The Epidemiology of Meniscus Injury.

Meniscus surgery is one of the most commonly performed orthopedic procedures worldwide. Modifiable risk factors for meniscus injury include body mass index, participation in athletics and occupation. Nonmodifiable risk factors include age, sex, lower extremity alignment, discoid meniscus, ligamentous laxity, and biconcave tibial plateau. Conditions commonly associated with meniscal injury are osteoarthritis, anterior cruciate ligament injury, and tibial plateau fractures. Tear type and location vary by patient age and functional status. Surgical management of meniscus injury is typically cost-effective in terms of quality-adjusted life years. The purpose of this review is to provide an overview of meniscal injury epidemiology by summarizing tear types and locations, associated conditions, and factors that increase the risk for meniscal injury. The economic burden of meniscus injury and strategies to prevent injury to the meniscus are also reviewed.

Direct treatment cost outcomes among patients with medial meniscus deficiency: results from a 24-month surveillance study.

Objective: Meniscus deficiency is highly prevalent in the United States and represents a substantial societal cost burden. The objective of this case series was to evaluate and compare direct costs associated with treatment for acute or degenerative medial meniscus deficiency.Methods: Case series patients (n = 50) received either non-surgical therapy or an operative partial meniscectomy based on clinical assessment by the principal study investigator which included physical examination and MRI. Cumulative 24-month direct treatment costs were compared between non-surgical and operative cohorts. Direct treatment costs were calculated using billing record reimbursements for all medical services administered by the treating institution, and imputed for medical services prescribed by the treating physician but provided external to the treating institution.Results: At study initiation, 33 patients (67%) were treated with non-surgical care, and 17 patients (33%) received a partial medial meniscectomy. By 24 months, average direct treatment costs were highest for patients who received a partial medial meniscectomy at study initiation ($4488 ± $1265) compared to patients who received non-surgical care at study initiation ($4092 ± $7466), although differences in average direct treatment costs were not statistically significant across treatment cohorts (p = .830). Average direct treatment costs were highest for the subgroup of patients who initiated non-surgical therapy but received a subsequent total knee arthroplasty during the study period (n = 2; $32,197 ± $169).Conclusion: Findings from this case series suggests that patients with acute or degenerative meniscus deficiency incur substantial direct treatment costs related to their knee pathology, particularly for patients receiving total knee arthroplasty.

Increased rates of knee arthroplasty and cost of patients with meniscal tears treated with arthroscopic partial meniscectomy versus non-operative management.

PURPOSE: The purpose of this study was to determine the cost of arthroscopic partial meniscectomy (APM), one of the most common surgeries performed by orthopaedic surgeons, and the associated rate of progression to knee arthroplasty (KA) compared to patients treated non-operatively after diagnosis of meniscal tear. METHODS: Utilizing data mining software (PearlDiver, Colorado Springs, CO), a national insurance database of approximately 23.5 million orthopaedic patients was queried for patients diagnosed with a meniscal tear. Patients were classified by treatment: non-operative and arthroscopic partial meniscectomy and were followed after initial diagnosis for cost and progression to knee arthroplasty. RESULTS: There were 176,407 subjects in the non-op group and 114,194 subjects in the arthroscopic partial meniscectomy group. Arthroscopic partial meniscectomy generated more cost than non-operative ($3842.57 versus $411.05, P < 0.001). Arthroscopic partial meniscectomy demonstrated greater propensity to need future knee arthroplasty (11.4% at 676 days) than those treated non-operatively (9.5% at 402 days) (P < 0.001). Female patients demonstrated a higher rate of progression to knee arthroplasty in the arthroscopic partial meniscectomy and non-operative groups (P < 0.001). CONCLUSION: Compared to non-operative treatment for meniscal tears, arthroscopic partial meniscectomy is more expensive and does not appear to decrease the rate of progression to knee arthroplasty. Patients undergoing arthroscopic partial meniscectomy yielded on average a delay of only 9 months (274 days) before undergoing knee arthroplasty. Female patients experienced a significantly higher rate of progression to knee arthroplasty. The authors recognize the limitations of this type of study including its retrospective nature, reliance upon accurate coding and billing information, and the inability to determine whether symptoms including mechanical locking played a role in the decision to perform an APM. LEVEL OF EVIDENCE: IV.

Cost-Effectiveness Analysis of Needle Arthroscopy Versus Magnetic Resonance Imaging in the Diagnosis and Treatment of Meniscal Tears of the Knee.

PURPOSE: To determine whether needle arthroscopy (NA) compared with magnetic resonance imaging (MRI) in the diagnosis and treatment of meniscal tears is cost-effective when evaluated over a 2-year period via patient-reported outcomes. The hypothesis is that improved diagnostic accuracy with NA would lead to less costly care and similar outcomes. METHODS: A Markov model/decision tree analysis was performed using TreeAge Pro 2017 software. Patients were evaluated for degenerative and traumatic damage to the lateral/medial meniscus. Assumed sensitivities and specificities were derived from the medical literature. The direct costs for care were derived from the 2017 Medicare fee schedule and from private payer reimbursement rates. Costs for care included procedures performed for false-positive findings and for care for false-negative findings. Effectiveness was examined using the global knee injury and osteoarthritis outcome score (KOOS). Patients were evaluated over 2 years for costs and outcomes, including complications. Dominance and incremental cost-effectiveness were evaluated, and 1- to 2-way sensitivity analysis was performed to determine those variables that had the greatest effect. The consolidated economics evaluation and reporting standards checklist for reporting economic evaluations was used. RESULTS: NA was less costly and had similar KOOS versus MRI for both the medial/lateral meniscus with private pay. Costs were less for both Medicare and private pay for medial meniscus, $780 to $1,862, and lateral meniscus, $314 to $1,256, respectively. CONCLUSIONS: Based on the reported MRI incidence of false positives with the medial meniscus and false negatives with the lateral meniscus and based on assumed standards of care, more costly care is provided when using MRI compared with NA. Outcomes were similar with NA compared with MRI. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness.

BACKGROUND: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. PURPOSE: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. STUDY DESIGN: Meta-analysis and cost-effectiveness analysis. METHODS: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. RESULTS: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. CONCLUSION: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

The Cost-Effectiveness of Meniscal Repair Versus Partial Meniscectomy in the Setting of Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare the cost-effectiveness of anterior cruciate ligament (ACL) reconstruction with meniscal repair to ACL reconstruction with partial meniscectomy. METHODS: A decision-analytic Markov disease progression model with a 40-year horizon was created simulating outcomes after both meniscal repair and partial meniscectomy at the time of ACL reconstruction. Event probabilities, costs, and utilities were used for the index procedures. The development of osteoarthritis and subsequent knee replacement were either calculated or selected from published literature. Difference in cost, difference in quality-adjusted life-years (QALYs), and incremental cost-effective ratio were calculated to determine which index procedure is most cost-effective. RESULTS: There is total direct cost from ACL reconstruction with meniscus repair of $17,898 compared with that with partial meniscectomy of $24,768 (cost savings of $6,870). There was an estimated gain of 18.00 QALYs after ACL reconstruction with meniscus repair compared with 17.16 QALYs with partial meniscectomy (increase of 0.84 QALYs). In this scenario, meniscus repair is the dominant index procedure at the time of ACL reconstruction. CONCLUSIONS: Meniscal repair at the time of ACL reconstruction is more cost-effective than partial meniscectomy. LEVEL OF EVIDENCE: Level IV, economic and decision analysis.

Arthroscopic meniscectomy for degenerative meniscal tears reduces knee pain but is not cost-effective in a routine health care setting: a multi-center longitudinal observational study using data from the osteoarthritis initiative.

OBJECTIVES: It is disputed whether arthroscopic meniscectomy is an (cost-) effective treatment for degenerative meniscus tears in day-to-day clinical practice. The objective of this study was to assess the cost-effectiveness of arthroscopic meniscectomy in subjects with knee osteoarthritis, in routine clinical practice, while taking into account the increased risk for future knee replacement surgery. We compared cost-effectiveness of arthroscopic meniscectomy compared to no surgery. DESIGN: We used a state transition (Markov) simulation model to evaluate the cost-effectiveness of arthroscopic meniscectomy compared to no surgery in subjects with knee osteoarthritis (age range 45-79 years). Data used in the preparation of the current study were obtained from the Osteoarthritis Initiative (AOI) database. We applied a 9 years' time horizon (which is equal to the current OAI study follow up period), and evaluated cost-effectiveness from a societal perspective. The main outcome measure was the incremental cost-effectiveness ratio (Euros per quality adjusted life-year (QALY) gained). RESULTS: Arthroscopic meniscectomy was associated with 8.09 (SD ± 0.07) QALYs at a cost of € 21,345 (SD ± 841), whereas the no surgery was associated with 8.05 (SD ± 0.07) QALYs at a cost of € 16,284 (SD ± 855). For arthroscopic meniscectomy, the incremental cost per QALY gained was € 150,754. CONCLUSIONS: In day-to-day clinical practice, arthroscopic meniscectomy in subjects with knee osteoarthritis is associated with € 150,754 per QALY gained, which exceeds the generally accepted willingness to pay (WTP) (range € 20,000-€ 80,000).

Cost-effectiveness of Early Surgery versus Conservative Treatment with Optional Delayed Meniscectomy for Patients over 45†years with non-obstructive meniscal tears (ESCAPE study): protocol of a randomised controlled trial.

INTRODUCTION: Recent studies show similar outcome between surgery and conservative treatment in patients with non-obstructive meniscal tears. However, surgery is still often preferred over conservative treatment. When conservative treatment is non-inferior to surgery, shifting the current standard treatment choice to conservative treatment alone could save over €30 millions of direct medical costs on an annual basis. Economic evaluation studies comparing surgery to conservative treatment are lacking. METHODS AND ANALYSIS: A multicentre randomised controlled trial (RCT) with an economic evaluation alongside was performed to assess the (cost)-effectiveness of surgery and conservative treatment for meniscal tears. We will include 402 participants between 45 and 70 years with an MRI-confirmed symptomatic, non-obstructive meniscal tears to prove non-inferiority of conservative treatment. Block randomisation will be web-based. The primary outcome measure is a physical function, measured by the International Knee Documentation Committee 'Subjective Knee Form'. Furthermore, we will perform a cost-effectiveness and cost-utility analysis from societal perspective and a budget impact analysis from a societal, government and insurer perspective. Secondary outcomes include general health, quality of life, activity level, knee pain, physical examination, progression of osteoarthritis and the occurrence of adverse events. ETHICS AND DISSEMINATION: This RCT will be performed in accordance with the Declaration of Helsinki and has been approved by the Ethics Committee (number NL44188.100.13). The results of this study will be reported in peer-reviewed journals and at international conferences. We further aim to disseminate our results to guideline committees. TRIAL REGISTRATION NUMBER: NCT01850719.

Characteristics of inpatient anterior cruciate ligament reconstructions and concomitant injuries.

PURPOSE: The purpose of this epidemiologic study was to quantify the incidence, expense, and concomitant injuries for anterior cruciate ligament reconstruction (ACLR) procedures in the USA from 2003 to 2011 that required an inpatient stay. It was hypothesized that the relative reported rates of concomitant knee injuries would be greater with the MCL and menisci compared to all other concomitant knee injuries. METHODS: The National Inpatient Sample from 2003 to 2011 was retrospectively sampled using ICD-9-CM codes to identify ACLR patients and to extrapolate national averages. RESULTS: Between the years of 2003-2011, an average of 9,037 ± 1,728 inpatient hospitalization included ACLRs, of which 4,252 ± 1,824 were primarily due to the ACLR. Inpatient visits primarily due to ACLR involved an average hospitalization of 1.7 ± 0.2 days and cost $30,118 ± 9,066 per patient. Knee injuries that were commonly reported along with inpatient ACLRs included medial meniscus damage (18.1 %), lateral meniscus damage (16.8 %), collateral ligament repairs (12.3 %), and medial collateral ligament strains (6.9 %). Prevalence of meniscus injuries was consistent across years, but MCL-related injuries increased over time. CONCLUSIONS: ACLR-related inpatient hospitalizations account for approximately 7.1 % of the total ACLRs performed annually in the USA. Inpatient ACLR procedures continue to decrease in frequency; however, the mean cost per patient increased. Meniscus and collateral ligament injuries were the most commonly reported concomitant knee injuries. The clinical relevance of this investigation is that it informs, on a large clinical cohort of patients, the current state of incidence and expense for ACLR surgeries in an inpatient setting. LEVEL OF EVIDENCE: Prognostic, retrospective study, Level II.