Abstract
Background
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Total hip arthroplasty is a reliable option to treat osteoarthritis. It reduces pain, increases quality of life, and restores function. The direct anterior approach (DAA), posterior approach (PA), and straight lateral approach (SLA) are mostly used. This systematic review evaluates current literature about costs and cost-effectiveness of DAA, PA, and SLA.
Methods
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A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic search, registered in the PROSPERO database (registration number: CRD42021237427), was conducted of databases PubMed, CINAHL, EMBASE, Cochrane, Clinical Trials, Current Controlled Trials, ClinicalTrials.gov, NHS Centre for Review and Dissemination, Econlit, and Web of Science. Eligible studies were randomized controlled trials (RCTs) or comparative cohort studies reporting or comparing costs or cost-effectiveness of either approach as the primary outcome. The risk of bias (RoB) was assessed. For comparison, all costs were converted to American Dollars (reference year 2016).
Results
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Six systematic review studies were included. RoB ranged from low to high, the level of evidence ranged from 2 to 4, and methodological quality was moderate. Costs ranged from $5313.85 to $15 859.00 (direct) and $1921.00 to $6364.30 (indirect) in DAA. From $5158.46 to $12 344.47 (direct) to $2265.70 to $5566.01 (indirect) for PA and from $3265.62 to $8501.81 (direct) and $2280.16 (indirect) for SLA. Due to heterogeneity of included costs, they were not directly comparable. Solid data about cost-effectiveness cannot be presented.
Conclusions
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Due to limited and heterogenous evidence about costs and cost-effectiveness, the effect of these in surgical approach is unknown. Further well-powered research to make undisputed conclusions is needed.
Introduction
The prevalence of hip osteoarthritis (OA) has increased significantly because of improved management of chronic diseases and a prolonged life expectancy (1). The end-stage of OA can be reliably treated by total hip arthroplasty (THA) which reduces pain, increases the quality of life (QoL), and restores function (2). Studies have shown that treatment with THA has increased in recent decades and will continue to rise significantly in the next 35 years (3, 4). It is estimated that the utilization of hip implants in member countries of the Organization of Economic Co-operation and Development will increase from 1.8 million per year in 2015 to 2.8 million in 2050 (5). Compared with conservative care, THA is a proven cost-effective intervention in hip OA (6, 7). However, due to the already high quantities and above that the expected increase in the future of using THA as an intervention, the associated costs will significantly increase as well. For the sake of limiting all these related costs, medical practitioners should implement the most cost-effective and patient-specific treatment when clinical outcomes are comparable.
Several surgical approaches are used in THA, each with unique advantages and disadvantages. The most used approaches are the direct anterior approach (DAA), posterior approach (PA), and straight lateral approach (SLA). Each approach can accomplish safe and efficient reconstruction of the joint (8). DAA is claimed to result in shorter recovery time with less pain medication, resulting in less use of physiotherapy and therefore may result in earlier return to work, less workingman compensation, and thus fewer overall costs (9, 10, 11, 12). However, damage of the lateral femoral cutaneous nerve and the claimed technical difficulty compared to other approaches are the most reported possible disadvantages (13, 14). Also, suboptimal fixation and subsequent stem loosening is described (15). PA is considered as the easiest approach with good visualization of the femur and easy access to the joint. Disruption of abductor musculature is not needed, and less perioperative bleeding is documented. Risks in PA include damaging de sciatic nerve and inferior gluteal artery and a greater postoperative dislocation risk (13, 16). For SLA, a disadvantage could be placing the patient in a lateral position during surgery and the location of the longitudinal incision must be accurate. Abductor weakness has commonly been associated with surgical approaches that involve the release of the abductor insertion from the greater trochanter, including the direct lateral, anterolateral, or transgluteal approaches (17). A big advantage is the lower dislocation rate by sparing the posterior capsule of the hip (13).
Since different approaches for THA are used in patients with the same indication for surgery and no clear evidence is available to prefer one surgical approach over the other on a clinical basis, the surgical approach in THA could play a role in the search for optimization of cost-effectiveness (1). Several studies have investigated the impact of postoperative pain, function, and QoL investigating any superiority and the incidence of (serious) adverse events ((S)AEs) (9, 10, 11, 12, 13, 14). (S)AEs may include decreased implant survival, periprosthetic fractures, and surgical site infections. The ideal approach should generate few complications and allow for functional recovery. To date, no superiority exists in the long term (18, 19). Universal economic constraints of healthcare services dictate that their cost-effectiveness will govern further advances in THA, which underlines the pertinence of reviewing this topic (20). This systematic review aims to evaluate the current literature and compare the direct and indirect costs and cost-effectiveness of the DAA, PA, and SLA in THA.
Methods
This systematic review was registered in the PROSPERO database (registration number: CRD42021237427) and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (21, 22). The research question was formulated as follows:
Which approach in total hip arthroplasty (THA) in case of osteoarthritis (OA) is more cost-effective: the direct anterior approach (DAA), posterior approach (PA), or the straight lateral approach (SLA)?
Eligibility criteria
The review was limited to studies that were available in the English language, and all selected studies had to be published as full-text articles. Inclusion criteria were randomized controlled trials (RCTs) or comparative cohort studies that compared approaches in THA for patients aged 18 years and older. The included studies needed to provide sufficient data related to all or part of the following outcome criteria: costs, cost-effectiveness, and type of surgical approach used (DAA and/or PA and/or SLA). Descriptive articles (e.g. historical articles), and studies investigating patients who underwent revision, fracture, or bilateral arthroplasty were excluded.
Search strategy
A systematic search of databases PubMed, CINAHL, EMBASE, Cochrane, Clinical Trials, Current Controlled Trials, ClinicalTrials.gov, NHS Centre for Review and Dissemination, Econlit, and Web of Science was conducted. A detailed search description is included as Supplementary Table 1 (see section on supplementary materials given at the end of this article) in the appendix. Relevant clinical studies were selected and reviewed. Full-text articles which met the inclusion criteria, based on their keywords, title, and abstract, were reviewed for further analysis. Articles identified through the reference list were considered for data collection based on their title. First, two independent reviewers (JG and SH) analyzed the articles by TiAb and keywords. Second, full-text papers were analyzed independently considering the in- and exclusion criteria. Inter-reviewer disagreements were solved by consensus and with the assistance of a third reviewer (RD).
Quality assessment
In the case of RCTs, the bias assessment tool of the Cochrane Handbook for Systematic Reviews of Interventions was consulted (23). Two reviewers (JG and RD) independently evaluated the selected RCTs based on six different domains (random sequence generation, allocation concealment, blinding of patients, clinician and outcome assessor, incomplete outcomes data, selective outcome data, and other bias) and scored the criteria with ‘low’, ‘high’ or ‘unclear’ risk of bias (RoB).
The Cochrane ROBINS-I tool was used to appraise the quality of selected non-randomized studies (24). Central features of ROBINS-I include the use of signaling questions to guide RoB judgments within seven bias domains. These domains were also independently evaluated by two reviewers (JG and RD) and scored with ‘low’, ‘moderate’, or ‘serious’ RoB.
The methodological quality of economic evaluations and inter-rater variability was analyzed using The Consensus Health Economic Criteria (CHEC)-list (25).
Levels of evidence were determined with the Oxford Centre for Evidence-based Medicine Levels of Evidence tool (2011) (26). A consensus was reached between both authors through discussion.
Results
Study selection
The systematic database search (July 2022) resulted in 3644 studies. No additional studies were identified through manual searches or other sources. After removing duplicates, 2914 studies were screened based on the TiAb and keywords. A total of 119 studies were eligible for full-text analysis. In total, 113 studies were excluded: 71 studies did not describe the surgical approach used, 18 studies did not publish full-texts, 6 studies were not RCTs or comparative cohort studies but mostly descriptive (e.g. evaluation studies, protocols, or reviews), 3 studies were not available in English, 13 studies did not report the outcome of interest, and 2 studies were model-based studies.
Results of the study selection process are summarized in Fig. 1.
Study characteristics
The study characteristics of the six included studies are summarized in Table 1. Only two studies compared their outcomes in all three surgical approaches (1, 2), one study compared DAA and PA (9). Three studies compared outcomes in two arms of the same approach (26, 27, 28). Reported costs were direct healthcare-related costs associated with the intervention (including but not limited to time spent in the operation room, anesthesia, imaging, recovery, admissions to hospital wards, and medication). None of the studies reported implant cost only. Two studies (2, 9) reported some societal perspective costs, but with different interpretations and inclusion of cost items. With that, these costs were not comparable. Publication years ranged from 2011 to 2019. Follow-up time ranged from the time of hospitalization to 12 months post-operative. Two studies were performed in Canada (1, 2), two in the USA (9, 26), one in Belgium (27), and one in the UK (28).
Study characteristics.
| Reference | Country of origin | Study design | Study | Follow-up time | Patients, n | Mean age (years) | Indication for surgery | Level of evidence | CHEC-list score | ||
|---|---|---|---|---|---|---|---|---|---|---|---|
| AA | LA | PA | |||||||||
| Marques et al. (28) | UK | RCT | Cost-effectiveness study | 1 year | - | - | 163/322 | NA | Osteoarthritis | 2 | 17 |
| Martin et al. (27) | Belgium | RCT | Cost-effectiveness study | 1 year | 41/79 | - | - | 63.1 | Osteoarthritis developmental dysplasia, Coxa vara | 2 | 8 |
| Brown et al. (26) | USA | RCCS | Financial analysis | - | 44/59 | - | 60.2 | Osteoarthritis avascular necrosis | 4 | 7.5 | |
| Joseph et al. (9) | USA | RCCS | Cost-effectiveness | 6 months | 98 | - | 69 | 62 | Osteoarthritis avascular necrosis, developmental dysplasia, fracture | 4 | 9.5 |
| Petis et al. (1) | Canada | RMCS | Financial analysis | 40 | 40 | 38 | 66.4 | Osteoarthritis avascular necrosis | 4 | 9.5 | |
| Sharma et al. (2) | Canada | RCS | Financial analysis | 6 years | 69 | 69 | 69 | 66 | Osteoarthritis | 4 | 7.5 |
NA, not available; RCCS, retrospective comparative cohort study; RCS, retrospective cohort study; RCT, randomized controlled study; RMCS, retrospective matched cohort study.
Quality of identified studies
Methodological quality assessment can be found in Table 2. Quality of the included studies using CHEC scores was moderate. Scores range from 7.5 to 17.0, with a mean of 9.8. Low quality was mainly caused by insufficient information in the following domains: time horizon, perspective, relevant costs, appropriately valued costs, ICER, discounted, sensitivity analysis, generalization, and ethical issues.
Methodological quality of economical evaluations (CHEC-list).
| CHEC-list | Brown et al. (26) | Joseph et al. (9) | Marques et al. (28) | Martin et al. (27) | Petis et al. (1) | Sharma et al. (2) |
|---|---|---|---|---|---|---|
| 1. Describes study population | + | + | + | + | + | + |
| 2. Competing alternatives | - | + | + | + | + | + |
| 3. Research question | + | + | + | + | + | + |
| 4. Economic study design | +/− | +/− | + | - | +/− | +/− |
| 5. Time horizon | − | − | − | − | − | − |
| 6. Perspective | − | − | + | − | − | − |
| 7. Relevant costs | − | − | + | − | − | − |
| 8. Appropriately measured costs | + | + | + | + | + | + |
| 9. Appropriately valued costs | − | − | + | − | − | − |
| 10. Relevant outcomes | + | + | + | + | + | − |
| 11. Appropriately measured outcomes | + | + | + | − | + | + |
| 12. Appropriately valued outcome | + | + | + | + | + | − |
| 13. ICER | − | − | + | − | − | − |
| 14. Discounted | − | − | + | − | − | − |
| 15. Sensitivity analyses | − | − | + | − | − | − |
| 16. Correct conclusions | + | + | + | + | + | + |
| 17. Generalization | − | − | + | − | − | − |
| 18. Conflict of interest | − | + | + | + | + | + |
| 19. Ethical issues | − | − | − | − | − | − |
| Total | 7.5 | 9.5 | 17 | 8 | 9.5 | 7.5 |
Out of the six identified studies, two were randomized and four were nonrandomized. Based on the criteria for randomized studies, one study had a low RoB (26) and one study had a high RoB (27) (Fig. 2). Based on the criteria for nonrandomized studies, all four nonrandomized studies had a moderate RoB (1, 2, 26, 27) (Table 3). The two randomized studies reached a level of evidence of 2 (9, 26). The four other studies reached a level of evidence of 4 (1, 2, 9, 26, 27) (Table 1).
Risk of bias of the included randomized controlled trials.
Citation: EFORT Open Reviews 8, 6; 10.1530/EOR-22-0108
Risk of bias.
| Types of bias | Brown et al. (26) | Joseph et al. (9) | Petis et al. (1) | Sharma et al. (2) |
|---|---|---|---|---|
| Bias due to confounding | Low – patient characteristics available with P values | Low – patient characteristics available with P values | Low – data available with P values. | Low – patient characteristics available with P values |
| Bias of selecting patients | Low – clearly described and logical | Low – inclusion and exclusion criteria clearly stated. The start of inclusion is logical. | Low – inclusion and exclusion criteria clearly stated. | Low – inclusion and exclusion criteria clearly stated. |
| Bias in classification of interventions | Low – there is only one group. |
Moderate – classification between groups clear and logical, but grouping of patients unclear | Moderate – it is unclear why patients were attributed to which intervention. | Moderate –classification between groups clear and logical, but grouping of patients unclear |
| Bias due to deviation from intended intervention | Low – no cross-over due to study design. | Low – no crossover due to study design | Unclear | Low – no crossover due to study design. |
| Bias due to missing data | Unclear – no lost-to-follow-up or missing data mentioned | Unclear – not mentioned | Unclear | Low – missing data for one patient in each group. |
| Bias in measure outcome | Low | Low | Low | Low |
| Bias in selection of the reported result | Low – non-significant values and outcomes are described (with P-values) | Low – non-significant values and outcomes are described (with P-values) | Low – non-significant values and outcomes are described (with P-values) | Moderate – non-significant are not available. |
| Other bias | Funding and conflict of interest not mentioned. | There might be a conflict of interest | There might be a conflict of interest | Authors working for Depuy, Stryker, Mizuho OSI, and Zimmer Biomet |
| Overall | Moderate | Moderate | Moderate | Moderate |
Study results
Results of the studies are summarized in Table 4. Costs were divided into direct healthcare related and indirect (e.g. societal perspective) costs, total costs included both. Due to clinical heterogeneity (variability in interventions, outcomes, included costs, and used definitions for direct and indirect costs) between studies, cost ranges instead of means were used. Given amounts are costs per patient per intervention for the follow-up time of that patient in the study.
Study results.
| Reference | Cost resource | Healthcare perspective costs (USD) | ||
|---|---|---|---|---|
| AA | LA | PA | ||
| Marques et al. (28) | Hospital FD | - | - | 5846.58 ± 2501.98 |
| Martin et al. (27) | Unclear | - | 3843.11 ± 459.55 | - |
| Brown et al. (26) | Unclear | 15 859 ± 2116 | - | - |
| Joseph et al. (9) | Hospital FD | - | ||
| Direct | 13 487.78 | 12 474.84 | ||
| Indirect | 6431.51 | 5624.80 | ||
| Petis et al. (1) | Hospital FD | 6157.86 (5959.02 – 6356.70) | 6624.23 (6391.57 – 6856.88) | 6990.62 (6669.20 – 7312.04) |
| Sharma et al. (2) | Hospital FD | |||
| Direct | 5444.97 ± 920.41 | 8711.60 ± 1184.49 | 8387.64 ± 1227.30 | |
| Indirect | 1968.47 ± 323.18 | 2352.36 ± 463.61 | 2321.61 ± 445.52 | |
Values in parentheses indicate 95% CI.
FD, finance department.
The cost for the DAA was mentioned in four studies (1, 2, 9, 26, 27). The direct costs, mentioned in all four studies, ranged from $5313.85 to $15 859.00. The indirect costs were mentioned in two of the four studies and varied from $1921.00 to $6364.30 (2, 9).
The cost for the PA was mentioned in four studies (1, 2, 9, 28). The direct costs, mentioned in all four studies, ranged from $5158.46 to $12 344.47. The indirect costs, mentioned in two of the four studies, varied from $2265.70 to $5566.01 (2, 9).
The cost for the SLA was mentioned in three studies (1, 2, 27). The direct costs, mentioned in all three studies, ranged from $3265.62 to $8501.81. The indirect costs were mentioned in one study and were $2280.16 (2).
One study (9) compared two approaches, DAA and PA. Costs differences were divided into direct and indirect costs. The direct costs were $13 487.78 for DAA to $12 474.84 in PA. The indirect costs were $6431.51 for DAA to $5624.80 in PA. Statistic rationales for these cost calculations were lacking.
Two studies (1, 2) compared all three approaches. One study (2) divided cost differences into direct and indirect costs. The direct costs were $5444.97 for DAA, $8387.64 in PA, and $8711.60 in SLA. The indirect costs for DAA, PA, and SLA, respectively, were $1968.47, $2321.61, and $2352.36, and s.d. was given for all costs.
One study (1) did not specify costs in direct and indirect costs. Total costs per approach (reported with 95% CI) were $6157.86 for DAA, $6990.62 in PA, and $6624.23 for SLA.
Cost-effectiveness was mentioned in three studies (26, 27, 28), but not comparing approaches. Only one study compared cost-effectiveness in different approaches, the DAA and the PA. A direct cost difference of $1002 in favor of the DAA was found (9).
Discussion
The aim of this systematic review was to present an overview of the literature mentioning costs and cost-effectiveness for the DAA, PA, and/or SLA in THA in patients with OA, assessing and considering the methodological quality of the included studies. To the best of our knowledge, no previous review has been written about the costs and cost-effectiveness comparing these different approaches in THA. We conclude there is little evidence of one approach being superior to the others regarding cost-effectiveness. The acclaimed faster recovery, potentially resulting in lower costs, using DAA still needs to be proven.
It is expected that the number of THA will significantly increase in the upcoming decades and with those the associated costs. Therefore, research on the cost-effectiveness of these surgical procedures is more relevant than ever. Although much research has been done to assess and improve clinical outcomes, little research is performed or published on (comparing) cost-effectiveness and economic evaluation of the different approaches. THA itself is a cost-effective intervention, compared with conservative care (6, 7). Currently, the surgeon determines the approach based on preference and experience mostly without considering the costs and cost differences, because these (and any differences in approaches) are generally.
In general, for cost-effectiveness analysis (CEA), two types of costs are important: direct and indirect costs. Direct costs are related to health care and directly to the intervention, such as length of hospital stay, used supplies, and pharmaceuticals. Indirect costs, preferably including societal perspective costs, typically consist of work absenteeism, reduced productivity, loss of income, and psychosocial costs. In our review, two studies mention indirect costs, both using different definitions than the abovementioned. (2, 9). They defined indirect costs as being related to administration, facility, and support overhead costs. This discrepancy makes clear that the term indirect cost is still up for debate, there is no consensus on which cost items should always be included (29).
In direct costs great variation was observed as well, mostly due to differences in the included costs and calculation of those. For example, one study only mentioned the costs of the studied approaches, but not how these costs came about (26). Due to variance in included cost data and cost calculations between studies, costs were reported in ranges instead of means. There was a big difference in these ranges for both the DAA, the PA, and the SLA.
Cost-effectiveness, comparing two approaches, was mentioned in one study with a cost difference of $1002 in favor of the DAA (9). No effect size (e.g. quality-adjusted life years (QALY)) or statistical analysis was mentioned. They compared direct healthcare-related costs.
Because reliable rationales of this concluded amount are lacking it is not relevant in hard conclusions of cost-effectiveness differences in DAA, PA, and SLA.
The two studies comparing all three surgical approaches conclude that the total costs of a THA are significantly less when the DAA is used (1, 2). A potential reason for this was because of less time spent with health professionals after surgery (e.g. physiotherapist), resulting in a shorter duration of hospitalization, less operation room time costs, and total procedural costs associated with the DAA compared to the PA and SLA. It is important to note that selection bias could play a role here. The DAA is preferred in young active patients with a body mass index < 30 kg/m2. Older patients often have more risk factors, are less mobile, and will mostly take longer time to recover (e.g. longer hospital stay and time spend with health professionals after surgery). Therefore, more total costs compared to younger people, regardless of the approach (29).
This review has several limitations. Multiple databases were used to collect all potentially eligible studies, using keyword searches could result in missed relevant studies. Studies were conducted in different countries. This makes different health care organizations and different stakeholders involved which may have an impact on reported outcomes. No studies are performed comparing the cost-effectiveness of DAA, PA, and SLA in THA altogether. To compare the cost-effectiveness, it is important to conduct a CEA comparing all three approaches with QALY as the primary outcome measure (30, 31). None of the included studies met this requirement or had cost-effectiveness as the primary outcome measure. In addition, costs mentioned in studies varied from average costs of hospitalization to precisely defined costs per category. Due to the great heterogeneity in costs mentioned, no definite conclusions can be drawn about the cost-effectiveness of one approach above the others.
To the best of our knowledge, there are no previous systematic reviews analyzing the cost-effectiveness of the DAA, PA, and SLA in THA. It might be suggested that the DAA in THA is preferred regarding total costs, not considering the indirect costs (preferably including societal perspective costs).
Apart from the costs, it is important to consider the clinical outcome. Much research has been done on clinical outcomes and complications in different approaches. Even though each approach has benefits and its own more frequent complications, the best approach is still up to debate with a possibility that they are all non-inferior. This non-inferiority may be an explanation for why 71 excluded studies did not mention the used approach. The PA is the most used method for THA due to the good visibility of the joint. But over the last years, DAA gained more popularity due to a lower dislocation rate and is associated with better early functional recovery (12). However, DAA is also associated with more surgical complications and surgical revision when compared to the PA and SLA (10, 11, 12, 32, 33, 34). Complications related to surgery were mentioned in two articles (1, 9). Both did not mention the effect of these complications on costs. Rehospitalization or surgical revision was not mentioned in any of the included studies. All of these are important measurements for decent cost-effectiveness studies.
Further research is necessary to determine the cost-effectiveness of the three approaches altogether. Important for future research is homogeneity in the included costs and outcome measures to make the comparison and conclusions more reliable. Total costs, for example, should include direct costs such as acquisition costs, costs of hospitalization (including implant used, pharmacology, and wardroom stay), costs of complications, and surgical revision including rehospitalization and indirect societal perspective costs, such as loss of productivity and disability pension, especially in younger patients who still labor (35). Outcome measures should be based on evidence-based measurements (e.g. EuroQol-5D-5L) and defined in QALY to assess the value of treatments that improve quality of life which is the main goal in joint replacement surgery (36).
Conclusion
THA is a cost-effective treatment for advanced OA. To make conclusive effects of the surgical approach on all related costs (direct and indirect) is difficult due to heterogeneity in costs. Currently, there is little evidence of one approach being superior to the others regarding cost-effectiveness. DAA gained more popularity, but its superiority still needs to be proven, being as cost-effective as its alternatives. Due to the increasing demand for THA, more detailed research analyzing the cost-effectiveness of the three most common approaches should be considered to limit costs in the future.
Supplementary materials
This is linked to the online version of the paper at https://doi.org/10.1530/EOR-22-0108.
ICMJE conflict of interest statement
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding
This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
The authors would like to thank Isabell Haveman for her assistance with this systematic review.
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