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Medial compartment knee osteoarthritis: age-stratified cost-effectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy

Knee Surgery, Sports Traumatology, Arthroscopy volume 25, pages 924–933 (2017)Cite this article

Abstract

Purpose

To compare the age-based cost-effectiveness of total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and high tibial osteotomy (HTO) for the treatment of medial compartment knee osteoarthritis (MCOA).

Methods

A Markov model was used to simulate theoretical cohorts of patients 40, 50, 60, and 70 years of age undergoing primary TKA, UKA, or HTO. Costs and outcomes associated with initial and subsequent interventions were estimated by following these virtual cohorts over a 10-year period. Revision and mortality rates, costs, and functional outcome data were estimated from a systematic review of the literature. Probabilistic analysis was conducted to accommodate these parameters’ inherent uncertainty, and both discrete and probabilistic sensitivity analyses were utilized to assess the robustness of the model’s outputs to changes in key variables.

Results

HTO was most likely to be cost-effective in cohorts under 60, and UKA most likely in those 60 and over. Probabilistic results did not indicate one intervention to be significantly more cost-effective than another. The model was exquisitely sensitive to changes in utility (functional outcome), somewhat sensitive to changes in cost, and least sensitive to changes in 10-year revision risk.

Conclusions

HTO may be the most cost-effective option when treating MCOA in younger patients, while UKA may be preferred in older patients. Functional utility is the primary driver of the cost-effectiveness of these interventions. For the clinician, this study supports HTO as a competitive treatment option in young patient populations. It also validates each one of the three interventions considered as potentially optimal, depending heavily on patient preferences and functional utility derived over time.

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Fig. 1
Fig. 2

Notes

  1. QALY, and when comparing multiple interventions, that with the highest NMB is the most cost-effective. An intervention is cost-effective when its NMB is positive, and when comparing multiple interventions, when its NMB is the highest. The NMB maximum cost per QALY society is willing to pay (λ), and when positive, reflects a cost-effective intervention. The output is calculated as the net of an intervention’s cost (Costintervention) and accrued QALYs (QALYintervention) multiplied by society’s willingness to pay per QALY, or λ(Costsociety/QALY).

    $${\text{NMB}} = {\text{QALY}}_{{{\text{intervention}}}} \times (\lambda ) - {\text{Cost}}_{{{\text{interverntion}}}}$$

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Authors and Affiliations

  1. University of California, San Francisco, CA, USA

    William B Smith II MD, MPH, MBA

  2. Tulane University, New Orleans, LA, USA

    Joni Steinberg PhD, MS, MPH

  3. University of Cambridge, Cambridge, UK

    Stefan Scholtes PhD

  4. Norfolk and Norwich University Hospital NHS Foundation Trust, University of East Anglia, Colney Lane, Norwich, NR4 2UY, UK

    Iain R Mcnamara MA MRCP FRCS (Tr Orth) MD

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  1. William B Smith II MD, MPH, MBA
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  2. Joni Steinberg PhD, MS, MPH
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  4. Iain R Mcnamara MA MRCP FRCS (Tr Orth) MD
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Correspondence to Iain R Mcnamara MA MRCP FRCS (Tr Orth) MD.

Appendix: Calculating revision rates and annual transition probabilities

Appendix: Calculating revision rates and annual transition probabilities

Displayed below is the methodology for converting revision probabilities (p) covering multiple years (t) into instantaneous event rates (r) and subsequently into annual revision probabilities (p 2).

$$r = - {\text{ln(}}1 - p )/t$$
(1)
$$p_{2} = \, 1 - \exp ( - rt)$$
(2)
$${\text{one - year transition probability }} = \, 1 - \exp ( - r*1)$$

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Smith, W.B., Steinberg, J., Scholtes, S. et al. Medial compartment knee osteoarthritis: age-stratified cost-effectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 25, 924–933 (2017). https://doi.org/10.1007/s00167-015-3821-3

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