Microfracture and Osteochondral Autograft Transplantation Are Cost-effective Treatments for Articular Cartilage Lesions of the Distal Femur

Abstract

Background:

Multiple techniques have been suggested for the treatment of isolated knee articular cartilage injuries. For smaller lesions (<2-5 cm²), microfracture and osteochondral autograft transplantation (OAT) are commonly used options. With an increasing focus on health care efficiency, analyzing the cost-effectiveness of treatment modalities has become increasingly important.

Purpose/Hypothesis:

The purpose of this study was to analyze the costs and outcomes of microfracture and OAT to compare their cost-effectiveness. The hypothesis was that microfracture would be more cost-effective.

Study Design:

Economic and decision analysis; Level of evidence, 2.

Methods:

A literature search was performed to identify studies comparing microfracture and OAT for the treatment of articular cartilage lesions of the distal femur in an adult population. Data from these studies including surgical time, failure rates, revision surgeries, outcome scores, and return to athletics were then incorporated into a constructed cost model using standard accounting methodology. The model was based on actual 2013 cost figures (in US dollars) for all procedure, operating room, and instrumentation costs.

Results:

Three studies, with a mean follow-up of 8.7 years, met the inclusion criteria of having evidence level 1 or 2 comparing microfracture and OAT. There was a cumulative 28.6% reoperation rate among patients undergoing microfracture compared with 12.5% among patients undergoing OAT. While both groups demonstrated significant improvements compared with preoperative levels, the only significant differences in any outcome score reported between the 2 procedures were the International Cartilage Repair Society (ICRS) score and patient-reported return to their previous sports activity level. While microfracture had a lower initial cost ($3100), these savings lessened over 1 year ($1843) and 10 years ($996). Microfracture was more cost-effective when comparing Lysholm and Hospital for Special Surgery scores, whereas OAT was more cost-effective when comparing Tegner and ICRS scores. There was a significantly lower cost for return to play in athletes after OAT versus microfracture at 1 year ($11,428 vs $16,953, respectively), 3 years ($12,856 vs $38,000, respectively), and 10 years ($32,141 vs $60,799, respectively).

Conclusion:

Published level 1 and 2 clinical studies with a 10-year follow-up demonstrated that the net cost and cost-effectiveness of microfracture and OAT are comparable for the treatment of isolated articular cartilage lesions of the distal femur.

Clinical Relevance:

Given similar clinical outcomes, microfracture and OAT are both viable, cost-effective first-line treatment options for these injuries.

Keywords

microfracture OAT osteochondral cost-effectiveness cost analysis

Chondral defects of the knee are commonly diagnosed by magnetic resonance imaging (MRI) and routine arthroscopic surgery. In a prospective survey of 993 knee arthroscopic procedures, Aroen et al¹ reported a 66% incidence of articular cartilage abnormalities. These lesions can occur both in isolation and in conjunction with other knee injuries and can be a source of significant functional limitation and disability. Cartilage defects have limited potential for spontaneous repair because of their avascularity and minimal chondrocyte migration and propagation.^3,4,13 Over the past 2 decades, significant research has been directed toward the treatment of these focal articular cartilage defects, particularly in young active patients, with the goal of restoring a durable joint surface to alleviate pain, restore function, and minimize future chondral degeneration. While multiple treatment modalities have been described, microfracture and osteochondral autograft transplantation (OAT) are the 2 most commonly used options in smaller (<2-5 cm²) focal chondral defects.²⁴

The microfracture technique, as described by Steadman et al,²² involves multiple penetrations of the subchondral bone within the cartilage lesion to a depth of 2 to 3 mm to stimulate the release of pluripotent mesenchymal stem cells from the bone marrow. The cells, contained in a fibrin clot within the lesion, eventually form fibrocartilage, filling the articular defect. While fibrocartilage has been shown to have inferior biomechanical properties compared with hyaline cartilage, short-range and midrange studies have shown significant clinical improvement in pain and function.^17,18,20,21 In addition to its technical simplicity, another potential advantage of microfracture is its low cost because it is relatively fast to perform, is technically simple, and does not require any expensive, single-use instrumentation. Additionally, there are no implantable materials or additional laboratory costs that are associated with other treatment modalities for chondral defects.¹⁷

The OAT procedure can be performed either open or arthroscopically and involves harvesting cylindrical osteochondral plugs from nonweightbearing articular regions of the knee that are transplanted into the chondral lesion, flush with the surrounding cartilage.¹¹ This technique restores a hyaline cartilage surface at the site of the lesion and has been associated with significant clinical improvement in pain and function in short-range and midrange studies.^10,11,16,19 However, OAT does require a more elaborate instrumentation system and longer operating room times compared with the microfracture technique.

Recently, several studies with evidence level 1 or 2 have reported midterm and long-term clinical results comparing the 2 procedures.^8,15,23 These studies have reported comparable outcome scores, complications, failure rates, and secondary surgeries. While these studies have assessed the clinical outcomes of these 2 procedures, no study, to date, has compared the cost-effectiveness of these techniques. With an increasing focus on health care efficiency, we conducted an analysis of these 2 techniques to test the hypothesis that microfracture is more cost-effective than OAT.

Methods

A literature search was performed using the PubMed database for all evidence level 1 or 2 studies comparing microfracture and OAT for the treatment of isolated, focal cartilage defects of the distal femur.² The search criteria included English-language publications between January 1, 2000 and July 1, 2014. The keywords used included microfracture, cartilage repair, mosaicplasty, osteochondral autograft, osteochondral transplantation, osteochondral transfer, osteochondral plugs, osteoarticular transfer system, and OAT. Only those articles that were reported as having evidence level 1 or 2 by the journal in which they were published were included. Pediatric studies were not included in this review as those studies focused on the treatment of isolated osteochondritis dissecans lesions. Studies also comparing other treatment modalities (ie, autologous chondrocyte implantation [ACI]) in addition to the 2 procedures were included as long as they met the above criteria. Five studies were identified as meeting the criteria; however, on further review by 2 authors (D.J.M., R.H.B.), 3 of these studies shared the same patient population; therefore, their results were aggregated.^8-10,15,23 Thus, a total of 3 study populations were reviewed to determine comparative demographics, operative details, and outcomes.^8,15,23

With use of the outcomes from the included study populations, a cost model was constructed to compare microfracture and OAT for the treatment of isolated cartilage lesions. The analysis assumed an otherwise healthy young adult and began at the time of initial surgical treatment with 1 of the 2 above-mentioned procedures, continuing for a maximum 10-year follow-up period. Ten years was used based on the results of the 3 study populations with evidence level 1 or 2 that were identified in the literature.^8,15,23 A decision tree was constructed for both procedures based on outcomes over the 10-year follow-up (Figures 1 and 2). Outcomes from these studies included surgical time, failure rates, revision surgeries, and outcome scores. Terminal endpoints for the analysis were those requiring no further procedures, early failure, and late failure. Both early and late failures were subdivided into specific procedures performed.

Figure 1.

Microfracture decision tree.

Figure 2.

Osteochondral autograft transplantation (OAT) decision tree. HTO, high tibial osteotomy.

Because of differences in reporting, all secondary arthroscopic procedures not requiring significant cartilage restoration or reconstruction (eg, diagnostic/debridement, chondroplasty, arthrolysis) were categorized as arthroscopic chondroplasty for cost-analysis purposes. Also, among those who underwent microfracture, 2 patients underwent ACI procedures as secondary surgeries. In our cost analysis, instead of using ACI cost data, we used cost figures for an OAT procedure. This was done because at this time, there is no clear consensus on the indications for the ACI versus OAT procedure, particularly in smaller lesions. As either surgery could have potentially been performed, we chose to use the substantially less expensive OAT cost figures. All outcomes and terminal endpoints were determined based on results reported in the identified study populations.

The probabilities for failure were collected from the 3 identified studies. Failure was defined as pain or functional loss directly related to the chondral lesion or treatment requiring a second procedure. Based on the identified literature, failure rates appeared bimodal and were analyzed accordingly in this study. Early failures were failures that required reoperation within the first year of the initial procedure. Late failures were those that underwent a secondary procedure after the 1-year period and were performed, on average, 5 years after the index procedure as indicated in the studies.

We used actual 2013 cost figures (in US dollars) from our institution (an academic medical center/surgical center in the central US). Costs for each procedure included charges for the operating room (eg, supply/instrumentation costs, operating room staff, and time), surgeon, and anesthesia (Table 1). We did not include preoperative costs (eg, initial evaluation, imaging) or initial postoperative costs for the primary procedure as they are assumed to be the same for both procedures. For patients who failed, we did include the costs of a physician evaluation and MRI of the knee without contrast in the calculation of the total cost of their secondary procedure as these would likely be obtained before any secondary procedures. With the exception of total knee arthroplasty, all other procedures were assumed to be outpatient procedures performed in a surgical center without hospital admission.

Table 1

Cost Data^a

Description of Procedure	Anesthesia	Operating Room Fees	Surgeon Fees	Return Visit	MRI	Initial Procedure Cost	Secondary Procedure Cost
OAT–arthroscopic	$720	$4300	$5300	$300	$600	$10,320	$11,220
OAT–open	$720	$4500	$4900	$300	$600	$10,120	$11,020
Microfracture	$720	$3200	$3300	$300	$600	$7220	$8120
Chondroplasty	$640	$2800	$3100	$300	$600	$6540	$7440
Total knee replacement	$1200	$37,900	$7800	$300	$600	$46,900	$47,800
High tibial osteotomy	$800	$15,000	$4800	$300	$600	$20,600	$21,500

Costs are based on 2013 US dollars. MRI, magnetic resonance imaging; OAT, osteochondral autograft transplantation.

We did not include any specific costs of rehabilitation or physical therapy in this analysis. For the 2 primary procedures, these costs should be the same and would not affect our comparative analysis. For secondary procedures, we did not have specific therapy regimens reported in the identified studies, nor did we have an accurate method of assessing total therapy and rehabilitation costs for these secondary procedures. Therefore, these costs were excluded. Also, indirect costs such as lost wages or productivity for either primary or secondary procedures were not included in our analysis as they could not be accurately assessed based on the identified studies.

Expected total costs for microfracture and OAT were calculated based on the decision tree mentioned above. The constructed model incorporated the cost of the primary surgery as well as the cost of failure based on the costs of the secondary procedures. All OAT procedures were assumed to be performed arthroscopically for the purpose of cost analysis. Early failures did not require any cost discounting as they were performed within the first year. The costs of late failures were discounted at a 3% annual rate and considered to occur at year 5. The sum of the primary surgery costs and revision procedure costs at their respective discounted rates of frequency and occurrence provided a net total cost for both microfracture and OAT.

We conducted a sensitivity analysis to evaluate how varying our base assumptions would affect our findings. First, we assessed how variance in the costs of microfracture and OAT, as well as the rate of revision surgery after microfracture and OAT, would affect our model. We also evaluated the effect of adding indirect costs (eg, potentially physical therapy, decreased earnings secondary to time lost from work) to each procedure. Given the uncertainty of calculating these costs, we evaluated the effect of mean indirect costs of $5000 per case and $10,000 per case, assumed to be the same for microfracture and OAT in each case.

A cost-effectiveness analysis compared the cost of specific treatments or procedures to their reported clinical outcome measure, providing an assessment of how much each incremental clinical improvement costs. With use of the clinical outcome data reported in the identified studies, in conjunction with the net total costs for microfracture and OAT from our cost-analysis model, we were able to calculate and compare the cost-effectiveness of OAT and microfracture for the treatment of small articular cartilage lesions in young adults.

Results

Three study populations in 5 articles met the inclusion criteria as having level 1 or 2 evidence comparing microfracture and OAT.^8-10,15,23 These studies had a total of 70 patients undergoing microfracture and 64 patients undergoing OAT, with a mean follow-up of 8.7 years. The cumulative mean age was 28.8 years (range, 15-42 years), with 59% being male. The mean size of the isolated cartilage lesions treated with microfracture was 2.7 cm² (range, 1.2-5.2 cm²); for OAT, the mean size was 2.8 cm² (range, 1.0-6.0 cm²). All lesions were located on the medial or lateral femoral condyles except for 2 cases in the OAT group, which were located on the trochlea. Cumulative failure rates were 28.6% (n = 20/70) among patients undergoing microfracture compared with 12.5% (n = 8/64) among patients undergoing OAT. There was a 14% early failure rate among patients undergoing microfracture, with a secondary procedure being either chondroplasty (1%; n = 1) or OAT (13%; n = 9). In contrast, patients undergoing OAT were found to have a 3% (n = 2/64) early failure rate requiring subsequent chondroplasty (1.5%; n = 1) or OAT (1.5%; n = 1). Late failures occurred in 14% (n = 10/70) of patients undergoing microfracture, requiring subsequent chondroplasty (3%; n = 2), revision microfracture (3%; n = 2), OAT (7%; n = 5), or total knee arthroplasty (1%; n = 1). In patients undergoing OAT, 9% (n = 6/64) had late failures, leading to chondroplasty (1.5%; n = 1), OAT (6%; n = 4), or high tibial osteotomy (1.5%; n = 1).

Of the 3 study populations, all reported statistically significant improvements from preoperative to postoperative levels based on the reported outcome measures for both microfracture and OAT. However, there was substantial variability in the method of outcome reporting, with measures including the Lysholm score, International Cartilage Repair Society (ICRS) score, Tegner score, Hospital for Special Surgery (HSS) score, and Knee injury and Osteoarthritis Outcome Score (KOOS) as well as return to the previous level of sports. Only 1 study population reported statistically significant differences between microfracture and OAT postoperative results.¹⁰ This study, by Gudas et al,⁸ found statistically significant improvements on ICRS scores and return to the previous level of sports with OAT compared with microfracture. There were no other significant differences in any other outcome measure between the 2 techniques (Table 2).

Table 2

Outcome Comparison^a

	Preoperative to Postoperative Difference	Cost per Point Improvement
Lysholm
Microfracture	30.9	$339
OAT	24.5	$469
Tegner
Microfracture	2.3	$4558
OAT	2.6	$4415
HSS
Microfracture	9.38	$1118
OAT	9.46	$1213
ICRS^b
Microfracture	25.8	$406.79
OAT	37.2	$308.50

Costs are based on 2013 US dollars. HSS, Hospital for Special Surgery; ICRS, International Cartilage Repair Society; OAT, osteochondral autograft transplantation.

Statistically significant difference between microfracture and OAT.

Based on the decision trees for each technique, the total costs for both microfracture and OAT were calculated at both 1-year and 10-year follow-up. Microfracture had an initial cost of $7220 with net total costs of $8769 at 1 year and $10,483 at 10 years versus OAT with an initial cost of $10,320 and net total costs of $10,612 at 1 year and $11,479 at 10 years (Table 3).

Table 3

Cost Comparison^a

		Total Net Cost
	Initial	1 y	10 y
Microfracture	$7220	$8769	$10,483
OAT	$10,320	$10,612	$11,479
Difference	−$3100	−$1843	−$996

Costs are based on 2013 US dollars. OAT, osteochondral autograft transplantation.

A comparative cost-effectiveness analysis was performed between microfracture and OAT based on each reported outcome measure from the identified studies. Cost-effectiveness was reported as the cost for a 1-point increase on each of the given scales and demonstrated mixed results. Microfracture was found to be more cost-effective by the Lysholm and HSS scores, whereas OAT was more cost-effective by the Tegner and ICRS scores (Table 2). The cost to return patients back to their previous level of sport was also reported at 1, 3, and 10 years, and results demonstrated OAT to be more cost-effective than microfracture for all years (Table 4).

Table 4

Cost of Return to Play^a

	Return to Play, y
	1	3	10
Microfracture	$16,953	$38,000	$60,799
OAT	$11,427.84	$12,856.42	$32,141.05

Costs are based on 2013 US dollars. OAT, osteochondral autograft transplantation.

The sensitivity analysis revealed that an 11.5% reduction in the reported cost of an OAT procedure or a 13.5% increase in the reported cost of microfracture would lead to equivalent total costs of the 2 procedures at 10 years. We found that if the overall reoperation rate for microfracture increased to 37.1%, or decreased to 1.8% for OAT, the 2 procedures would have equivalent costs over 10 years. Assuming a total of $5000 in indirect costs for each surgery, microfracture was $1285 less than OAT at 1 year and $220 less at 10 years. However, assuming $10,000 in indirect costs after each surgery, microfracture was $727 less than OAT at 1 year but $556 more at 10 years. If the indirect costs associated with surgery were $16,500, the total costs of microfracture and OAT were equivalent at 1 year. If the indirect costs associated with surgery were $6400, the total costs of microfracture and OAT were equivalent at 10 years.

Discussion

This study showed that microfracture and OAT are both cost-effective for the treatment of small (≤6 cm²) focal articular cartilage defects of the distal femur. While OAT had higher initial costs, microfracture had higher costs for additional surgeries during short- and long-term follow-up. With similar cost-effectiveness between the 2 techniques, and a less costly return to play for athletes after OAT, both techniques are viable options in patients with these defects. We cannot extrapolate the cost-effectiveness of either procedure (based on the results of this study) for similar defects of the patella or tibia.

Microfracture and OAT are 2 of the most commonly suggested initial surgical options²⁴ for isolated articular cartilage defects in the knee that are less than 2 cm². However, the recommended technique continues to be debated, particularly as studies with longer follow-ups are published. Multiple studies with evidence level 3 or 4 have reported statistically significant improvements between preoperative and postoperative outcome scores for both techniques.^{5,6,11,12,14,18,21,22} Unfortunately, as our literature search demonstrated, there is a dearth of quality level 1 and 2 evidence studies directly comparing these 2 techniques.

The current study identified only 5 articles^8-10,15,23 representing 3 patient populations that met the criteria as evidence level 1 and 2 studies. Multiple outcome measures were used, and only 1 study reported any outcome measures with significant differences between the 2 techniques.⁸ A recent systematic review of all level 1 and 2 studies of microfracture by Goyal et al⁷ reported similar findings. These authors concluded that comparisons of microfracture with other techniques for treating cartilage lesions in the knee were inconclusive because of a paucity of relevant literature.⁷ While clinical findings have not suggested either microfracture or OAT to be clearly superior, some have suggested microfracture as a first-line treatment because of the low cost of the procedure.¹⁷ However, there is no study, to our knowledge, comparing costs between these 2 procedures. This is the first study to perform a comparative cost analysis and cost-effectiveness analysis between microfracture and OAT for the treatment of focal, isolated articular cartilage injuries in the distal femur.

The cost analysis of both techniques demonstrated initial costs of microfracture to be $3100 less than OAT. However, because of the higher revision surgery rates for microfracture compared with OAT, this difference narrows to $1843 at 1-year follow-up and $996 at 10-year follow-up. Further long-term results are needed to determine if this trend would continue or even accelerate, particularly as some studies have suggested a more rapid deterioration of microfracture results beginning 5 years after the procedure.^7,14 In addition, because of the higher failure rates with microfracture, the inclusion of rehabilitation and indirect costs such as loss of wages related to the secondary procedure would likely further mitigate and perhaps even reverse these cost differences. Unfortunately, we are limited in evaluating the associated costs of rehabilitation as no information was provided by the studies regarding the rehabilitation protocol for any of the primary or secondary procedures. There may be substantial variability in the rehabilitation protocol between different patient populations and between different types of secondary procedures. Therefore, including rehabilitation in our analysis without information from the selected studies would be highly speculative. We also recognize that we did not account for indirect costs such as lost wages related to prolonged recovery periods and secondary procedures. Similar to rehabilitation, the selected studies did not provide any information regarding these costs, and as such, no accurate data could be estimated. However, we did add a sensitivity analysis to assess how this information would affect the findings of our study. Finally, in this study, revision OAT was the most common procedure for failed OAT. Some surgeons may elect to use other more costly procedures (osteochondral allografts, ACI, osteotomy, etc) as their standard revision procedure for failed OAT. This could also potentially significantly affect the results of our study, leading to higher total costs of OAT. Starting with microfracture may give patients another option (ie, OAT) before moving to a bigger surgery.

The comparative cost-effectiveness analysis was inconclusive as both techniques were shown to be superior with different outcome measures. The variability in cost-effectiveness, particularly when comparing the 2 techniques, may reflect the different emphasis of, and factors influencing, each outcome measure. For example, the Lysholm score focuses more on assessing instability, whereas the Tegner score assesses changes in activity level. In addition, these outcome measures vary in their specificity and depth of assessing results. For example, return to play simply addresses whether the patient is able to return to his or her previous level of activity without specifically addressing factors such as instability or pain. Thus, the cost-effectiveness analysis for each outcome measure demonstrates, to a large degree, the cost benefits of the particular focus of the specific outcome instrument (ie, the cost-effectiveness of improving stability or the cost-effectiveness of returning to a particular level of play). This may account for the variability seen between the cost-effectiveness results of different outcome measures. However, among the 2 outcome measures with significant differences (ICRS score and return to previous level of sport), OAT was found to be more cost-effective. While these findings do not provide specific recommendations, it may suggest that with particular patient focuses (ie, young athletes returning to sports), OAT may be more cost-effective despite higher initial costs.

A common measure found in the literature for assessing cost-effectiveness employs the metric of quality-adjusted life years (QALYs). The QALY is calculated by multiplying the patient’s health-related quality of life, represented on a scale of 0 to 1 (referred to as the health utility) by the length of time at that level. The cost of the treatment per QALY is then reported as a measure of cost-effectiveness. There are multiple ways of calculating the health utility, ranging from time trade-off surveys to visual analog scales, resulting in variability particularly based on different demographic populations. As such, we felt that QALYs would not be an appropriate measure for this study to compare the cost-effectiveness between microfracture and OAT as the health utility reported in the literature may not accurately reflect quality of life differences in this study, particularly given our young, athletic patient population.

There are several limitations to this study. As noted above, the limited number of evidence level 1 and 2 studies resulted in a small population size for each technique. In addition, a variety of outcome measures were used between the study populations, with only 1 measure (Lysholm score) reported in multiple studies. While this makes the aggregation of the results more difficult, it may also provide a broader picture of the actual clinical outcome. Different measures may reflect different improvements by the patient such as changes in pain versus function or general functional improvement versus ability to return to specific activities between the techniques. Also, the cost data used in our analysis were obtained from a single large academic medical center in the central US and were based on actual 2013 costs. These data may not reflect costs at other institutions or time points. On the basis of the studies that we reviewed, we could not distinguish trochlea lesions from femoral condyle lesions, which may be a confounder of our analysis. The cost of return to sports may be sensitive to physical therapy/rehabilitation costs and indirect costs as patients who return to sports may require more physical therapy or have other indirect costs that were not accounted for in this study. Finally, the published literature is limited to only 10-year postoperative follow-ups. As longer term results are reported, this may significantly affect the cost analysis, particularly if microfracture experiences a significant decline in outcomes after 5 years as some literature suggests.^8,12

Despite the limitations of this study, it does provide valuable information in assessing the factors influencing our choice of treatment modalities. Comparative cost analysis and cost-effectiveness studies are becoming increasingly more important as they are being used to guide health care policy decisions, influence treatment reimbursement, support future research, and direct fiscal responsibility among physicians. Although these analyses should not be used as the sole determinant between treatment modalities, they should be incorporated as a factor in the decision algorithm to help increase the cost-effectiveness of health care.

In conclusion, this study demonstrates that while microfracture has time zero cost savings compared with OAT, it appears that these savings are not sustained over the short or long term. Furthermore, the net cost and cost-effectiveness of microfracture and OAT are comparable based on the level 1 and 2 evidence. OAT may be preferable in more active populations aiming for return to sports. As such, microfracture and OAT are both viable first-line treatment options for small isolated articular cartilage lesions in the distal femur.

Footnotes

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.

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