Advertisement

The cost-effectiveness of meniscal repair versus partial meniscectomy: A model-based projection for the United States

      Highlights

      • The cost effectiveness of meniscal debridement or repair is not known.
      • A Markov model of to compare meniscal treatment strategies was developed.
      • Repair was associated with increased failure rates but reductions in TKA rate.
      • Meniscal repair was also associated with a discounted savings of $2384.
      • Meniscal repair is the dominant cost strategy up to age 55.

      Abstract

      Background

      Meniscal tears are the most common knee condition requiring surgery, and represent a substantial disease burden with clinical and cost implications. The success rates partial meniscectomy and meniscal repair have been studied, but limited information is available investigating their long-term costs and effects. Our objective was to assess the long-term cost-effectiveness of meniscal repair compared to meniscectomy.

      Methods

      We constructed a decision-analytic Markov disease progression model, using strategy-specific failure rates and treatment-specific probabilities for the development of osteoarthritis (OA) and subsequent knee replacement (TKR). Failure rates and OA incidence were derived from controlled and uncontrolled studies as well as meta-analyses. Costs were derived from 2014 U.S. reimbursement amounts and published literature.

      Results

      Meniscal repair was associated with an increased failure rate (RR of 4.37), but meaningful reductions in OA and TKR incidence (29.7% vs. 39.4% and 19.6% vs. 27.9%, respectively) in our model-based analysis. Over the 30-year horizon, meniscal repair was associated with an increase in discounted QALYs to 16.52 (compared to 16.37 QALYs for meniscectomy), at overall discounted savings of $2384, making it the dominant index procedure strategy. Using age-specific per-patient cost and QALYs projected for the 30-year horizon, our computations suggest that payers could save approximately $43 million annually if 10% of current meniscectomies could be performed as meniscal repairs.

      Conclusions

      Our projection suggests that meniscal repair, despite substantially higher failure rates, is associated with improved long-term outcomes and cost savings relative to meniscectomy in the majority of patients, making it the dominant treatment strategy.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Knee
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kim S.
        • Bosque J.
        • Meehan J.P.
        • Jamali A.
        • Marder R.
        Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of ambulatory surgery, 1996 and 2006.
        J Bone Joint Surg Am. 2011; 93: 994-1000
        • Seedhom B.B.
        • Dowson D.
        • Wright V.
        Proceedings: functions of the menisci. A preliminary study.
        Ann Rheum Dis. 1974; 33: 111
        • Voloshin A.S.
        • Wosk J.
        Shock absorption of meniscectomized and painful knees: a comparative in vivo study.
        J Biomed Eng. 1983; 5: 157-161
        • Han S.B.
        • Shetty G.M.
        • Lee D.H.
        • Chae D.J.
        • Seo S.S.
        • Wang K.H.
        • et al.
        Unfavorable results of partial meniscectomy for complete posterior medial meniscal root tear with early osteoarthritis: a 5- to 8-year follow-up study.
        Arthroscopy. 2010; 26: 1326-1332
        • Katz J.N.
        • Losina E.
        Arthroscopic partial meniscectomy for degenerative tears: where do we stand?.
        Osteoarthritis Cartilage. 2014; 22: 1749-1751
        • Nepple J.J.
        • Dunn W.R.
        • Wright R.W.
        Meniscal repair outcomes at greater than five years: a systematic literature review and meta-analysis.
        J Bone Joint Surg Am. 2012; 94: 2222-2227
        • Sommerlath K.G.
        Results of meniscal repair and partial meniscectomy in stable knees.
        Int Orthop. 1991; 15: 347-350
        • Ahn J.H.
        • Kwon O.J.
        • Nam T.S.
        Arthroscopic repair of horizontal meniscal cleavage tears with marrow-stimulating technique.
        Arthroscopy. 2015; 31: 92-98
        • Chung K.S.
        • Ha J.K.
        • Yeom C.H.
        • Ra H.J.
        • Jang H.S.
        • Choi S.H.
        • et al.
        Comparison of clinical and radiologic results between partial meniscectomy and Refixation of medial meniscal posterior root tears: a minimum 5-year follow-up.
        Arthroscopy. 2015; 31: 1941-1950
        • Steadman J.R.
        • Matheny L.M.
        • Singleton S.B.
        • Johnson N.S.
        • Rodkey W.G.
        • Crespo B.
        • et al.
        Meniscal suture repair: minimum 10-year outcomes in patients younger than 40 years compared with patients 40 and older.
        Am J Sports Med. 2015; 43: 2222-2227
        • Souza R.B.
        • Wu S.J.
        • Morse L.J.
        • Subburaj K.
        • Allen C.R.
        • Feeley B.T.
        Cartilage MRI relaxation times after arthroscopic partial medial meniscectomy reveal localized degeneration.
        Knee Surg Sports Traumatol Arthrosc. 2014;
        • Losina E.
        • Walensky R.P.
        • Kessler C.L.
        • Emrani P.S.
        • Reichmann W.M.
        • Wright E.A.
        • et al.
        Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume.
        Arch Intern Med. 2009; 169 ([discussion 21-2]): 1113-1121
        • Ruiz Jr., D.
        • Koenig L.
        • Dall T.M.
        • Gallo P.
        • Narzikul A.
        • Parvizi J.
        • et al.
        The direct and indirect costs to society of treatment for end-stage knee osteoarthritis.
        J Bone Joint Surg Am. 2013; 95: 1473-1480
        • Gold M.
        • Siegel J.
        • Russell L.
        • Weinstein M.
        Cost-effectiveness in health and medicine.
        Oxford University Press, New York1996
        • Cohen D.J.
        • Reynolds M.R.
        Interpreting the results of cost-effectiveness studies.
        J Am Coll Cardiol. 2008; 52: 2119-2126
        • Chatain F.
        • Adeleine P.
        • Chambat P.
        • Neyret P.
        • Societe Francaise dA
        A comparative study of medial versus lateral arthroscopic partial meniscectomy on stable knees: 10-year minimum follow-up.
        Arthroscopy. 2003; 19: 842-849
        • Paxton E.S.
        • Stock M.V.
        • Brophy R.H.
        Meniscal repair versus partial meniscectomy: a systematic review comparing reoperation rates and clinical outcomes.
        Arthroscopy. 2011; 27: 1275-1288
        • Englund M.
        • Roos E.M.
        • Lohmander L.S.
        Impact of type of meniscal tear on radiographic and symptomatic knee osteoarthritis: a sixteen-year followup of meniscectomy with matched controls.
        Arthritis Rheum. 2003; 48: 2178-2187
        • Bozic K.J.
        • Kurtz S.M.
        • Lau E.
        • Ong K.
        • Vail T.P.
        • Berry D.J.
        The epidemiology of revision total hip arthroplasty in the United States.
        J Bone Joint Surg Am. 2009; 91: 128-133
        • Bedi A.
        • Kelly N.H.
        • Baad M.
        • Fox A.J.
        • Brophy R.H.
        • Warren R.F.
        • et al.
        Dynamic contact mechanics of the medial meniscal as a function of radial tear, repair, and partial meniscectomy.
        J Bone Joint Surg Am. 2010; 92: 1398-1408
        • Brophy R.H.
        • Gray B.L.
        • Nunley R.M.
        • Barrack R.L.
        • Clohisy J.C.
        Total knee arthroplasty after previous knee surgery: expected interval and the effect on patient age.
        J Bone Joint Surg Am. 2014; 96: 801-805
        • Bedair H.
        • Cha T.D.
        • Hansen V.J.
        Economic benefit to society at large of total knee arthroplasty in younger patients: a Markov analysis.
        J Bone Joint Surg Am. 2014; 96: 119-126
        • Gupta S.
        • Hawker G.A.
        • Laporte A.
        • Croxford R.
        • Coyte P.C.
        The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition.
        Rheumatology (Oxford). 2005; 44: 1531-1537
        • Bozic K.J.
        • Stacey B.
        • Berger A.
        • Sadosky A.
        • Oster G.
        Resource utilization and costs before and after total joint arthroplasty.
        BMC Health Serv Res. 2012; 12: 73
        • Labor USDo
        CPI calculator.
        2013
        • Arias E.
        United States life tables, 2010.
        Natl Vital Stat Rep. 2014; 63: 1-63
        • Montgomery S.R.
        • Zhang A.
        • Ngo S.S.
        • Wang J.C.
        • Hame S.L.
        Cross-sectional analysis of trends in meniscectomy and meniscal repair.
        Orthopedics. 2013; 36: e1007-e1013
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness–the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; 371: 796-797
        • Mather III, R.C.
        • Hug K.T.
        • Orlando L.A.
        • Watters T.S.
        • Koenig L.
        • Nunley R.M.
        • et al.
        Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty.
        BMC Musculoskelet Disord. 2014; 15: 22
        • Badlani J.T.
        • Borrero C.
        • Golla S.
        • Harner C.D.
        • Irrgang J.J.
        The effects of meniscal injury on the development of knee osteoarthritis: data from the osteoarthritis initiative.
        Am J Sports Med. 2013; 41: 1238-1244
        • Jain N.B.
        • Higgins L.D.
        • Ozumba D.
        • Guller U.
        • Cronin M.
        • Pietrobon R.
        • et al.
        Trends in epidemiology of knee arthroplasty in the United States, 1990-2000.
        Arthritis Rheum. 2005; 52: 3928-3933
        • Roos H.
        • Lauren M.
        • Adalberth T.
        • Roos E.M.
        • Jonsson K.
        • Lohmander L.S.
        Knee osteoarthritis after meniscectomy: prevalence of radiographic changes after twenty-one years, compared with matched controls.
        Arthritis Rheum. 1998; 41: 687-693
        • McDermott I.D.
        • Amis A.A.
        The consequences of meniscectomy.
        J Bone Joint Surg Br. 2006; 88: 1549-1556
        • Mahomed N.N.
        • Barrett J.
        • Katz J.N.
        • Baron J.A.
        • Wright J.
        • Losina E.
        Epidemiology of total knee replacement in the United States Medicare population.
        J Bone Joint Surg Am. 2005; 87: 1222-1228
        • Padalecki J.R.
        • Jansson K.S.
        • Smith S.D.
        • Dornan G.J.
        • Pierce C.M.
        • Wijdicks C.A.
        • et al.
        Biomechanical consequences of a complete radial tear adjacent to the medial meniscal posterior root attachment site: in situ pull-out repair restores derangement of joint mechanics.
        Am J Sports Med. 2014; 42: 699-707
        • Ramappa A.J.
        • Chen A.
        • Hertz B.
        • Wexler M.
        • Grimaldi Bournissaint L.
        • DeAngelis J.P.
        • et al.
        A biomechanical evaluation of all-inside 2-stitch meniscal repair devices with matched inside-out suture repair.
        Am J Sports Med. 2014; 42: 194-199
        • Kurzweil P.R.
        • Lynch N.M.
        • Coleman S.
        • Kearney B.
        Repair of horizontal meniscal tears: a systematic review.
        Arthroscopy. 2014; 30: 1513-1519
        • Ra H.J.
        • Ha J.K.
        • Jang S.H.
        • Lee D.W.
        • Kim J.G.
        Arthroscopic inside-out repair of complete radial tears of the meniscal with a fibrin clot.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 2126-2130
        • Kim S.J.
        • Lee S.K.
        • Kim S.H.
        • Jeong J.H.
        • Kim H.S.
        • Lee S.W.
        • et al.
        Does decreased meniscal thickness affect surgical outcomes after medial meniscectomy?.
        Am J Sports Med. 2014;
        • Lingard E.A.
        • Katz J.N.
        • Wright E.A.
        • Sledge C.B.
        • Kinemax Outcomes G
        Predicting the outcome of total knee arthroplasty.
        J Bone Joint Surg Am. 2004; 86-A: 2179-2186