Choosing Between Unicompartmental and Total Knee Replacement: What Can Economic Evaluations Tell Us? A Systematic Review

Abstract

Background and objectivePatients with anteromedial arthritis who require a knee replacement could receive either a unicompartmental knee replacement (UKR) or a total knee replacement (TKR). This review has been undertaken to identify economic evaluations comparing UKR and TKR, evaluate the approaches that were taken in the studies, assess the quality of reporting of these evaluations, and consider what they can tell us about the relative value for money of the procedures.MethodsA search of MEDLINE, EMBASE and the Centre for Reviews and Dissemination National Health Service Economic Evaluation Database was undertaken in January 2016 to identify relevant studies. Study characteristics were described, the quality of reporting and methods assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, and study findings summarised.ResultsTwelve studies satisfied the inclusion criteria. Five were within-study analyses, while another was based on a literature review. The remaining six studies were model-based analyses. All studies were informed by observational data. While methodological approaches varied, studies generally had either limited follow-up, did not fully account for baseline differences in patient characteristics or relied on previous research that did not. The quality of reporting was generally adequate across studies, except for considerations of the settings to which evaluations applied and the generalisability of the results to other decision-making contexts. In the short-term, UKR was generally associated with better health outcomes and lower costs than TKR. Initial cost savings associated with UKR seem to persist over patients’ lifetimes even after accounting for higher rates of revision. For older patients, initial health improvements also appear to be maintained, making UKR the dominant treatment choice. However, for younger patients findings for health outcomes and overall cost effectiveness are mixed, with the difference in health outcomes depending on the lifetime risk of revision and patient outcomes following revision.ConclusionsUKR appears to be less costly than TKR. For older patients, UKR is also expected to lead to better health outcomes, making it the dominant choice; however, for younger patients health outcomes are more uncertain. Future research should better account for baseline differences in patient characteristics and consider how the relative value of UKR and TKR varies depending on patient and surgical factors.

Cost-effectiveness of unicompartmental compared with total knee replacement: a population-based study using data from the National Joint Registry for England and Wales

“…In line with findings from previous economic evaluations of UKR and TKR, 22 in this study, we found UKR to be less costly than TKR. Furthermore, consistent with previous research, UKR was also found to lead to better health outcomes for patients aged 65 years and over.…”

Unicompartmental knee arthroplasty, an enigma, and the ten enigmas of medial UKA

“…This should involve both the cost and quality-adjusted life years in the final evaluation. Therefore, effectiveness of a treatment modality should be measured in terms of (a) cost-effectiveness analysis (a common unit of clinical effect), (b) cost-utility analysis (a generic measure of health gain), and (c) cost-benefit analysis (a monetary measure) [158].…”

“…Among patient factors, age is an important variable in UKA cost-benefit analysis. Burn and Liddle in their population-based study using data from NJR from England and Wales found that the largest expected savings were for males over 75 years, while the biggest improvement in the quality of life was for females over 75 years [158]. However, it is less certain and highly variable for younger patients who have a higher risk of lifetime reoperations and revision.…”

Partial or total knee replacement? Identifying patients’ information needs on knee replacement surgery: a qualitative study to inform a decision aid

“…age/length of procedure/recovery/time in hospital [e.g. 13,14,49,[65][66][67][68][69][70]). It further identifies original priorities, such as cosmetic concerns including the appearance of the knee and scar concerns.…”