Konopka Joseph F, Gomoll Andreas H, Thornhill Thomas S, Katz Jeffrey N, Losina Elena
Orthopedic and Arthritis Center for Outcomes Research (J.F.K., J.N.K., and E.L.), Department of Orthopedic Surgery (J.F.K., T.S.T., J.N.K., and E.L.), Brigham and Women's Hospital, 75 Francis Street, BC-4016, Boston, MA 02115. E-mail address for E. Losina:
Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 850 Boylston Street, Chestnut Hill, MA 02467.
J Bone Joint Surg Am. 2015 May 20;97(10):807-17. doi: 10.2106/JBJS.N.00925.
Surgical options for the management of medial compartment osteoarthritis of the varus knee include high tibial osteotomy, unicompartmental knee arthroplasty, and total knee arthroplasty. We sought to determine the cost-effectiveness of high tibial osteotomy and unicompartmental knee arthroplasty as alternatives to total knee arthroplasty for patients fifty to sixty years of age.
We built a probabilistic state-transition computer model with health states defined by pain, postoperative complications, and subsequent surgical procedures. We estimated transition probabilities from published literature. Costs were determined from Medicare reimbursement schedules. Health outcomes were measured in quality-adjusted life-years (QALYs). We conducted analyses over patients' lifetimes from the societal perspective, with health and cost outcomes discounted by 3% annually. We used probabilistic sensitivity analyses to account for uncertainty in data inputs.
The estimated discounted QALYs were 14.62, 14.63, and 14.64 for high tibial osteotomy, unicompartmental knee arthroplasty, and total knee arthroplasty, respectively. Discounted total direct medical costs were $20,436 for high tibial osteotomy, $24,637 for unicompartmental knee arthroplasty, and $24,761 for total knee arthroplasty (in 2012 U.S. dollars). The incremental cost-effectiveness ratio (ICER) was $231,900 per QALY for total knee arthroplasty and $420,100 per QALY for unicompartmental knee arthroplasty. Probabilistic sensitivity analyses showed that, at a willingness-to-pay (WTP) threshold of $50,000 per QALY, high tibial osteotomy was cost-effective 57% of the time; total knee arthroplasty, 24%; and unicompartmental knee arthroplasty, 19%. At a WTP threshold of $100,000 per QALY, high tibial osteotomy was cost-effective 43% of time; total knee arthroplasty, 31%; and unicompartmental knee arthroplasty, 26%.
In fifty to sixty-year-old patients with medial unicompartmental knee osteoarthritis, high tibial osteotomy is an attractive option compared with unicompartmental knee arthroplasty and total knee arthroplasty. This finding supports greater utilization of high tibial osteotomy for these patients. The cost-effectiveness of high tibial osteotomy and of unicompartmental knee arthroplasty depend on rates of conversion to total knee arthroplasty and the clinical outcomes of the conversions.
内翻膝内侧间室骨关节炎的手术治疗方案包括高位胫骨截骨术、单髁膝关节置换术和全膝关节置换术。我们试图确定对于50至60岁的患者，高位胫骨截骨术和单髁膝关节置换术作为全膝关节置换术替代方案的成本效益。
我们构建了一个概率性状态转换计算机模型，其健康状态由疼痛、术后并发症及后续手术操作定义。我们从已发表的文献中估算转换概率。成本根据医疗保险报销明细表确定。健康结局以质量调整生命年（QALYs）衡量。我们从社会角度对患者的一生进行分析，健康和成本结局按每年3%进行贴现。我们使用概率敏感性分析来考虑数据输入中的不确定性。
高位胫骨截骨术、单髁膝关节置换术和全膝关节置换术的估算贴现QALYs分别为14.62、14.63和14.64。高位胫骨截骨术的贴现总直接医疗成本为20,436美元，单髁膝关节置换术为24,637美元，全膝关节置换术为24,761美元（2012年美元）。全膝关节置换术的增量成本效益比（ICER）为每QALY 231,900美元，单髁膝关节置换术为每QALY 420,100美元。概率敏感性分析表明，在每QALY支付意愿（WTP）阈值为50,000美元时，高位胫骨截骨术在57%的时间内具有成本效益；全膝关节置换术为24%；单髁膝关节置换术为19%。在每QALY支付意愿阈值为100,000美元时，高位胫骨截骨术在43%的时间内具有成本效益；全膝关节置换术为31%；单髁膝关节置换术为26%。
对于50至60岁的内侧单髁膝关节骨关节炎患者，与单髁膝关节置换术和全膝关节置换术相比，高位胫骨截骨术是一个有吸引力的选择。这一发现支持对这些患者更多地采用高位胫骨截骨术。高位胫骨截骨术和单髁膝关节置换术的成本效益取决于转换为全膝关节置换术的比率及转换后的临床结局。
