Cost Comparison of Synthetic Hydrogel Implant and First Metatarsophalangeal Joint Arthrodesis.

Background. First metatarsophalangeal (MTP) arthrodesis is the "gold standard" treatment for hallux rigidus. Recently, there has been increased interest in new synthetic cartilage implants to preserve joint motion while eradicating pain. With current health care economics, the cost of a treatment is gaining particular importance. This study set out to perform a cost comparison between MTP arthrodesis and synthetic hydrogel implant to determine which treatment modality is more cost-effective based on direct aggregate costs. Study design. Economic and decision analysis. Methods. Studies in the available literature were analyzed to estimate hardware removal rates for MTP fusion and failure rates for a synthetic hydrogel implant and MTP fusion. Costs were determined by examining direct costs at a single institution for implants and data reported in the literature for operating room time. Sensitivity analysis and Monte Carlo simulation were performed to examine cost and measurement uncertainty. Results. Assuming a 4.76% MTP arthrodesis revision rate and 7.06% hardware removal rate, the total direct cost of MTP joint arthrodesis was $3632. Using a 9.2% failure rate with subsequent conversion to MTP arthrodesis, the total cost of synthetic hydrogel implant was $4565. Sensitivity analysis revealed that MTP fusion was more cost-effective even if the failure rate increased to 15% and synthetic hydrogel implant failure rate was 0%. The synthetic cartilage implant cost would have to be reduced 28% or approximately 200% the cost of MTP fusion implants to be comparable to MTP arthrodesis. Conclusion. Hallux rigidus treatment with a synthetic hydrogel implant resulted in a higher direct aggregate cost than MTP arthrodesis.Level of Evidence: Level II: Cost analysis.

Consumer Prices for Surgical Management of End-Stage Hallux Rigidus.

Background. Hallux rigidus is the most prevalent arthritic condition of the foot. Treatment of end-stage disease traditionally consists of a first metatarsophalangeal joint (MTPJ) arthrodesis; however, the use of a synthetic cartilage implant is becoming more common. With the high prevalence of disease and implementation of new treatment modalities, health care consumers should be aware of the costs associated with management. The purpose of this study was to determine access to the cost and variability in price of first MTPJ arthrodesis and synthetic cartilage implantation. Methods. Forty academic centers were contacted using a standardized patient script. The patient was a 59-year-old female who had failed conservative treatment of hallux rigidus. Each institution was contacted up to 3 times in an attempt to obtain a full bundled operative quote for a first MTPJ arthrodesis and synthetic cartilage implantation. Results. Twenty centers (50%) provided a quote for first MTPJ arthrodesis and 15 centers (38%) provided a quote for synthetic cartilage implantation. Only 14 centers (35%) were able to provide a quote for both procedures. The mean bundled price for MTPJ arthrodesis was $21 767 (range $8417 to $39 265). The mean bundled price for synthetic cartilage implantation was $21 546 (range $4903 to $74 145). There was no statistically significant difference between the bundled price for first MTPJ arthrodesis and synthetic cartilage implantation. Conclusions. There was limited availability of consumer prices for first MTPJ arthrodesis and synthetic implantation, thus impeding health care consumers' decision making. There was a wide range of quotes for both procedures, indicating potential cost savings.Levels of Evidence: IV, basic science.

Metallic hemiarthroplasty for the treatment of end-stage hallux rigidus: mid-term implant survival, functional outcome and cost analysis.

AIMS: To examine the mid-term outcome and cost utility of the BioPro metallic hemiarthroplasty for the treatment of hallux rigidius. PATIENTS AND METHODS: We reviewed 97 consecutive BioPro metallic hemiarthroplasties performed in 80 patients for end-stage hallux rigidus, with a minimum follow-up of five years. There were 19 men and 61 women; their mean age was 55 years (22 to 74). No patient was lost to follow-up. RESULTS: A total of 12 patients (15 first metatarso-phalangeal joints (MTPJs)) required a revision; one for infection, two for osteolysis and 12 for pain. The all cause rate of survival at five years was 85.6% (95% confidence interval (CI) 83.5 to 87.9). Younger age was a significant predictor of revision (odds ratio 1.09, 95% CI 1.02 to 1.17, p = 0.014) on excluding infection and adjusting for confounding variables (Cox regression). Significant improvements were demonstrated at five years in the Manchester Oxford Foot Questionnaire (13.9, 95% CI 10.5 to 17.2) and in the physical component of the Short Form-12 score (6.5, 95% CI 4.1 to 8.9). The overall rate of satisfaction was 75%. The cost per quality adjusted life year at five years, accounting for a 14% rate of revision was between £4431 and £6361 depending on the complexity and morbidity of the patient. CONCLUSION: The BioPro hemiarthroplasty offers good short to mid-term functional outcome and is a cost effective intervention. The relatively high revision rate is associated with younger age and perhaps the use of this implant should be limited to older patients. Cite this article: Bone Joint J 2016;98-B:945-51.

Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score.

Compared with other surgical procedures for hallux rigidus, dorsal cheilectomy involves relatively less bone removal, maintains joint motion, and leaves the potential for further salvage surgery. The Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) has a maximum score of 64 (worst foot health) and has been endorsed by the British Foot and Ankle Society to measure surgical outcome. We prospectively assessed patient-reported outcomes after dorsal cheilectomy for hallux rigidus using the MOXFQ. Patients were deemed suitable for dorsal cheilectomy if they had painful restriction of terminal dorsiflexion, with absence of pain in the mid-range of passive movement, and radiographic evidence of dorsal osteophytosis. Twenty-five patients with a mean age of 62 years (range, 39-80 years), including 17 (68%) women, underwent dorsal cheilectomy for hallux rigidus. The mean preoperative MOXFQ score was 33.0 (95% confidence interval = 27.4-38.6), and, at a mean of 17 months (range, 9-27 months) follow-up, the mean postoperative score was 9.6 (95% confidence interval = 6.0-13.2). Eighty-four percent of patients experienced clinically significantly improved walking domain, 68% in the social domain, and 59% in the pain domain of the MOXFQ. Four patients failed cheilectomy, including 3 who subsequently underwent arthrodesis for persistent pain and 1 who experienced no improvement in any domain of the MOXFQ. This prospective study provided further evidence of the success of dorsal cheilectomy as a treatment for hallux rigidus and demonstrated the potential usefulness of the MOXFQ in assessing surgical outcomes in foot surgery.

Cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal joint arthrodesis.

UNLABELLED: Expensive surgical implants can significantly add to the cost of a procedure. We performed a crude cost analysis to evaluate and compare the crossed screw technique versus dorsal plating for first metatarsophalangeal arthrodesis. First metatarsophalangeal arthrodeses performed over a 20-month period were selected. Exclusion criteria included diabetes, neuroarthropathy, revision surgery, or alternate fixation. Hospital records were reviewed for each case to determine implant charges. Patient charts and radiographs were also reviewed to determine time to fusion, delayed union/nonunion, revision surgery, or hardware removal. Fifty-five first metatarsophalangeal arthrodeses were performed during the study period. Ten fusions were excluded, leaving 45 fusions for review. The overall fusion rate was 91.1%. The average time to fusion in crossed screw versus plating technique was 73.2 +/- 32.5 days (range, 43 to 162) and 69.3 +/- 37.3 days (range, 44 to 238), respectively, and not statistically significant. The mean implant cost in the crossed screw versus dorsal plating technique was $374.05 +/- 76.3 (range, 278.72 to 530.00) and $603.57 +/- 234.7 (range, 543.40 to 1677.00) respectively and was strongly significant (P = .0002). Complications included 2 delayed unions (1 screw, 1 plate), 4 nonunions (1 screw, 3 plate), 2 revisions (1 screw, 1 plate), and 2 hardware removals (1 screw, 1 plate). SUMMARY: A cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal arthrodesis is performed. No statistical difference was found in the time to fusion between the 2 constructs but there was strong statistical difference in hardware cost. This information may aid in the cost management of this procedure without compromising clinical results. ACFAS Level of Clinical Evidence: 2c.