Cost-effectiveness of treatments for non-osteoarthritic knee pain conditions: A systematic review

Addressing meniscal deficiency part 1: An umbrella review of systematic reviews and meta-analyses on meniscal allograft transplantation

Purpose

Meniscal injuries are common in the young and active population. There is increasing utilization of surgical interventions like meniscal allograft transplantation (MAT) to restore the protective function of menisci following injury leading to meniscal deficiency. Extensive research and publications exist on the management of meniscal injury and the sequalae of meniscal deficiency. However, a comprehensive synthesis of the existing evidence through an umbrella review is lacking. This study aims to fill this gap by providing a current examination of the literature on MAT.

Methods

A comprehensive search was conducted in the MEDLINE, Embase and Scopus databases to identify relevant systematic reviews and meta-analyses. Studies were screened based on predefined inclusion and exclusion criteria. The quality of the included studies was assessed using the AMSTAR-2 tool.

Results

A total of 41 studies were included in the review, with most published within the last decade. The majority of studies (56.1%) received a 'Critically Low' confidence rating, 26.8% were rated as 'Low', and only 14.6% were rated as 'High' confidence. From the included studies, 51.2% reported on PROMs, with the Lysholm score being the most common. Transplant failure and reoperation rate were reported in 34.1% and 19.5% of studies respectively. Studies on MAT reported favourable short-term outcomes in terms of patient-reported outcome measures (PROMs) but were limited by the lack of randomized control trials and consistent comparison groups.

Conclusions

This umbrella review highlights an increase in interest in MAT but underscores the need for higher-quality reviews with standardized reporting and rigorous methodologies. Future research should focus on long-term outcomes, optimal surgical techniques, patient selection criteria and risk factors for transplant failure. There is also a need for more studies focusing on MAT in pediatric populations. Overall, this review provides a comprehensive assessment of the current state of research in MAT and identifies areas for improvement in future studies.

Level of Evidence

Level IV.

Molecular Detection of a Pathogenic Entamoeba among Symptomatic Children in Eastern Kurdistan of Iraq

Entamoeba histolytica infects the large intestine of humans, causing a spectrum of clinical appearances ranging from asymptomatic colonization to severe intestinal and extra-intestinal disease. The parasite is identical microscopically to commensal nonpathogenic amoeba. To detect the pathogenic Entamoeba and estimate the precise prevalence of the parasite among the symptomatic pediatric population using molecular techniques. 323 fecal samples were collected from symptomatic children admitted to Sulaimani Pediatric Teaching Hospital, Sulaimaniyah Province, Iraq, from June to October 2021. A structured, validated questionnaire was prepared and used to report participants' gender, residency, and drinking water source. Then, stool samples were microscopically examined, and the positive samples were submitted to molecular analysis by amplifying the 18s rRNA gene using nested PCR to differentiate E. histolytica from other nonpathogenic Entamoeba. Finally, gene sequences were done to confirm the species. Microscopically, 58 positive samples represented Entamoeba species infection rate of 18% among symptomatic patients. However, only 18 samples were positive for E. histolytica based on molecular methods, which accounts for 31% of the positive by microscopy and 5.6% among the 323 symptomatic populations. NCBI, available in their database, gives the gene sequence and accession number. Patients' sociodemographic data and water sources were directly related to the infection rate. Classical microscopic examination provides a misleading profile about the prevalence of E. histolytica in an endemic region that might lead to unnecessary treatments and a lack of appropriate management for patients.

Content validity of the International Classification of Functioning, Disability and Health core set for knee dysfunction: a Delphi study

OBJECTIVE

To assess the content validity of the preliminary core set for knee dysfunction based on the opinion of experts.

DESIGN

A panel of 180 experts in knee disorders or on the use of the International Classification of Functioning, Disability, and Health for musculoskeletal conditions was invited for this Delphi study. The experts gave their opinion on whether to include the categories of the preliminary core set for knee dysfunction in a more comprehensive core set, using a six-item Likert scale. Kappa coefficient was used to analyze the agreement between the experts, and a consensus of 75% among responses was considered acceptable.

RESULTS

Nineteen experts participated in all rounds. Of the 24 categories from the preliminary core set for knee dysfunction, 15 remained in the comprehensive core set and one category was further detailed into three new categories. Seven new categories were included. Thus, the comprehensive core set for knee dysfunction was composed of 25 categories with an agreement of 81.5% among responses and a Kappa value of 0.63.

CONCLUSION

After validation by experts, the comprehensive core set for knee dysfunction was composed of 25 categories that can be used to assess the functioning of patients with knee dysfunction.

Health-economic evaluation of meniscus tear treatments: a systematic review

PURPOSE

To evaluate the overall evidence of published health-economic evaluation studies on meniscus tear treatment.

METHODS

Our systematic review focuses on health-economic evaluation studies of meniscus tear treatment interventions found in PubMed and Embase databases. A qualitative, descriptive approach was used to analyze the studies' results and systematically report them following PRISMA guidelines. The health-economic evaluation method for each included study was categorized following one of the four approaches: partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), or cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. Comparisons of input variables and outcomes were made, if applicable.

RESULTS

Sixteen studies were included; of these, six studies performed PEE, seven studies CUA, two studies CEA, and one study combined CBA, CUA, and CEA. The following economic comparisons were analyzed and showed the respective comparative outcomes: (1) meniscus repair was more cost-effective than arthroscopic partial meniscectomy (meniscectomy) for reparable meniscus tear; (2) non-operative treatment or physical therapy was less costly than meniscectomy for degenerative meniscus tear; (3) physical therapy with delayed meniscectomy was more cost-effective than early meniscectomy for meniscus tear with knee osteoarthritis; (4) meniscectomy without physical therapy was less costly than meniscectomy with physical therapy; (5) meniscectomy was more cost-effective than either meniscus allograft transplantation or meniscus scaffold procedure; (6) the conventional arthroscopic instrument cost was lower than laser-assisted arthroscopy in meniscectomy procedures.

CONCLUSION

Results from this review suggest that meniscus repair is the most cost-effective intervention for reparable meniscus tears. Physical therapy followed by delayed meniscectomy is the most cost-effective intervention for degenerative meniscus tears. Meniscus scaffold should be avoided, especially when implemented on a large scale.

LEVEL OF EVIDENCE

Systematic review of level IV studies.

"Cost-effectiveness of ACL treatment is dependent on age and activity level: a systematic review"

PURPOSE

To systematically review the literature on health-economic evaluations of anterior cruciate ligament (ACL) injury between reconstruction surgery (ACLR) and non-operative treatment (NO) and suggest the most cost-effective strategy between the two.

METHODS

All economic studies related to ACLR versus NO post-ACL injury, either trial based or model based, published until April 2022, were identified using PubMed and Embase. The methodology of the health-economic analysis for each included study was categorized according to the four approaches: cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list.

RESULTS

Of the seven included studies, two compared the strategies of early ACLR and NO alone, and five compared early ACLR and NO with optional delayed ACLR. All studies performed a CUA, and one study performed a CBA additionally. The CHEC scores of the included studies can be considered good, ranging from 15 to 18 from a maximum of 19. Applying the common standard threshold of $50,000 per QALY, six studies in young people with high-activity levels or athletes showed that early ACLR would be preferred over either NO alone or delayed ACLR. Of six studies, two even showed early ACLR to be the dominant strategy over either NO alone or delayed ACLR, with per-patient cost savings of $5,164 and $1,803 and incremental per-patient QALY gains of 0.18 and 0.28, respectively. The one study in the middle-aged people with a moderate activity level showed that early ACLR was not more cost-effective than delayed ACLR, with ICER $101,939/QALY using the societal perspective and ICER $63,188/QALY using the healthcare system perspective.

CONCLUSION

Early ACLR is likely the more cost-effective strategy for ACL injury cases in athletes and young populations with high-activity levels. On the other hand, non-operative treatment with optional delayed ACLR may be the more cost-effective strategy in the middle age population with moderate activity levels.

LEVEL OF EVIDENCE

Systematic review of level III studies.

Advanced MR Imaging for Knee Osteoarthritis: A Review on Local and Brain Effects

Knee osteoarthritis is one of the leading causes of chronic disability worldwide and is a significant social and economic burden on healthcare systems; hence it has become essential to develop methods to identify patients at risk for developing knee osteoarthritis at an early stage. Standard morphological MRI sequences are focused mostly on alterations seen in advanced stages of osteoarthritis. However, they possess low sensitivity for early, subtle, and potentially reversible changes of the degenerative process. In this review, we have summarized the state of the art with regard to innovative quantitative MRI techniques that exploit objective and quantifiable biomarkers to identify subtle alterations that occur in early stages of osteoarthritis in knee cartilage before any morphological alteration occurs and to capture potential effects on the brain. These novel MRI imaging tools are believed to have great potential for improving the current standard of care, but further research is needed to address limitations before these compositional techniques can be robustly applied in research and clinical settings.

Particulated Juvenile Articular Cartilage and Matrix-Induced Autologous Chondrocyte Implantation Are Cost-Effective for Patellar Chondral Lesions

PURPOSE

To compare the cost-effectiveness of nonoperative management, particulated juvenile allograft cartilage (PJAC), and matrix-induced autologous chondrocyte implantation (MACI) in the management of patellar chondral lesions.

METHODS

A Markov model was used to evaluate the cost-effectiveness of three strategies for symptomatic patellar chondral lesions: 1) nonoperative management, 2) PJAC, and 3) MACI. Model inputs (transition probabilities, utilities, and costs) were derived from literature review and an institutional cohort of 67 patients treated with PJAC for patellar chondral defects (mean age 26 years, mean lesion size 2.7 cm²). Societal and payer perspectives over a 15-year time horizon were evaluated. The principal outcome measure was the incremental cost-effectiveness ratio (ICER) using a $100,000/quality-adjusted life year (QALY) willingness-to-pay threshold. Sensitivity analyses were performed to assess the robustness of the model and the relative effects of variable estimates on base case conclusions.

RESULTS

From a societal perspective, nonoperative management, PJAC, and MACI cost $4,140, $52,683, and $83,073 and were associated with 5.28, 7.22, and 6.92 QALYs gained, respectively. PJAC and MACI were cost-effective relative to nonoperative management (ICERs $25,010/QALY and $48,344/QALY, respectively). PJAC dominated MACI in the base case analysis by being cheaper and more effective, but this was sensitive to the estimated effectiveness of both strategies. PJAC remained cost-effective if PJAC and MACI were considered equally effective.

CONCLUSIONS

In the management of symptomatic patellar cartilage defects, PJAC and MACI were both cost-effective compared to nonoperative management. Because of the need for one surgery instead of two, and less costly graft material, PJAC was cheaper than MACI. Consequently, when PJAC and MACI were considered equally effective, PJAC was more cost-effective than MACI. Sensitivity analyses accounting for the lack of robust long-term data for PJAC or MACI demonstrated that the cost-effectiveness of PJAC versus MACI depended heavily on the relative probabilities of yielding similar clinical results.

LEVEL OF EVIDENCE

III, economic and decision analysis.

The use of transcutaneous electrical nerve stimulation along with functional tasks for immediate pain relief in individuals with knee osteoarthritis

BACKGROUND

Knee pain is the major complaint in individuals with knee osteoarthritis (OA), and the effects of transcutaneous electrical nerve stimulation (TENS) on knee pain are controversial. The present study applied TENS along with functional tests to investigate its effect on pain level in individuals with mild to moderate knee OA.

METHODS

Twenty volunteers with knee OA classification of graded 2-3 performed four functional tests (stair climb test - SCT, timed up and go test - TUG, 6-minute walk test - 6MWT, knee extensor strength test - KES, and 2-step test from the locomotive syndrome risk test - LSR_2ST) while wearing either an active or inactive TENS. Knee pain level before and after each test was self-accessed by the visual analog scale (VAS). The effect of TENS (active vs. inactive) on pain level was submitted to statistical analyses.

RESULTS

Knee pain during SCT, TUG, and LSR_2ST tests was significantly lower when subjects used the active TENS, compared to using the inactive unit. The effect of the active TENS on pain level was also more significant in subjects with no anxiety or depression.

CONCLUSIONS

The results provided evidence of immediate pain relief in individuals with mild to moderate knee OA when TENS is applied along with functional activities, that usually induced pain in people with knee OA.

Timing of physical therapy for individuals with patellofemoral pain and the influence on healthcare use, costs and recurrence rates: an observational study

Background

Early physical therapy has been shown to decrease downstream healthcare use, costs and recurrence rates in some musculoskeletal conditions, but it has not been investigated in individuals with patellofemoral pain. The purpose was to evaluate how the use and timing of physical therapy influenced downstream healthcare use, costs, and recurrence rates.

Methods

Seventy-four thousand four hundred eight individuals aged 18 to 50 diagnosed with patellofemoral pain between 2010 and 2011 in the Military Health System were categorized based on use and timing of physical therapy (first, early, or delayed). Healthcare use, costs, and recurrence rates were compared between the groups using descriptive statistics and a binary logit regression.

Results

The odds for receiving downstream healthcare use (i.e. imaging, prescription medications, and injections) were lowest in those who saw a physical therapist as the initial contact provider (physical therapy first), and highest in those who had delayed physical therapy (31–90 days after patellofemoral pain diagnosis). Knee-related costs for those receiving physical therapy were lowest in the physical therapy first group ($1,136, 95% CI $1,056, $1,217) and highest in the delayed physical therapy group ($2,283, 95% CI $2,192, $2,374). Recurrence rates were lowest in the physical therapy first group (AOR = 0.55, 95% CI 0.37, 0.79) and highest in the delayed physical therapy group (AOR = 1.78, 95% CI 1.36, 2.33).

Conclusions

For individuals with patellofemoral pain using physical therapy, timing is likely to influence outcomes. Healthcare use and costs and the odds of having a recurrence of knee pain were lower for patients who had physical therapy first or early compared to having delayed physical therapy.

Association between knee symptoms, change in knee symptoms over 6-9 years, and SF-6D health state utility among middle-aged Australians

OBJECTIVES

Health state utilities (HSUs) are an input metric for estimating quality-adjusted life-years (QALY) in cost-utility analyses. Currently, there is a paucity of data on association of knee symptoms with HSUs for middle-aged populations. We aimed to describe the association of knee symptoms and change in knee symptoms with SF-6D HSUs and described the distribution of HSUs against knee symptoms' severity.

METHODS

Participants (36-49-years) were selected from the third follow-up (completed 2019) of Australian Childhood Determinants of Adult Health study. SF-6D HSUs were generated from the participant-reported SF-12. Association between participant-reported WOMAC knee symptoms' severity, change in knee symptoms over 6-9 years, and HSUs were evaluated using linear regression models.

RESULTS

For the cross-sectional analysis, 1,567 participants were included; mean age 43.5 years, female 54%, BMI ± SD 27.18 ± 5.31 kg/m². Mean ± SD HSUs for normal, moderate, and severe WOMAC scores were 0.820 ± 0.120, 0.800 ± 0.120, and 0.740 ± 0.130, respectively. A significant association was observed between worsening knee symptoms and HSUs in univariable and multivariable analyses after adjustment (age and sex). HSU decrement for normal-to-severe total-WOMAC and WOMAC-pain was - 0.080 (95% CI - 0.100 to - 0.060, p < 0.01) and - 0.067 (- 0.085 to - 0.048, p < 0.01), exceeding the mean minimal clinically important difference (0.04). Increase in knee pain over 6-9 years was associated with a significant reduction in HSU.

CONCLUSION

In a middle-aged population-based sample, there was an independent negative association between worse knee symptoms and SF-6D HSUs. Our findings may be used by decision-makers to define more realistic and conservative baseline and ongoing HSU values when assessing QALY changes associated with osteoarthritis interventions.

An Up-to-Date Review of the Meniscus Literature: A Systematic Summary of Systematic Reviews and Meta-analyses

Background:

A large number of systematic reviews and meta-analyses regarding the meniscus have been published.

Purpose:

To provide a qualitative summary of the published systematic reviews and meta-analyses regarding the meniscus.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of all meta-analyses and systematic reviews regarding the meniscus and published between July 2009 and July 2019 was performed with PubMed, CINAHL, EMBASE, and the Cochrane database. Published abstracts, narrative reviews, articles not written in English, commentaries, study protocols, and topics that were not focused on the meniscus were excluded. The most pertinent results were extracted and summarized from each study.

Results:

A total of 332 articles were found, of which 142 were included. Included articles were summarized and divided into 16 topics: epidemiology, diagnosis, histology, biomechanics, comorbid pathology, animal models, arthroscopic partial meniscectomy (APM), meniscal repair, meniscal root repairs, meniscal allograft transplantation (MAT), meniscal implants and scaffolds, mesenchymal stem cells and growth factors, postoperative rehabilitation, postoperative imaging assessment, patient-reported outcome measures, and cost-effectiveness. The majority of articles focused on APM (20%), MAT (18%), and meniscal repair (17%).

Conclusion:

This summary of systematic reviews and meta-analyses delivers surgeons a single source of the current evidence regarding the meniscus.

Microcurrent therapy in the treatment of knee osteoarthritis: could it be more than a placebo effect? A randomized controlled trial

BACKGROUND

Microcurrent therapy (MCT) is a novel electrotherapy modality with very low current-levels that may reduce pain especially in joints and muscles.

AIM

The aim of this study is to explore potential effects of MCT on pain in patients with knee osteoarthritis, to explore effects of different treatment parameters and to distinguish them from placebo-effects.

DESIGN

Randomized four arms controlled clinical trial.

SETTING

Outpatient tertiary medical care center.

POPULATION

Fifty-six patients with knee OA (Kellgren-Lawrence Score II or III, 14 male and 38 female, mean age: 71.7±7.3 years, pain intensity higher than Numeric Rating Scale [NRS] score 3 from 10).

METHODS

Patients were randomized into four groups: MCT with 100 µA (group A), MCT with 25 µA (group B), sham-treatment (group C) and a control-group without intervention. Treatment groups received 10 sessions of MCT for 30 minutes each over a period of 22 days. The primary outcome was daily pain intensity throughout the treatment period measured by a NRS from 0-10. Second outcome measurements were the Knee Osteoarthritis Outcome Score (KOOS), the SF-36 Questionnaire, the Six-Minute Walking Test and the Get-Up-and-Go Test.

RESULTS

Evening pain was reduced significantly in the verum-groups compared to sham group (Group A vs. Group C: P<0.001, Group B vs. Group C: P=0.006) and to no intervention (Group A vs. Group D: P<0.001, Group B vs. Group D: P=0.002). The difference between sham-therapy and no therapy was not significant. In the pre-post analysis of the KOOS group A improved significantly in the subscale Symptoms. Group A and B and D improved in the Activities of Daily Living subscale.

CONCLUSIONS

The results of this RCT suggest that MCT has beneficial effects on pain in patients with knee osteoarthritis that are not explained by a placebo effect. Due to the explorative, pilot character of the study, further confirmation is needed before clear recommendations can be given.

CLINICAL REHABILITATION IMPACT

More high-quality RCTs with transparent parameters should be investigated to elucidate potential effects of MCT in the field of physical medicine and rehabilitation. At the present time MCT is a treatment option that could be helpful, in particular for patients who are afraid of unpleasant sensations from electrotherapy with stronger currents.

The Effect of the Phytocomplex Electrophoresis on the Clinical Symptomatology and Quality of Life of Patients with the Knee Joint Osteoarthritis

BACKGROUND:

Improving the effectiveness of rehabilitation of patients with osteoarthritis necessitates the use of drug electrophoresis with sinusoidal modulated currents (SMC-electrophoresis) in conjunction with drug therapy. The phytocomplex is proposed for electrophoresis composed of the compared, alfalfa and hops dry extract, containing flavonoids, coumestans, polysaccharides, steroids, essential amino acids, vitamins, mineral components and causing its possible use in osteoarthritis.

AIM:

The research aims to study the effect of the phytocomplex SMC-electrophoresis on the clinical symptoms and quality of life of patients with the knee joint osteoarthritis.

METHODS:

One hundred and eight patients were randomly distributed into 3 groups (n = 36). The phytocomplex SMC-electrophoresis was assigned to the first group, the amplipulse therapy (SMC) – to the second group, and the “basic” drug therapy – to the third group. The drug therapy of the patients of the third group was comparable with the drug treatment of those in the first two groups. The concentration of phytocomplex in the working solution was 10%. The electrotherapy was carried out in the aligned SMC mode in the first and fourth kind of works. Comparative indicators were as follows: WOMAC index, pain level on a visual analogue scale (VAS), Lequesne index, joint range of motion (JROM), articular and tendon indices, quality of life as per Health Assessment Questionnaire (HAQ).

RESULTS:

The use of the phytocomplex SMC-electrophoresis had a more pronounced positive effect on pain, knee joint function and quality of life of the patients compared with the treatment with drugs alone or using amplitude therapy. This was especially pronounced immediately after the rehabilitation. The analgesic effect was consistently maintained in the patients of the first group for up to 6 – 12 months, the second group – up to 3 – 6 months in terms of the level of pain according to the WOMAC and Lequesne indices, VAS, articular and tendon indices. Stable results have been obtained for improving the functions of the knee joint for up to 6 – 12 months using the phytocomplex SMC-electrophoresis as per the WOMAC and Lequesne indices. In the treatment by the phytocomplex SMC-electrophoresis, no side effects were registered.

CONCLUSION:

The obtained results give grounds for further research on the evaluation of the effectiveness of using the phytocomplex SMC-electrophoresis in microcirculatory disorders in the affected joint, for correcting connective tissue metabolism and electrolyte metabolism in the patients with the knee joint osteoarthritis.