Published online Jun 18, 2023. doi: 10.5312/wjo.v14.i6.458
Peer-review started: December 21, 2022
First decision: April 13, 2023
Revised: April 26, 2023
Accepted: May 15, 2023
Article in press: May 15, 2023
Published online: June 18, 2023
Over the years, extensive research into the clinical outcomes of patient specific instrumentation (PSI) for total knee arthroplasty (TKA) compared to conventional instrumentation (CI) for TKA have been performed. Clinically, the instrumentation techniques are considered equal. However, decreased operating time and sterilization tray usage have been reported when using PSI TKA. These factors could influence the healthcare cost.
Multiple studies into the cost and cost-effectiveness of PSI and CI TKA have been performed since its introduction. Most studies consider specific aspects of their costs, such as: Additional imaging costs, PSI production costs, operating time costs, and tray sterilization costs. Furthermore, studies on Quality Adjusted Life Years (QALY) and Incremental Cost Effectiveness Ratio (ICER) for PSI and CI TKA have been performed. Despite the abundance of research, no clear overview or comparison has been presented. The motivation for this systematic review was to give a clear overview of the cost and cost-effectiveness of PSI TKA compared to CI TKA.
The objective of this research was to present the different aspects of cost of PSI TKA and CI TKA. Furthermore, cost-effectiveness was investigated. By doing this, the secondary objective was to advise orthopaedic surgeons in their decision making when choosing either PSI TKA or CI TKA.
A systematic literature search was performed in healthcare, economical healthcare, and medical databases (MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane Library, EconLit). Relevant literature included randomised controlled trials, retrospective studies, prospective studies, observational studies, and case control studies. Data extraction was performed to obtain the following results: ICER, QALYs, total costs, imaging costs, production costs, sterilization associated costs, surgery duration associated costs and readmission rates and associated costs. Meta-analysis was performed for outcomes with sufficient data.
Thirty-two studies were included into the systematic review. Two were included in the meta-analysis. 3994 PSI TKAs and 13267 CI TKAs were included in the sample size. We found that when considering mean OR time and its associated costs and tray sterilization per patient case, PSI TKA costs less than CI TKA. PSI TKA is more costly compared to CI TKA when considering imaging and production costs. Considering total costs per patient case, PSI TKA is more expensive in comparison to CI TKA. Meta-analysis comparing total costs for PSI TKA, and CI TKA showed a significant higher cost for PSI TKA.
This study showed that costs for PSI TKA and CI TKA can differ when considering different aspects of their implementation. When directly comparing PSI and CI TKA, results showed that total costs per patient case are more for PSI TKA.
Based on the results presented, we recommend orthopaedic surgeons worldwide make careful decisions when deciding on which instrumentation technique to use for TKA. In anatomically challenging cases PSI is a helpful planning modality for TKA. However, this systematic review showed that the total cost of its implementation is higher per patient case. Surgeons are advised to take the cost-effectiveness and total cost into consideration.