumbar fusion. Health economic evaluation is needed to justify the continued use of TC, given that this treatment is less effective and, all things being equal, is assumed more costly than FRA. Methods. Eighty-three patients were randomly allocated to receive either the TC or FRA between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF-6D) was administered pre-operatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs) for the trial period. Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness. Results. A significant cost difference of £1,942 (95% CI £849 to £3,145) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of -0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 in favour of FRA. Conclusion. From an NHS perspective, this data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was both cheaper and generated greater QALY gains. FRA patients also reported a greater return to work rate

Background. One untested back pain treatment model is to stratify management depending on prognosis (low, medium or high-risk). This 2-arm RCT investigated: (i) overall clinical and cost-effectiveness of stratified primary care (intervention), versus non-stratified current best practice (control); and (ii) whether low-risk patients had non-inferior outcomes, and medium/high-risk groups had superior outcomes. Methods. 1573 adults with back pain (+/− radiculopathy) consulting at 10 general practices in England responded to invitations to attend an assessment clinic, at which 851 eligible participants were randomised (intervention n=568; control n=283). Primary outcome using intention-to-treat analysis was the difference in change in the Roland-Morris Disability Questionnaire (RMDQ) score at 12 months. Secondary outcomes included 4-month RMDQ change between arms overall, and at risk-group level at both time-points. The economic evaluation estimated incremental quality-adjusted life years (QALYs) and back pain-related health care costs. Results. Overall, between-group differences in RMDQ adjusted mean change scores significantly favoured stratified care; 1·8 (95%CI 1·1, 2·6) at 4-months and 1·1 (95%CI 0·3, 1·9) at 12-months. Stratified care was associated with an increase in generic health benefit (0.039 additional QALYs) and cost savings. Low-risk patients had non-inferior outcomes compared with controls, and there were significant between-group differences in RMDQ adjusted mean change scores for medium-risk patients at 4 (1·99 [95%CI 0·75, 3·22]) and 12 months (1·33 [95%CI 0·15, 2·52]), and high-risk patients at 4 months (2·53 [95%CI 0·90, 4·16]). Conclusion. A stratified approach of prognostic screening with treatment matched pathways for patients in primary care with back pain provides significant improvements in clinical and economic outcomes compared to current best practice. Conflicts of Interest. None. Source of Funding. Arthritis Research UK. This abstract has been presented at 3 international conferences but not yet at a national conference. It has also been accepted for publication in the Lancet – but is not yet published

Study Design: Economic evaluation alongside a prospective, randomized, controlled trial from a 2-year NHS perspective. Objective: To determine the cost-effectiveness of Titanium Cages (TC) compared to Femoral Ring Allografts (FRA) in circumferential lumbar fusion. Summary of background data: A randomised controlled trial has shown the use of TC to be clinically inferior to the established practice of using FRA in circumferential lumbar fusion. Health economic evaluation is urgently needed to justify the continued use of TC, given that this treatment is less effective and, all things being equal, more costly than FRA. Methods: Eighty-three patients were randomly allocated to receive either the TC or FRA as part of a circumferential lumbar fusion between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF- 6D) was administered preoperatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs). Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness. Results: A significant cost difference of £1,942 (95% CI £849 to £3,145) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of 0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 in favour of FRA. Conclusion: From an NHS perspective, the trial data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was both cheaper and generated greater QALY gains. FRA patients reported a greater return to work rate

Introduction: A prospective randomised controlled trial of circumferantial spinal fusion has shown superior clinical outcome when a femoral ring allograft (FRA) is used compared to when a titanium cage (TC) is used. The implant cost of the TC is nearly ten fold that of the FRA. However the additional costs of surgery and related costs also need to be considered to determine if there is a real cost advantage of FRA over TC. We can find no previously reported studies which economically evaluate the TC and the FRA in circumferential lumbar spinal fusion. The aim of this study was to investigate cost-effectiveness of TCs in comparison to FRAs for circumferential lumbar spinal fusion over a two year National Health Service (NHS) perspective using a cost-utility evaluation. Methods: This randomised study had the approval of the local ethical committee and the institutional research and development board (Reference OR059844) prior to its commencement. Eighty-three patients were randomly allocated to receive either the TC or FRA as part of a circumferential lumbar fusion between 1998 and 2002. NHS costs related to the surgery and revision surgery needed during the trial period were monitored and adjusted to the base year (2005/6 pounds sterling). The Short Form-6D (SF-6D) was administered preoperatively and at 6, 12 and 24 months in order to elicit patient utility and subsequently Quality-Adjusted Life Years (QALYs) for the trial period. Return to paid employment was also monitored. Bootstrapped mean differences in discounted costs and benefits were generated in order to explore cost-effectiveness. Results: Baseline demographic data including age, sex, smoking history, previous surgery history and number of operated levels did not differ between the two groups. A significant cost difference of £1,942 (AUD4,255), (95% CI £849 (AUD1,860) to £3,145 (AUD6,891)) in favour of FRA was found. Mean QALYs per patient over the 24 month trial period were 0.0522 (SD 0.0326) in the TC group and 0.1914 (SD 0.0398) in the FRA group, producing a significant difference of −0.1392 (95% CI 0.2349 to 0.0436). With regard to employment, incremental productivity costs were estimated at £185,171 (AUD 405,745) in favour of FRA. Discussion: From an NHS perspective, the trial data show that TC is not cost-effective in circumferential lumbar fusion. The use of FRA was found to dominate (generating greater QALY gains and less cost). In addition FRA patients reported a greater return to work rate and hence, productivity costs were also in favour of FRA

Introduction: Rivaroxaban is a novel, oral, direct Factor Xa inhibitor for the prevention of venous thromboembolism (VTE) after total hip and knee arthroplasty (THA, TKA). The pivotal RECORD trials showed that 35 days’ rivaroxaban significantly reduced total VTE following THA versus both 35-day and 14-day enoxaparin regimens. Following TKA, 14 days’ rivaroxaban significantly reduced total and symptomatic VTE versus 14 days enoxaparin. Major bleeding was similar for rivaroxaban and enoxaparin. An economic model was developed based on these results to assess the cost-effectiveness of rivaroxaban relative to enoxaparin in Sweden. Methods: The incidence of clinical events and resulting consequences on resource use and quality of life were modelled for rivaroxaban and enoxaparin over 5 years. VTE incidence during the prophylaxis period was based upon RECORD2 (THA) and RECORD3 (TKA) and extrapolated out to 90 days following surgery based on published epidemiological data. These trials were used because they best reflect the treatment length currently applied in clinical practice in Sweden. Recurrent VTE and post-thrombotic syndrome (PTS) beyond 90 days were modelled from published clinical data. Literature indicates that 10% of enoxaparin patients require visits from a district nurse following hospital discharge to administer subcutaneous (sc) enoxaparin, a cost not incurred with oral rivaroxaban. The cost associated with clinical events (major bleed, VTE and PTS) and home care visit was derived from published Swedish sources and expressed in Swedish kroner (SEK). Rivaroxaban and enoxaparin costs were included. Results: In THA, 35 days’ rivaroxaban produced an additional cost (SEK 119 [€12.59] per patient) versus 14 days enoxaparin. However, rivaroxaban resulted in a gain of quality-adjusted life years (QALYs) and in fewer symptomatic events per patient relative to enoxaparin. This means an extra cost with rivaroxaban of SEK 29,378 (€3,109) per QALY gained and SEK 3,929 (€416) per symptomatic event avoided. Because the cost for treating a VTE range from SEK 12,000 to 30,000, it is less costly to avoid such an event by using rivaroxaban than treating it once it occurs. In TKA, 14 days’ rivaroxaban produced savings of SEK 873 (€92) per patient versus 14 days’ enoxaparin, as well as an improvement in QALYs and a reduction in symptomatic VTE events. Consequently, rivaroxaban was both more effective and less costly. Extensive sensitivity analyses showed that these results persist in a clear majority of situations. Conclusion: The economic analysis showed that by reducing VTE, and providing an oral alternative to sc enoxaparin, oral rivaroxaban has the potential to significantly improve health outcomes in Sweden at a slightly higher (in THA) or lower (in TKA) cost than existing VTE prophylaxis

Aims

The aim of this study was to evaluate the cost-effectiveness of arthroscopic partial meniscectomy versus physical therapy plus optional delayed arthroscopic partial meniscectomy in young patients aged under 45 years with traumatic meniscal tears.