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Cost-Effectiveness of Unicompartmental and Total Knee Arthroplasty in Elderly Low-Demand PatientsA Markov Decision Analysis
James Slover, MD, MS1; Birgitte Espehaug, PhD2; Leif Ivar Havelin, MD, PhD2; Lars Birger Engesaeter, MD, PhD2; Ove Furnes, MD, PhD2; Ivan Tomek, MD3; Anna Tosteson, ScD3
1 Department of Orthopaedic Surgery S456, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114. E-mail address: jslover@partners.org
2 Department of Orthopaedic Surgery, Haukeland University Hospital, N-5021 Bergen, Norway
3 Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, Department of Orthopaedic Surgery, Hinman Box 7541, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received a National Institute of Arthritis and Musculoskeletal and Skin Diseases Grant (P60-AR48094). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Nov 01;88(11):2348-2355. doi: 10.2106/JBJS.E.01033
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Background: Interest in unicompartmental knee arthroplasty has recently increased in the United States, making a firm understanding of the indications for this procedure important. The purpose of this study was to examine the cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in elderly low-demand patients.

Methods: A Markov decision model was used to evaluate the cost-effectiveness of unicompartmental knee arthroplasty as compared with total knee arthroplasty in the elderly population. Transition probabilities were estimated from the Norwegian Arthroplasty Register and the arthroplasty literature, and costs were based on the average Medicare reimbursement for unicompartmental, tricompartmental, and revision knee arthroplasties. Outcomes were measured in quality-adjusted life-years.

Results: Our model showed unicompartmental knee arthroplasty to be a cost-effective strategy for this population as long as the annual probability of revision is <4%. The cost of unicompartmental knee arthroplasty must be greater than $13,500 or the cost of total knee arthroplasty must be less than $8500 before total knee arthroplasty becomes more cost-effective.

Conclusions: Our model suggests that, on the basis of currently available cost and outcomes data, unicompartmental knee arthroplasty and total knee arthroplasty have similar cost-effectiveness profiles in the elderly low-demand patient population. However, several important parameters that could alter the cost-effectiveness analysis were identified; these included implant survival rates, costs, perioperative mortality and infection rates, and utility values achieved with each procedure. The thresholds identified in this study may help decision-makers to evaluate the cost-effectiveness of each strategy as further research characterizes the variables associate with unicompartmental and total knee arthroplasties and may be helpful for designing future appropriate clinical trials.

Level of Evidence: Economic and decision analysis, Level II. See Instructions to Authors for a complete description of levels of evidence.

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    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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