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The Bone & Joint Journal
Vol. 106-B, Issue 1 | Pages 38 - 45
1 Jan 2024
Leal J Mirza B Davies L Fletcher H Stokes J Cook JA Price A Beard DJ

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.


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.

Methods

A total of 100 patients with isolated patellofemoral osteoarthritis were randomized to receive either PFA or TKA by experienced knee surgeons trained in using both implants. Patients completed patient-reported outcomes including EuroQol five-dimension questionnaire (EQ-5D) and 6-Item Short-Form Health Survey questionnaire (SF-6D) before the procedure. The scores were completed again after six weeks, three, six, and nine months, and again after one- and two-year post-surgery and yearly henceforth. Time-weighted outcome measures were constructed. Cost data were obtained from clinical registrations and patient-reported questionnaires. Incremental gain in health outcomes (quality-adjusted life-years (QALYs)) and incremental costs were compared for the two groups of patients. Net monetary benefit was calculated assuming a threshold value of €10,000, €35,000, and €50,000 per QALY and used to test the statistical uncertainty and central assumptions about outcomes and costs.


Orthopaedic Proceedings
Vol. 101-B, Issue SUPP_11 | Pages 6 - 6
1 Oct 2019
Masri BA Zamora T Garbuz DS Greidanus NV
Full Access

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


The Bone & Joint Journal
Vol. 105-B, Issue 11 | Pages 1177 - 1183
1 Nov 2023
van der Graaff SJA Reijman M Meuffels DE Koopmanschap MA

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.

Methods

We conducted a multicentre, open-labelled, randomized controlled trial in patients aged 18 to 45 years, with a recent onset, traumatic, MRI-verified, isolated meniscal tear without knee osteoarthritis. Patients were randomized to arthroscopic partial meniscectomy or standardized physical therapy with an optional delayed arthroscopic partial meniscectomy after three months of follow-up. We performed a cost-utility analysis on the randomization groups to compare both treatments over a 24-month follow-up period. Cost utility was calculated as incremental costs per quality-adjusted life year (QALY) gained of arthroscopic partial meniscectomy compared to physical therapy. Calculations were performed from a healthcare system perspective and a societal perspective.


Bone & Joint Open
Vol. 4, Issue 11 | Pages 889 - 898
23 Nov 2023
Clement ND Fraser E Gilmour A Doonan J MacLean A Jones BG Blyth MJG

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.


The Bone & Joint Journal
Vol. 104-B, Issue 4 | Pages 452 - 463
1 Apr 2022
Elcock KL Carter TH Yapp LZ MacDonald DJ Howie CR Stoddart A Berg G Clement ND Scott CEH

Aims

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.

Methods

This single-centre study compared 169 consecutive patients with severe obesity (BMI ≥ 40 kg/m2) (mean age 65.2 years (40 to 87); mean BMI 44.2 kg/m2 (40 to 66); 129/169 female) undergoing unilateral TKA to a propensity score matched (age, sex, preoperative Oxford Knee Score (OKS)) cohort with a BMI < 40 kg/m2 in a 1:1 ratio. Demographic data, comorbidities, and complications to one year were recorded. Preoperative and one-year patient-reported outcome measures (PROMs) were completed: EuroQol five-dimension three-level questionnaire (EQ-5D-3L), OKS, pain, and satisfaction. Using national life expectancy data with obesity correction and the 2020 NHS National Tariff, QALYs (discounted at 3.5%), and direct medical costs accrued over a patient’s lifetime, were calculated. Probabilistic sensitivity analysis (PSA) was used to model variation in cost/QALY for each cohort across 1,000 simulations.


Bone & Joint Open
Vol. 3, Issue 1 | Pages 35 - 41
9 Jan 2022
Buchalter DB Nduaguba A Teo GM Kugelman D Aggarwal VK Long WJ

Aims

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.

Methods

This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI.


The Bone & Joint Journal
Vol. 103-B, Issue 5 | Pages 864 - 871
3 May 2021
Hunt LP Matharu GS Blom AW Howard PW Wilkinson JM Whitehouse MR

Aims

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.

Methods

A retrospective observational study of the National Joint Registry (NJR) was performed. All primary TKRs for osteoarthritis alone performed between 1 April 2003 and 31 December 2016 were eligible (n = 842,072). Patellar resurfacing during TKR was performed in 36% (n = 305,844). The primary outcome was all-cause revision surgery. Secondary outcomes were the number of excess all-cause revisions associated with using TKRs without (versus with) patellar resurfacing, and the risk of re-revision after secondary patellar resurfacing.


The Bone & Joint Journal
Vol. 101-B, Issue 11 | Pages 1331 - 1347
1 Nov 2019
Jameson SS Asaad A Diament M Kasim A Bigirumurame T Baker P Mason J Partington P Reed M

Aims

Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients.

Materials and Methods

Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients.


The Bone & Joint Journal
Vol. 99-B, Issue 8 | Pages 1028 - 1036
1 Aug 2017
Chawla H Nwachukwu BU van der List JP Eggman AA Pearle AD Ghomrawi HM

Aims

Patellofemoral arthroplasty (PFA) has experienced significant improvements in implant survivorship with second generation designs. This has renewed interest in PFA as an alternative to total knee arthroplasty (TKA) for younger active patients with isolated patellofemoral osteoarthritis (PF OA). We analysed the cost-effectiveness of PFA versus TKA for the management of isolated PF OA in the United States-based population.

Patients and Methods

We used a Markov transition state model to compare cost-effectiveness between PFA and TKA. Simulated patients were aged 60 (base case) and 50 years. Lifetime costs (2015 United States dollars), quality-adjusted life year (QALY) gains and incremental cost-effectiveness ratio (ICER) were calculated from a healthcare payer perspective. Annual rates of revision were derived from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Deterministic and probabilistic sensitivity analysis was performed for all parameters against a $50 000/QALY willingness to pay.


Bone & Joint Research
Vol. 4, Issue 6 | Pages 93 - 98
1 Jun 2015
Smith NA Achten J Parsons N Wright D Parkinson B Thompson P Hutchinson CE Spalding T Costa ML

Objectives

Subtotal or total meniscectomy in the medial or lateral compartment of the knee results in a high risk of future osteoarthritis. Meniscal allograft transplantation has been performed for over thirty years with the scientifically plausible hypothesis that it functions in a similar way to a native meniscus. It is thought that a meniscal allograft transplant has a chondroprotective effect, reducing symptoms and the long-term risk of osteoarthritis. However, this hypothesis has never been tested in a high-quality study on human participants. This study aims to address this shortfall by performing a pilot randomised controlled trial within the context of a comprehensive cohort study design.

Methods

Patients will be randomised to receive either meniscal transplant or a non-operative, personalised knee therapy program. MRIs will be performed every four months for one year. The primary endpoint is the mean change in cartilage volume in the weight-bearing area of the knee at one year post intervention. Secondary outcome measures include the mean change in cartilage thickness, T2 maps, patient-reported outcome measures, health economics assessment and complications.