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.

Introduction

More than 500,000 meniscal tears are treated annually in the United States [1]. The menisci are fibrocartilage discs that are vital for maintaining the health of the cartilage in the knee, by distributing load, absorbing shock, and providing additional stability [2], [3]. Tears to the meniscal are common with athletic activities, and can occur without significant trauma in the setting of cartilage degeneration and early osteoarthritis (OA).

There are two surgical treatment options for patients with meniscal tears and without significant OA. In younger patients with large meniscal tears involving the periphery of the meniscal (i.e., longitudinal tears or tears in the red-red and red-white zone) or in those patients with tears disrupting the hoop stresses of the knee (i.e., radial and root tears), meniscal repair is indicated to preserve the biomechanical stresses on the knee [4]. Partial meniscectomy is indicated for patients with degenerative tears, or tears that do not have an adequate blood supply, and for patients who have failed previous repair attempts [5]. In short- and long-term follow-up, meniscal repair has generally been found to be associated with higher failure rates when compared to partial meniscectomy [6], [7]. Recent studies have shown that repair can be successful for older patients and patients with horizontal cleavage tears, suggesting expanding indications for meniscal repair are imminent [8], [9], [10]. Further, partial meniscectomy has been shown to increase the risk of OA [4], and increased cartilage degeneration after partial meniscectomy has been observed in a number of studies even at short-term follow-up [11]. In cases where cartilage degenerates following partial or complete meniscectomy, OA can progress to the point where it is necessary to perform TKR—a procedure associated with significant costs to the healthcare system [12].

Meniscal injuries therefore present a substantial disease burden with long-term clinical and cost implications [13]. Our objectives were to develop an analytical framework for assessing the long-term cost-effectiveness of meniscectomy compared to meniscal repair, and to project the impact of potential changes in current treatment strategy for the United States healthcare system.