Do the Potential Benefits of Metal-on-Metal Hip Resurfacing Justify the Increased Cost and Risk of Complications?
Metal-on-metal hip resurfacing arthroplasty (MoM HRA) may offer potential advantages over total hip arthroplasty (THA) for certain patients with advanced osteoarthritis of the hip. However, the cost effectiveness of MoM HRA compared with THA is unclear.
The purpose of this study was to compare the clinical effectiveness and cost-effectiveness of MoM HRA to THA.
A Markov decision model was constructed to compare the quality-adjusted life-years (QALYs) and costs associated with HRA versus THA from the healthcare system perspective over a 30-year time horizon. We performed sensitivity analyses to evaluate the impact of patient characteristics, clinical outcome probabilities, quality of life and costs on the discounted incremental costs, incremental clinical effectiveness, and the incremental cost-effectiveness ratio (ICER) of HRA compared to THA.
MoM HRA was associated with modest improvements in QALYs at a small incremental cost, and had an ICER less than $50,000 per QALY gained for men younger than 65 and for women younger than 55. MoM HRA and THA failure rates, device costs, and the difference in quality of life after conversion from HRA to THA compared to primary THA had the largest impact on costs and quality of life.
MoM HRA could be clinically advantageous and cost-effective in younger men and women. Further research on the comparative effectiveness of MoM HRA versus THA should include assessments of the quality of life and resource use in addition to the clinical outcomes associated with both procedures.
Level of Evidence
Level I, economic and decision analysis. See Guidelines for Authors for a complete description of levels of evidence.
- Agency for Healthcare Research and Quality. HCUPnet, Healthcare Cost and Utilization Project. Available at: http://hcupnet.ahrq.gov/. Accessed July 1, 2009.
- Amstutz HC, Beaule PE, Dorey FJ, Le Duff MJ, Campbell PA, Gruen TA. Metal-on-metal hybrid surface arthroplasty: two to six-year follow-up study. J Bone Joint Surg Am. 2004;86:28–39.
- Arias E. United States life tables, 2004. National vital statistics reports; vol 56 no 9. Hyattsville, MD: National Center for Health Statistics, 2007.
- Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. 2008. Available at: http://www.surfacehippy.info/aoanationalreg08.php. Accessed April 1, 2009.
- Back DL, Dalziel R, Young D, Shimmin A. Early results of primary Birmingham hip resurfacings. An independent prospective study of the first 230 hips. J Bone Joint Surg Br. 2005;87:324–329. CrossRef
- Bell RS, Schatzker J, Fornasier VL, Goodman SB. A study of implant failure in the Wagner resurfacing arthroplasty. J Bone Joint Surg Am. 1985;67:1165–1175.
- Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002;84:171–177.
- Bozic KJ, Morshed S, Silverstein MD, Rubash HE, Kahn JG. Use of cost-effectiveness analysis to evaluate new technologies in orthopaedics. The case of alternative bearing surfaces in total hip arthroplasty. J Bone Joint Surg Am. 2006;88:706–714. CrossRef
- Bozic KJ, Rubash HE, Sculco TP, Berry DJ. An analysis of medicare payment policy for total joint arthroplasty. J Arthroplasty. 2008;23(6 Suppl 1):133–138. CrossRef
- Briggs AH, Ades AE, Price MJ. Probabilistic sensitivity analysis for decision trees with multiple branches: use of the Dirichlet distribution in a Bayesian framework. Med Decis Making. 2003;23:341–350. CrossRef
- Centers for Medciare and Medicaid Services. Inpatient PPS PC Pricer. 2008. Available at: http://www.cms.hhs.gov/PCPricer/03_inpatient.asp#TopOfPage. Accessed November 1, 2008.
- Centers for Medciare and Medicaid Services. Physician Fee Schedule. 2009. Available at: http://www.cms.hhs.gov/PFSlookup/01_Overview.asp#TopOfPage. Accessed April 14, 2009.
- Chang RW, Pellisier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. 1996;275:858–865. CrossRef
- D’Antonio JA, Capello WN, Manley MT, Geesink R. Hydroxyapatite femoral stems for total hip arthroplasty: 10- to 13-year followup. Clin Orthop Relat Res. 2001;393:101–111. CrossRef
- Dearborn JT, Harris WH. Postoperative mortality after total hip arthroplasty. An analysis of deaths after two thousand seven hundred and thirty-six procedures. J Bone Joint Surg Am. 1998;80:1291–1294.
- Engh CA, Jr., Claus AM, Hopper RH, Jr., Engh CA. Long-term results using the anatomic medullary locking hip prosthesis. Clin Orthop Relat Res. 2001;393:137–146. CrossRef
- Ethgen O, Bruyere O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am. 2004;86:963–974.
- Federal Coordinating Council for Comparative Effectiveness Research. Report to the President and Congress. June 2009. Available at: http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf.. Accessed January 25, 2010.
- Freeman MA, Bradley GW. ICLH surface replacement of the hip. An analysis of the first 10 years. J Bone Joint Surg Br. 1983;65:405–411.
- Garellick G, Malchau H, Herberts P, Hansson E, Axelsson H, Hansson T. Life expectancy and cost utility after total hip replacement. Clin Orthop Relat Res. 1998;346:141–151. CrossRef
- Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996.
- Gross AJ, Clark VA. Survival Distributions; Reliability Applications in the Biomedical Sciences. New York, NY: John Wiley & Sons; 1975.
- Head WC. Wagner surface replacement arthroplasty of the hip. Analysis of fourteen failures in forty-one hips. J Bone Joint Surg Am. 1981;63:420–427.
- Health Care Advisory Board Web site. Future of Orthopedics Strategic Forecast for a Service Line Under Siege. Service Line Innovation Brief. 2003. Available at: http://www.advisoryboardcompany.com/pdf/IC_Future_of_Orthopedics.pdf. Accessed January 19, 2010.
- Hozack WJ, Rothman RH, Albert TJ, Balderston RA, Eng K. Relationship of total hip arthroplasty outcomes to other orthopaedic procedures. Clin Orthop Relat Res. 1997;344:88–93. CrossRef
- Jolley MN, Salvati EA, Brown GC. Early results and complications of surface replacement of the hip. J Bone Joint Surg Am. 1982;64:366–377.
- Katz JN, Losina E, Barrett J, Phillips CB, Mahomed NN, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2001;83:1622–1629. CrossRef
- Laupacis A, Bourne R, Rorabeck C, Feeny D, Wong C, Tugwell P, Leslie K, Bullas R. The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am. 1993;75:1619–1626.
- Laupacis A, Bourne R, Rorabeck C, Feeny D, Wong C, Tugwell P, Leslie K, Bullas R. Costs of elective total hip arthroplasty during the first year. Cemented versus noncemented. J Arthroplasty. 1994;9:481–487. CrossRef
- Leibowitz D, Rivkin G, Schiffman J, Rott D, Weiss AT, Mattan Y, Kandel L. Effect of Severe Aortic Stenosis on the Outcome in Elderly Patients Undergoing Repair of Hip Fracture. Gerontology. 2009;55:303–306. CrossRef
- MacWilliam CH, Yood MU, Verner JJ, McCarthy BD, Ward RE. Patient-related risk factors that predict poor outcome after total hip replacement. Health Serv Res. 1996;31:623–638.
- Mahomed NN, Barrett JA, Katz JN, Phillips CB, Losina E, Lew RA, Guadagnoli E, Harris WH, Poss R, Baron JA. Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am. 2003;85:27–32.
- Maloney WJ, Schmalzried T, Harris WH. Analysis of long-term cemented total hip arthroplasty retrievals. Clin Orthop Relat Res. 2002;405:70–78. CrossRef
- McGrath MS, Marker DR, Seyler TM, Ulrich SD, Mont MA. Surface replacement is comparable to primary total hip arthroplasty. Clin Orthop Relat Res. 2009;467:94–100. CrossRef
- McKenzie L, Vale L, Stearns S, McCormack K. Metal on metal hip resurfacing arthroplasty. An economic analysis. Eur J Health Econ. 2003;4:122–129. CrossRef
- McMinn D, Treacy R, Lin K, Pynsent P. Metal on metal surface replacement of the hip. Experience of the McMinn prothesis. Clin Orthop Relat Res. 1996(329 Suppl):S89–S98.
- Memtsoudis SG, Gonzalez Della Valle A, Besculides MC, Esposito M, Koulouvaris P, Salvati EA. Risk Factors for Perioperative Mortality after Lower Extremity Arthroplasty: A Population-Based Study of 6 901 324 Patient Discharges. J Arthroplasty. 2008 December 22 [Epub ahead of print].
- Mendenhall S. Hip and knee implant list prices: 2007-2008. Orthopaedic Network News. 2008;19:1–9.
- Mont MA, Schmalzried TP. Modern metal-on-metal hip resurfacing: important observations from the first ten years. J Bone Joint Surg Am. 2008;90 Suppl 3:3–11. CrossRef
- Novak EJ, Silverstein MD, Bozic KJ. The cost-effectiveness of computer-assisted navigation in total knee arthroplasty. J Bone Joint Surg Am. 2007;89:2389–2397. CrossRef
- Parvizi J, Johnson BG, Rowland C, Ereth MH, Lewallen DG. Thirty-day mortality after elective total hip arthroplasty. J Bone Joint Surg Am. 2001;83:1524–1528.
- Parvizi J, Sullivan T, Duffy G, Cabanela ME. Fifteen-year clinical survivorship of Harris-Galante total hip arthroplasty. J Arthroplasty. 2004;19:672–677. CrossRef
- Patil S, Garbuz DS, Greidanus NV, Masri BA, Duncan CP. Quality of life outcomes in revision vs primary total hip arthroplasty: a prospective cohort study. J Arthroplasty. 2008;23:550–553. CrossRef
- Phillips CB, Barrett JA, Losina E, Mahomed NN, Lingard EA, Guadagnoli E, Baron JA, Harris WH, Poss R, Katz JN. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am. 2003;85:20–26. CrossRef
- Pollard TC, Baker RP, Eastaugh-Waring SJ, Bannister GC. Treatment of the young active patient with osteoarthritis of the hip. A five- to seven-year comparison of hybrid total hip arthroplasty and metal-on-metal resurfacing. J Bone Joint Surg Br. 2006;88:592–600. CrossRef
- Rasanen P, Paavolainen P, Sintonen H, Koivisto AM, Blom M, Ryynanen OP, Roine RP. Effectiveness of hip or knee replacement surgery in terms of quality-adjusted life years and costs. Acta Orthop. 2007;78:108–115. CrossRef
- Silva M, Lee KH, Heisel C, Dela Rosa MA, Schmalzried TP. The biomechanical results of total hip resurfacing arthroplasty. J Bone Joint Surg Am. 2004;86:40–46.
- Slover J, Espehaug B, Havelin LI, Engesaeter LB, Furnes O, Tomek I, Tosteson A. Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients. A Markov decision analysis. J Bone Joint Surg Am. 2006;88:2348–2355. CrossRef
- Stinnett AA, Mullahy J. Net health benefits: a new framework for the analysis of uncertainty in cost-effectiveness analysis. Med Decis Making. 1998;18(2 Suppl):S68–S80. CrossRef
- Vail TP, Mina CA, Yergler JD, Pietrobon R. Metal-on-metal hip resurfacing compares favorably with THA at 2 years followup. Clin Orthop Relat Res. 2006;453:123–131. CrossRef
- Williams O, Fitzpatrick R, Hajat S, Reeves BC, Stimpson A, Morris RW, Murray DW, Rigge M, Gregg PJ. Mortality, morbidity, and 1-year outcomes of primary elective total hip arthroplasty. J Arthroplasty. 2002;17:165–171. CrossRef
- Zhan C, Kaczmarek R, Loyo-Berrios N, Sangl J, Bright RA. Incidence and short-term outcomes of primary and revision hip replacement in the United States. J Bone Joint Surg Am. 2007;89:526–533. CrossRef
- Do the Potential Benefits of Metal-on-Metal Hip Resurfacing Justify the Increased Cost and Risk of Complications?
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Clinical Orthopaedics and Related Research®
Volume 468, Issue 9 , pp 2301-2312
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- 1. Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus, MU 320W, San Francisco, CA, 94143-0728, USA
- 2. Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
- 3. Institute for Clinical and Economic Review, Massachusetts General Hospital, Boston, MA, USA