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

Aims

The aim is to assess the cost-effectiveness of patellofemoral arthroplasty (PFA) in comparison with total knee arthroplasty (TKA) for the treatment of isolated patellofemoral osteoarthritis (OA) based on prospectively collected data on health outcomes and resource use from a blinded, randomized, clinical trial.

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.

Aims. The aim of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was to determine the optimal treatment for adults with a bicortical undisplaced or minimally displaced fracture of the waist of the scaphoid, comparing early surgical fixation with initial cast immobilization, with immediate fixation being offered to patients with nonunion. Methods. A cost-effectiveness analysis was conducted to assess the relative merits of these forms of treatment. The differences in costs to the healthcare system and quality-adjusted life years (QALYs) of the patients over the one-year follow-up of the trial in the two treatment arms were estimated using regression analysis. Results. Our base case analysis found that patients randomized to early surgical fixation had statistically significantly higher mean costs to the NHS of £1,295 more than for the cast immobilization arm (p < 0.001), primarily due to the cost of surgery. They also had a marginally better quality of life, over the period, of 0.0158 QALYs; however, this was not statistically significant (p = 0.379). The mean combined cost per additional QALY was £81,962, well above the accepted threshold for cost-effectiveness used in the UK and internationally. The probability of early surgery being cost-effective in this setting was only 5.6%. Conclusion. Consistent with the clinical findings of SWIFFT, these results indicate that initial cast immobilization of minimally displaced scaphoid fractures, with immediate fixation only offered to patients with nonunion, is the optimal form of treatment, resulting in comparable outcomes with less cost to the healthcare system. Cite this article: Bone Joint J 2021;103-B(7):1277–1283

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.

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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.

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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

A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults.

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. The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery. Materials and Methods. We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale. Results. The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding. Conclusion. It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416–23

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

Aims

The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to aspirin in the prevention of symptomatic venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) using data from the CRISTAL trial.

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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.

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To compare the cost-effectiveness of high-dose, dual-antibiotic cement versus single-antibiotic cement for the treatment of displaced intracapsular hip fractures in older adults.

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The aim of this study was to compare the cost-effectiveness of cemented hemiarthroplasty (HA) versus hydroxyapatite-coated uncemented HA for the treatment of displaced intracapsular hip fractures in older adults.

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

Aims

Ankle fractures are common, mainly affecting adults aged 50 years and over. To aid recovery, some patients are referred to physiotherapy, but referral patterns vary, likely due to uncertainty about the effectiveness of this supervised rehabilitation approach. To inform clinical practice, this study will evaluate the effectiveness of supervised versus self-directed rehabilitation in improving ankle function for older adults with ankle fractures.

Economic evaluation provides a framework for assessing the costs and consequences of alternative programmes or interventions. One common vehicle for economic evaluations in the healthcare context is the decision-analytic model, which synthesizes information on parameter inputs (for example, probabilities or costs of clinical events or health states) from multiple sources and requires application of mathematical techniques, usually within a software program. A plethora of decision-analytic modelling-based economic evaluations of orthopaedic interventions have been published in recent years. This annotation outlines a number of issues that can help readers, reviewers, and decision-makers interpret evidence from decision-analytic modelling-based economic evaluations of orthopaedic interventions.

Cite this article: Bone Joint J 2023;105-B(1):17–20.

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Within healthcare, several measures are used to quantify and compare the severity of health conditions. Two common measures are disability weight (DW), a context-independent value representing severity of a health state, and utility weight (UW), a context-dependent measure of health-related quality of life. Neither of these measures have previously been determined for developmental dysplasia of the hip (DDH). The aim of this study is to determine the DW and country-specific UWs for DDH.

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Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures.

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The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting.

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The escalating demand for medical resources to address spinal diseases as society ages is an issue that requires careful evaluation. However, few studies have examined trends in spinal surgery, especially unscheduled hospitalizations or surgeries performed after hours, through large databases. Our study aimed to determine national trends in the number of spine surgeries in Japan. We also aimed to identify trends in after-hours surgeries and unscheduled hospitalizations and their impact on complications and costs.

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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).

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The aim of this study was to explore the functional results in a fitter subgroup of participants in the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial to determine whether there was an advantage of total hip arthroplasty (THA) versus hemiarthroplasty (HA) in this population.

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Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care.

Summary. Alignment results did not differ between PSG and conventional instrumentation. A small reduction in operation time and blood loss was found with the PSG system, but is unlikely of clinical significance. Length of hospital stay was identical for both groups. Introduction. Several techniques for aligning a TKA exist nowadays. Patient-specific guiding (PSG) has relatively recently been introduced to try to resolve the shortcomings of existing techniques while optimising the operative procedure. Still few reports have been published on the clinical outcome and on the peroperative results of this new technique. This prospective, double-blind, randomised controlled trial was designed to address the following research questions: 1. Is there a significant difference in outliers in alignment in the frontal and sagittal plane between PSG TKA and conventional TKA. 2. Is there a significant difference in operation time, blood loss and length of hospital stay between the 2 techniques. Patients & Methods. 180 patients were randomised for PSG TKA (group 1) or conventional TKA (group 2) in 2 centres. Patients were stratified per hospital. Alignment of the mechanical axis of the leg and flexion/extension and varus/valgus of the individual prosthesis components were measured on digital, standing, long-leg and standard lateral radiographs by 2 independent outcome assessors in both centres. Percentages of outliers, > 3°, were determined. We compared blood loss, operation time and length of hospital stay. Results. There was no statistically significant difference in mean mechanical axis or outliers in mechanical axis between groups. No statistically significant difference was found for the alignment of the individual components in the frontal plane, nor for the percentages of outliers. There was a statistically significant difference in outliers for the femoral component in the sagittal plane, with a higher percentage of outliers in the group 1 (p = 0.017). No such significant result was found for the tibial component in that plane. All interclass correlation coefficients were good. Blood loss was 100 mL less in group 1 (p = 0.000). Operation time was 5 minutes shorter in group 1 (p = 0.000). Length of hospital stay was almost identical with a mean of 3.6 days (p = 0.657). Discussion/Conclusions. The results in terms of obtaining a neutral mechanical axis and a correct position of the prosthesis components did not differ between groups. A small reduction in operation time and blood loss was found with the PSG system, but is unlikely of any clinical significance. Future research should especially focus on cost-effectiveness analysis and functional outcome of PSG TKA

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The aim of this study was to assess medium-term improvements following total hip arthroplasty (THA), and to evaluate what effect different preoperative Oxford Hip Score (OHS) thresholds for treatment may have on patients’ access to THA and outcomes.

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Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m²). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m² to examine whether this is supported.

The role of MRI or CT in the management of patients with LBP, for whom there is no clear clinical indication for the use of sophisticated imaging, is uncertain. The aim of The Scottish Back Trial was to determine whether early use of MRI or CT influences clinical management and outcome of patients with LBP and whether it is cost-effective. Elective patients were new referrals to orthopaedic or neurosurgeons with symptomatic lumbar spine disorders (without ‘red flags’). After obtaining informed consent, patients were randomised to ‘early imaging’ (imaging as soon as practicable) or ‘delayed, selective imaging’ (imaging only if an imperative clinical indication developed). Principal outcomes measures were the SF-36, questionnaire, the Aberdeen LBP Scale and the EQ-5D. Patients completed questionnaires at trial entry and after 8 and 24 months. From 15 hospitals, 2657 patients were assessed and 783 were recruited and randomised. Eight months and twenty-four months after trial entry, comparison of data abstracted from case notes indicated that, apart from the use of imaging, both groups had received similar clinical management. At follow-up, an improvement in health status, as measured by the SF-36 and Aberdeen LBP Scale, was reported by both groups. At 24 months, there was a statistically significant but small difference in favour of the ‘early imaging’ group (p=0. 002) as measured by the Aberdeen LBP Scale but no difference in the SF-36 except a marginal improvement in the bodily pain subscale. The use of MRI or CT imaging for this group of LBP patients did not significantly affect their management. The clinical significance of the marginal improvement in health status in the ‘early imaging’ group is uncertain. The results of the cost-effectiveness analysis may clarify whether a policy of ‘early imaging’ would be a cost effective use of resources

Objective: Dislocation is a well known complication after total hip arthroplasty (THA), and the second cause of revision surgery. Our objective was to assess the effect of a pre-operative patient education session on the occurrence of hip dislocation within 6 months after primary THA. Methods: Between 1998 and 2007 we conducted a prospective cohort study at the University Hospital Department of Orthopaedic Surgery including all primary THAs performed via a transgluteal approach and with use of a 28mm diameter head. The preoperative education session was introduced in June 2002 and included advice on muscle strengthening exercises and postoperative restrictions of range of motion as means of preventing dislocation. Main outcome was the incidence of dislocation within 6 months of surgery. The following potentially confounding factors were assessed: age, sex, body mass index, number of co-morbidities, presence of a neurological disorder, history of alcohol abuse, American Society of Anaesthesiologists (ASA) score, diagnosis (primary or secondary osteoarthritis), previous surgery of the hip, surgeon experience, preoperative functional status, pain level, and motion (Harris Hip Score), preoperative general health status (SF-12), and private or public health care insurance (as proxy for socioeconomic status). Multivariable logistic regression was used for adjustment. Results: 597 patients who underwent 656 THAs between June 2002 and June 2007 participated in the education session, while 1641 patients who underwent 1945 procedures did not. Forty-six dislocations occurred over the study period, 5 (0.8%) in participants and 41 (2.1%) in non-participants (risk difference 1.3%; 95% CI 0.4; 2.3), with the time interval between surgery and dislocation being significantly shorter among participants (0.2 vs. 1.2 months, p=0.016). Preoperative counselling of 77 patients allowed for preventing one dislocation (number needed to treat). Non-participants had a 2.8 times higher risk of dislocation than participants (unadjusted odds ratio 2.80, 95% CI 1.10; 7.13). Adjustment for age, sex, co-morbidities and prior surgery did not change the results (adjusted odds ratio 2.79, 95% CI 1.09; 7.15). Conclusion: Preoperative patient education reduced the dislocation risk within 6 months after THA, and particularly after the patient had returned home. Other peri-operative benefits from patient education have been reported and should be considered in a cost-effectiveness analysis

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Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP.

Purpose. Femoroacetabular impingement syndrome (FAI) is a common cause of hip and groin pain in young adults. Physiotherapy and surgery have both been used to treat FAI syndrome, but there is no robust evidence of comparative effectiveness. UK FASHIoN compared the clinical and cost-effectiveness of arthroscopic hip surgery (HA) versus best conservative care in patients with FAI syndrome. Methods. UK FASHIoN was a pragmatic, multicentre, 2 parallel arm, superiority, randomised controlled trial in patients with FAI syndrome. Eligible patients were over 16 without radiographic signs of osteoarthritis, deemed suitable for arthroscopic FAI surgery. Participants were randomly allocated to HA or Personalised Hip Therapy (PHT - a physiotherapist-led programme comprising 6 to 10 sessions). The primary outcome measure was hip-related quality of life using the patient-reported International Hip Outcome Tool (iHOT-33) at 12 months. Secondary outcomes included EQ5D5L, SF12, adverse events, and cost-effectiveness. Primary analysis compared differences in iHOT-33 scores at 12 months by intention to treat. Results. 348 patients were randomised. Time to surgery was 132 days (SD71) versus 47 days (SD52) to PHT. 92.5% were followed-up at 12 months. Baseline mean iHOT-33 scores were 39.2 (SD21) and 35.6 (SD18) in the surgery and PHT groups, and at 12 months 58.8 (SD27) and 49.7 (SD25) respectively. Mean scores in both groups improved over 12 months, but the mean iHOT-33 score increased more in those allocated to HA than to PHT, with an adjusted mean difference of 6.8 points (95% CI 1.7,12.0 p=0.009). One HA patient developed an infection requiring further surgery. Mean overall costs were £3713 for HA and £1283 for PHT. Conclusions. Hip arthroscopy and best conservative care both led to improved hip-related quality of life in patients with FAI syndrome. At 12-month follow-up, improvement was greater in those allocated to hip arthroscopy

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Debate remains whether the patella should be resurfaced during total knee replacement (TKR). For non-resurfaced TKRs, we estimated what the revision rate would have been if the patella had been resurfaced, and examined the risk of re-revision following secondary patellar resurfacing.

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Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

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A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.