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Economic Benefit to Society at Large of Total Knee Arthroplasty in Younger PatientsA Markov Analysis
Hany Bedair, MD1; Thomas D. Cha, MD, MBA1; Viktor J. Hansen, MD2
1 Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Yawkey Suite 3B, Boston, MA 02114. E-mail address for H. Bedair: hbedair@gmail.com
2 Harris Orthopaedics Lab, Massachusetts General Hospital, 55 Fruit Street, GRJ 1121, Boston, MA 02114
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Investigation performed at the Department of Orthopaedics and the Harris Orthopaedics Lab, Massachusetts General Hospital, Boston, Massachusetts

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Jan 15;96(2):119-126. doi: 10.2106/JBJS.L.01736
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To our knowledge, the economic implications of total knee arthroplasty to society at large have not been assessed with specific consideration of the young working population with osteoarthritis of the knee. The goal of the present study was to use a Markov analysis to estimate the overall average cost to society—in terms of medical expenses and lost wages—of delaying early total knee arthroplasty in favor of nonoperative treatment for end-stage knee osteoarthritis in a hypothetical fifty-year-old patient.


A Markov state-transition decision model was constructed to compare the overall average cost over thirty years of total knee arthroplasty with the average thirty-year cost of nonoperative treatment for a fifty-year-old patient with end-stage osteoarthritis. Earned income, lost wages, and direct medical costs related to nonoperative treatment and to total knee arthroplasty, including revisions and complications, were considered. A sensitivity analysis was performed to assess the effect that variation of key model parameters had on the overall outcome of the model.


This Markov model favored early total knee arthroplasty over nonoperative treatment across all plausible values for most input parameters assessed during one-way sensitivity analysis. Total knee arthroplasty was more expensive during the first 3.5 years because of higher initial costs, but over thirty years the cost benefit of total knee arthroplasty was $69,800 (2012 U.S. dollars). Only when lost wages were <17.7 equivalent work days per year for patients treated nonoperatively or when the rate of returning to work after total knee arthroplasty was <81% did the model favor nonoperative treatment.


The results of the current study demonstrated that the total economic cost to society for treatment of severe knee osteoarthritis in a relatively young working person is markedly lower with total knee arthroplasty than it is with nonoperative treatment. The increasing financial restrictions on health-care providers in the U.S. necessitate careful consideration of the economic impact of different treatment options from the societal perspective.

Clinical Relevance: 

The results of this model illustrate the need to account for the implications of treatment choices, not only at the individual patient level, but also for society at large. When deciding among available treatment options, patients, physicians, payers, and policymakers must consider individual treatment cost and effectiveness but also should account for future potential earnings generated when a treatment may restore a patient’s ability to contribute to society.

Peer Review 

This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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