The Cost-Effectiveness of Platelet-Rich Plasma Compared With Hyaluronic Acid Injections for the Treatment of Knee Osteoarthritis.

PURPOSE: To examine the cost-effectiveness of a series (total of 3 injections) of intra-articular platelet-rich plasma (PRP) injections in comparison to that of hyaluronic acid (HA) viscosupplementation for the treatment of symptomatic knee osteoarthritis. METHODS: Outcome data regarding the use of PRP or HA injections for the treatment of symptomatic knee osteoarthritis were determined from the highest-quality data (Level I) available in the literature until 2015. Health utility values were then derived from these high-quality data. Costs were determined by examining typical charges for patients undergoing a series of either PRP or HA injections for the treatment of this condition at a large private orthopaedic practice. These health utility values and costs were used to create an expected-value decision analysis model. RESULTS: The results of the model revealed that the cost per quality-adjusted life-year (QALY) of a series of PRP injections was $8,635.23/QALY and that of a series of HA injections was $5,331.75/QALY. A series of PRP injections was associated with a higher initial cost than a series of HA injections (difference, $1,433.67); however, PRP was also more effective (higher utility value) than HA by 0.11 QALYs (0.69 vs 0.58, P = .0062) at 1 year. The incremental cost-effectiveness ratio of the use of PRP injections as opposed to HA was $12,628.15/QALY. CONCLUSIONS: Although a series of either PRP ($8,635.23/QALY) or HA ($5,331.75/QALY) injections for the treatment of symptomatic knee osteoarthritis would be considered cost-effective (cost per QALY < $50,000), PRP injections were not more cost-effective than HA injections. However, PRP was significantly more effective at 1 year, and being associated with an incremental cost-effectiveness ratio of $12,628.15/QALY when compared with HA, a series of PRP injections should be considered a reasonable and acceptable alternative to HA injections for the treatment of symptomatic knee osteoarthritis. LEVEL OF EVIDENCE: Level II, economic and decision analysis of Level I studies.

Quadruple Versus Double Flexible Intramedullary Nails to Treat Pediatric Distal-third Tibial Shaft Fractures: A Biomechanical Comparison.

BACKGROUND: The vast majority of pediatric distal-third tibial shaft fractures can be treated with closed reduction and casting. If conservative measures fail, then these fractures are usually treated with 2 antegrade flexible intramedullary nails. A postoperative cast is usually applied because of the tenuous fixation of the 2 nails. Recent studies have described the use of 4 nails to increase the stability of the fixation, a technique that may preclude the need for postoperative casting. The purpose of this biomechanical study is to quantify the relative increase in stiffness and load to failure when using 4 versus 2 nails to surgically stabilize these fractures. METHODS: Short, oblique osteotomies were created in the distal third of small fourth-generation tibial sawbones and stabilized with 2 (double) or 4 (quadruple) flexible intramedullary nails. After pilot testing, 5 models per fixation method were tested cyclically in axial compression, torsion, and 4-point bending in valgus and recurvatum. At the end of the study, each model was loaded to failure in valgus. Stiffness values were calculated, and yield points were recorded. The data were compared using Student's t tests. Results are presented as mean±SD. The level of significance was set at P≤0.05. RESULTS: Stiffness in valgus 4-point bending was 624±231 and 336±162 N/mm in the quadruple-nail and double-nail groups, respectively (P=0.04). There were no statistically significant differences in any other mode of testing. CONCLUSIONS: The quadruple-nail construct was almost 2 times as stiff as the double-nail construct in resisting valgus deformation. This provides biomechanical support for a previously published study describing the clinical success of this fixation construct.

The Cost-Effectiveness of Using Platelet-Rich Plasma During Rotator Cuff Repair: A Markov Model Analysis.

PURPOSE: To perform a cost-utility analysis to determine if the use of platelet-rich plasma (PRP) products during arthroscopic rotator cuff repair (RCR) is cost-effective. METHODS: A cost-utility analysis was conducted using a Markov decision model. Model inputs including health utility values, retear rates, and transition probabilities were derived from the best evidence available in the literature regarding full-thickness rotator cuff tears and their repair, as well as the augmentation of their repair with PRP. Costs were determined by examining the typical patient undergoing treatment for a full-thickness rotator cuff tear in a private orthopaedic clinic and outpatient surgery center. RESULTS: The cost per quality-adjusted life-year ($/QALY) of RCR with and without PRP was $6,775/QALY and $6,612/QALY, respectively. In our base case, the use of PRP to augment RCR was not cost-effective because it had exactly the same "effectiveness" as RCR without PRP augmentation while being associated with a higher cost (additional $750). Sensitivity analysis showed that to achieve a willingness-to-pay threshold of $50,000/QALY, the addition of PRP would need to be associated with a 9.1% reduction in retear rates. If the cost of PRP were increased to $1,000, the retear rate would need to be reduced by 12.1% to reach this same threshold. This compared with a necessary reduction of only 6.1% if the additional cost of PRP was $500. CONCLUSIONS: This cost-utility analysis shows that, currently, the use of PRP to augment RCR is not cost-effective. Sensitivity analysis showed that PRP-augmented repairs would have to show a reduced retear rate of at least 9.1% before the additional cost would be considered cost-effective. LEVEL OF EVIDENCE: Level III, analysis of Level I, II, and III studies.

Recurrent Anterior Cruciate Ligament Tears in the National Football League: A Case-Control Study.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common in American football players. The risk of subsequent ACL reinjury to either the ipsilateral or the contralateral knee in National Football League (NFL) draftees with a history of successful ACL reconstruction before entering the NFL remains unknown. HYPOTHESIS: NFL athletes with a history of successful ACL reconstruction before being drafted will likely demonstrate increased risk of subsequent ACL injury when compared with a control cohort consisting of players of similar positions and draft class. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Detailed orthopaedic evaluations of NFL Combine participants from 2006 to 2012 were obtained to identify players entering the NFL draft with a history of successful ACL reconstruction. A control cohort was created in a 2:1 ratio, consisting of players matched by position and draft class. RESULTS: Of the 2016 players invited to the NFL Combine during the study period, 100 met the inclusion criteria. A total of 26 subsequent ACL reinjuries (12 ipsilateral, 14 contralateral) occurred in 25 players (25%) while playing in the NFL, with injuries occurring at a mean of 22.1 months after the NFL draft. In comparison, 18 of the 200 (9%) carefully matched cohort players without history of prior ACL injury sustained a new ACL injury during this time period (P < .001). CONCLUSION: NFL athletes with a history of successful ACL reconstruction before being drafted into the NFL have a significantly higher rate of subsequent ACL reinjury while playing in the NFL when compared with a carefully matched cohort of players without a history of prior ACL injury.

Cost-effectiveness analysis of autologous chondrocyte implantation: a comparison of periosteal patch versus type I/III collagen membrane.

BACKGROUND: Autologous chondrocyte implantation (ACI) involves the use of a periosteal patch (ACI-P) as a cover for transplanted chondrocytes. Theoretically, this periosteal patch provides mesenchymal stem cells and growth factors that encourage chondrocyte development/differentiation. However, there is a significant rate of graft hypertrophy with the use of periosteum compared with using a type I/III collagen patch (ACI-C). This type I/III collagen patch, although not approved by the United States Food and Drug Administration for ACI, has been used extensively in Europe and in an "off-label" nature in the United States as a cover during ACI. PURPOSE: To examine the cost effectiveness of ACI and determine whether ACI-C is more cost effective than ACI-P. STUDY DESIGN: Economic and decision analysis; Level of evidence, 2. METHODS: Outcome data and complication rates from patients undergoing ACI (ACI-P and ACI-C) were derived from the best evidence in the literature. Costs were determined by examining the typical patient charges undergoing ACI at a local orthopaedic hospital. The costs, results, and complication rates were used to develop a decision analysis model comparing ACI-P to ACI-C. RESULTS: The cost of ACI-P was $66,752 and for ACI-C was $66,939.50 ($187.50 difference). The cost per quality-adjusted life year (QALY) for ACI-P was $9466 compared with $9243 for ACI-C. Sensitivity analysis was performed regarding the additional cost of the type I/III collagen patch ($780) in ACI-C as well as the rate of graft hypertrophy after ACI-P (25%). This analysis revealed that the cost of the type I/III collagen patch would have to reach $1721, or the rate of graft hypertrophy after ACI-P reduced to almost 11%, before ACI-P became more cost effective than ACI-C. CONCLUSION: This cost-effectiveness analysis reveals that, while both ACI-P and ACI-C are cost effective, ACI-C is slightly more cost effective than ACI-P. This is likely secondary to the significant rate of patch-related complications associated with ACI-P, which is significantly reduced with ACI-C. Although the model is very sensitive to differences in outcomes between ACI-P and ACI-C, there is no high-quality evidence to suggest that there is a significant difference between the two. Thus, ACI-P becomes more cost effective if the cost of the type I/III collagen membrane is significantly increased or if the rate of graft hypertrophy after ACI-P were to be markedly reduced.

Fracture of a reverse total shoulder arthroplasty retentive liner.

Reverse shoulder arthroplasty may be indicated in shoulders that cannot be effectively managed by conventional reconstruction procedures. Reported complications include instability, infection, hematoma, scapular notching, and premature component loosening. To our knowledge, however, fracture of a humeral component polyethylene inlay has not been described. A 72-year-old man presented with unstable, painful shoulders after undergoing unsuccessful open repairs and acromioplasties at an outside institution for bilateral massive rotator cuff tears. We performed a left reversed shoulder arthroplasty with a 36-mm glenosphere and a +9-mm polyethylene liner. In the operating room under general anesthesia with chemical paralysis and an interscalene block, his shoulder was stable. The patient required revision with a metal 9-mm lateralizer following an atraumatic dislocation 4 weeks postoperatively. Four weeks following the revision, the patient again presented with a dislocated left shoulder without antecedent trauma. During this second revision, the +6-mm standard polyethylene liner was replaced with a +6-mm lateral retentive polyethylene liner. A third revision surgery was performed after the patient experienced 2 more dislocations with minor activity. Intraoperatively, a fracture of the previously placed +6-mm retentive polyethylene liner was noted. This article may represent a case of dramatic scapular impingement by the humeral components. More subtle forms of scapular notching are common and may suggest significant long-term problems. Many reverse shoulder prostheses are being refined or modified in an attempt to eliminate or reduce the scapular notching phenomenon.

Do rods influence the hue of foveal stimuli?

To understand the generality and mechanisms of previously reported rod hue biases, we examined whether they are present for small foveal stimuli by comparing the wavelengths of the three spectral unique hues under dark-adapted and flash-bleached conditions. Rod green bias (shift of unique yellow) and rod blue bias (shift of unique green) were found for some observers with 1 degrees -diameter foveal stimuli, the size most likely to stimulate rods. Smaller stimuli (0.2 degrees and 0.6 degrees diameter), which were least likely to stimulate rods, produced no large or consistent differences between dark-adapted and bleached conditions. This suggests that rod hue biases result from the local stimulation of rods by light, not from remote suppression by dark-adapted, unstimulated rods, and not from bleaching light artifacts.