Early Surgical Treatment of Intact Juvenile Osteochondritis Dissecans Lesions: A Cost Effectiveness Analysis with Implications For Future Prospective Study Design

ABSTRACT: Introduction: Stable low-grade osteochondritis dissecans (OCD) lesions in adolescents are typically treated with an initial trial of conservative management including bracing, activity limitation, and physical therapy. While there are some tools to help predict healing rates, overall only about 2/3rd heal with non-surgical management. Surgical treatment, on the other hand, has an overall higher success rate for healing, over 90%, in a shorter time frame. We sought to better understand the factors that influence the treatment choice by investigating the tradeoff between initial conservative treatment and early surgical management through a cost-effectiveness analysis (CEA). Methods: A decision model was constructed using Python to evaluate two alternative initial treatment options for low-grade stable juvenile OCD lesions: an extended period of conservative management followed by transarticular drilling in the case of non-healing lesions, versus early transarticular drilling conducted at the time of diagnosis for all lesions. Starting parameters for outcome probabilities and effectiveness were estimated from the literature or expert opinion where necessary. Costs were estimated using pooled patient billing data. Effectiveness was calculated as quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, incremental effectiveness, and net health benefits. Multivariate sensitivity analysis was then performed on relevant variables to determine the factors that most influence the treatment choice. Results: Based on the initial assumptions, early surgical intervention was found to have a higher average cost ($4224/patient vs. $1677/patient for conservative treatment) but also a higher utility. Under the model’s initial assumptions, conservative management was not the most cost effective treatment because the significantly reduced probability of healing success did not justify the cost difference with surgical treatment. All of the variables tested in the model influenced the decision process to varying degrees but the most sensitive variables included the probability of ‘normal’ outcomes after early surgical intervention, the quality of life during treatment recovery, the probability that a delayed surgery is successful after failed initial conservative treatment, and the time duration of a conservative treatment course. Discussion: While early surgery is more expensive, our analyses suggest that there is likely a threshold where the enhanced healing rate of initial surgical treatment ultimately makes it a cost-effective treatment option. Sensitivity analysis suggests that by gaining a better understanding of the healing rate of a particular lesion with operative and conservative treatment, the time to healing with each treatment option, and the life quality impact of the treatment decision on the patient, the optimal treatment strategy can better be identified. Future studies should seek to elucidate these factors. Level of Evidence: Economic and Decision Analysis, Level II.