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.

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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.

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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.

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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.

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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