Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Cost-Effectiveness Analysis of Periacetabular Osteotomy"
by Emile Sharifi, MD, et al.

Commentary & Perspective by
Christopher L. Peters, MD*,
Department of Orthopaedics, University of Utah, Salt Lake City, Utah

Posted July 2008

Over the past decade, there has been increased interest in the field of hip preservation surgery as patients and surgeons seek alternatives to prosthetic replacement of the hip, particularly for younger patients. Newer concepts, such as acetabular retroversion, femoroacetabular impingement, and hip pathomorphology as a predisposing factor to labral injury, are now widely recognized by orthopaedic surgeons and are areas of increasing clinical and basic-science research.

Redirectional acetabular osteotomy of various types for the treatment of the congruous yet volumetrically deficient dysplastic acetabulum has proven to be an effective intervention in skeletally mature patients. Excellent results at intermediate-term follow-up have been reported from centers in Japan (which made use of rotational acetabular osteotomy), Berne (which pioneered the use of the Bernese periacetabular osteotomy) and several centers in the United States (which also made use of the Bernese periacetabular osteotomy)1-6. Experience from these centers has emphasized the importance of patient selection, particularly from a clinical and radiographic perspective. To date, data reflecting the cost-effectiveness and improvement in quality of life offered by redirectional acetabular osteotomy have been lacking.

Thus the economic and decision analysis work of Sharifi et al. is timely and adds additional perspective to this growing field. With use of an elegant and sophisticated cost-utility modeling technique, Sharifi et al. showed that, for patients who are forty-five years of age or younger and who have mild (Tönnis grade-1) or moderate (Tönnis grade-2) coxarthritis, periacetabular osteotomy is more cost-effective than total hip arthroplasty. Conversely, for patients with Tönnis grade-3 coxarthritis, total hip arthroplasty is the dominant treatment strategy.

That Sharifi et al. showed periacetabular osteotomy to be highly cost-effective for the dysplastic hip with mild-to-moderate degenerative changes is especially impressive considering the very conservative parameters that the authors utilized in their analysis. For example, the model did not include sports performance as a measure of functional outcome—an area that would further favor periacetabular osteotomy. Furthermore, several of the parameters regarding total hip arthroplasty, including an estimated survivorship of fourteen years and a limit to two revision total hip replacements in this young patient population may be overly optimistic, again further favoring periacetabular osteotomy as the preferred intervention. Finally, as the authors readily admit, the assumptions regarding periacetabular osteotomy survivorship and rate of failure are based on a limited number of studies, several of which may have included surgeon learning curves, which may bias against periacetabular osteotomy.

Despite these limitations, the results of their cost-effectiveness analysis from a patient, physician, and societal perspective further support the concept of hip preservation for the young adult with a dysplastic hip and Tönnis grade-1 or 2 coxarthritis. With regard to a hip with more advanced osteoarthritis, in the last several years interesting information has emerged from Japan illustrating the effectiveness of rotational acetabular osteotomy in patients who are older than forty years and who have advanced osteoarthritis secondary to dysplasia1,2. Although the preferred treatment of this patient population in the United States remains total hip arthroplasty, longer follow-up studies such as these from Japan will facilitate and strengthen subsequent cost-utility analysis for the field of hip-preservation surgery.

*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family 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, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References

1. Okano K, Enomoto H, Osaki M, Shindo H. Rotational acetabular osteotomy for advanced osteoarthritis secondary to developmental dysplasia of the hip. J Bone Joint Surg Br. 2008;90:23-6.
2. Yasunaga Y, Ochi M, Terayama H, Tanaka R, Yamasaki T, Ishii Y. Rotational acetabular osteotomy for advanced osteoarthritis secondary to dysplasia of the hip. Surgical technique. J Bone Joint Surg Am. 2007;89 Suppl 2 Pt.2:246-55.
3. Steppacher SD, Tannast M, Ganz R, Siebenrock KA. Mean 20-year Followup of Bernese Periacetabular Osteotomy. Clin Orthop Relat Res. 2008 May 1. [Epub ahead of print]
4. Peters CL, Erickson JA, Hines JL. Early results of the Bernese periacetabular osteotomy: the learning curve at an academic medical center. J Bone Joint Surg Am. 2006;88:1920-6.
5. Trousdale RT, Cabanela ME. Lessons learned after more than 250 periacetabular osteotomies. Acta Orthop Scand. 2003;74:119-26.
6. Clohisy JC, Barrett SE, Gordon JE, Delgado ED, Schoenecker PL. Periacetabular osteotomy for the treatment of severe acetabular dysplasia. J Bone Joint Surg Am. 2005;87:254-9.