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Journal of Experimental Orthopaedics
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The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis

Journal of Experimental Orthopaedics volume 10, Article number: 146 (2023) Cite this article

Abstract

Purpose

The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA).

Methods

A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options.

Results

Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects.

Conclusions

This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Introduction

Osteoarthritis (OA) represents an important public health problem and one of the world’s leading disabling diseases [19]. Its prevalence has been steadily rising over the years, due to demographic shifts such as aging population, an upsurge in overweight individuals, and a more physically active lifestyle among the elderly population [50]. This led to a significant increase in the number of total joint replacement surgeries, which represent the end-stage treatment for OA patients. Total joint arthroplasty (TJA) is considered one of the most successful surgical innovations of the 20th century, thanks to its proved efficacy in relieving pain and improving function in a durable and cost-effective manner when appropriately indicated [1, 40, 63]. The volume of these procedures has risen dramatically over the past several decades, with over 800,000 total hip and knee arthroplasties being performed annually in the United States only [17, 24, 32, 72]. Moreover, a further increase is expected with 1.22 million prostheses foreseen by 2040 in the United States [72]. This implies important consequences for the healthcare systems [61, 72].

The growth in TJA can be viewed as a consequence of the success of these procedures, with an expansion of indications and the tendency of surgeons to perform joint replacement also in younger patients and in earlier OA stages [18, 44, 55, 73]. Almost a third of primary total knee arthroplasties (TKAs) is performed in patients younger than 65 years, where the indication of prosthesis is raising, with patients aged between 45 and 55 years being the fastest increasing age group [17, 34, 37, 41, 55, 78]. However, results in younger patients are less satisfactory, and they present a higher risk of needing revision surgery in their lifetime [67, 77]. In this light, it would be better to bring an increasing number of patients up to an age where their life expectancy matches the longevity of joint replacement [68]. To this end, several alternative less invasive approaches have been developed with promising results, ranging from the more documented treatments like intra-articular injections and osteotomies [59], to new experimental options like subchondral bone injections, intra-articular spacers, and implantable shock absorbers [35, 51, 71]. Still, the available strategies to postpone metal resurfacing do not seem able to contrast the increase in prosthetic replacements. A possible explanation for this trend in treatment indications could be related to the reimbursement system. In fact, procedures are currently associated with Diagnosis-Related Groups (DRG), each one corresponding to a specific value that is reimbursed by the health system [13]. Reimbursements differ among the different treatment strategies, and this could influence the medical choice [16, 33].

The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of OA patients.

Material and methods

A survey was prepared by the members of the Cartilage and Regenerative Medicine Committee of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey was a self-administered questionnaire in Italian language that was first distributed among society members at the Society’s National congress in March 2022. To further increase the response rate the survey was then administered at the faculty meeting (SIAGASCOT Day) in October 2022. The survey presented three multiple choice questions, and each question was kept short, simple, and unambiguous to specifically answer the study objectives. The survey also asked supplementary questions to capture demographic information on the respondents, including age, professional role, and place of work (Table 1). The questionnaire was completed anonymously and not traceable to individual participants. The inclusion criteria for this survey included all physicians attending the SIAGASCOT events. Data obtained from the completed questionnaires were transferred in a spreadsheet and then analyzed using Microsoft Excel (Microsoft Office 365 for Windows). Incomplete surveys were eliminated from the analysis and data have been reported per-protocol. Possibly duplicated answers were sorted based on demographic and professional data and eliminated. Results were presented as frequencies and percentages, following the guidelines “Guidelines for Reporting Survey-Based Research Submitted to Academic Medicine” [5].

Table 1 Schematic representation of the survey
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Results

A total of 295 members of the SIAGASCOT society completed the survey. Among the completed questionnaires, 283 were included in the analysis, while 12 were excluded because they were completed by non-physician members (researchers, physiotherapists, osteopaths). In detail, 139 were specialists (132 orthopaedic and 7 not-orthopaedic), 109 were residents (106 orthopaedic and 3 not), and 35 were directors of operating units (31 orthopaedic and 4 not). The most represented age was 30–40 years (36.4%), followed by < 30 years (23.7%), 40–50 years (19.8%), 50–60 years (12.3%), and > 60 years (7.8%). Regarding the place of work, over half of the participants (61.8%) were working in the National Health Service (NHS), 14.1% in private clinics accredited to the NHS, 12.0% in the private practice, while the remaining 12.1% in other frameworks (i.e., physicians working in both NHS and private practice). A schematic representation of the demographic characteristics of the responders is reported in Table 2 and Fig. 1, while a schematic representation of the responses to the survey questions is reported in Table 3. A more detailed representation and analysis of the responses is presented in the following paragraphs.

Table 2 Demographic characteristics of the responders to the survey
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Fig. 1
figure 1

Characteristics of the responders to the survey

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Table 3 Responses to the survey
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“Do you think that the current DRG system allows access to all necessary options to best treat patients affected by OA?”

Almost 70% of the participants thought that the current DRG system does not allow access to all necessary options to best treat patients affected by OA, 20% responded “I do not know”, while only 10% considered adequate the current DRG system for OA treatment. Analyzing the answers based on age groups, a trend has been observed: the current DRG system has been considered inadequate by 82% of over 60 physicians, by 86% of the group 50–60 years old, by 73% of the group 40–50 years old, by 67% of the group 30–40 years old, and by 55% of the group under 30. Excluding the residents from the analysis, the response trend was confirmed also for the specialists alone (including directors of clinic) with 75% considering the current DRG system inadequate. Regarding the place of work, the current DRG system has been considered not adequate by 82% of physicians working in the private NHS accredited, by 71% of physicians working in other frameworks, by 68% of physicians working in the NHS, and by the 56% of physicians working in private practice. More details on this question are reported in Fig. 2.

Fig. 2
figure 2

Answers to the question on the adequacy of the current DRG system to best treat patients affected by OA

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“Do you think that DRGs for OA treatments are unbalanced and favor the choice of prosthetic solutions?”

More than half (55%) of the participants thought that the current DRG system is unbalanced and favors the choice of prosthetic solutions, 23% responded “I do not know”, while only 22% considered balanced the current DRG system for OA treatment. Based on age groups, the current DRG system has been considered unbalanced by 50% of physicians over 60, by 60% of the group 50–60 years old, by 64% of the group 40–50 years old, by 54% of the group 30–40 years old, and by 48% of the group under 30. Excluding the residents from the analysis, the response trend was confirmed also for the specialists alone (including directors of clinic) with 58% responding that the current DRG system is unbalanced and favors the choice of prosthetic solutions. Regarding the place of work, the current DRG system has been considered unbalanced and in favor of the choice of prosthetic solutions by 73% of physicians working in the private NHS accredited, by 60% of physicians working in other frameworks, by 53% of physicians working in the NHS, and by 44% of physicians working in private practice. More details on the first question are reported in Fig. 3.

Fig. 3
figure 3

Answers to the question on the current DRG system being unbalanced towards the choice of prosthetic solutions

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“Do you think that the current DRG system can contribute to the increase in prosthetic implantation at the expense of other less invasive solutions?”

More than half (54%) of the participants thought that the current DRG system can contribute to the increase in prosthetic implantation at the expense of other less invasive solutions, 21% responded “I do not know”, while only 25% of responders did not attribute the increase in prosthetic implantation to the DRG system. Based on age groups, the current DRG system has been considered to contribute to the increase in prosthetic implantation by 45% of physicians over 60, by 54% of the group 50–60 years old, by 61% of the group 40–50 years old, by the 50% of the group 30–40 years old, and by 55% of the group under 30. Excluding the residents from the analysis, the response trend was confirmed also for the specialists alone (including directors of clinic) with 52% responding that the current DRG system can contribute to the increase in prosthetic implantation. Regarding the place of work, the current DRG system has been considered to contribute to the increase in prosthetic implantation and in favor of the choice of prosthetic solutions by 63% of physicians working in the private NHS accredited, by 47% of physicians working in other frameworks, by 55% of physicians working in the NHS, and by 38% of physicians working in private practice. Other details on this question are reported in Fig. 4.

Fig. 4
figure 4

Answers to the question on the contribution of the current DRG system to the prosthesis implantation increase

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Discussion

The main finding of this survey is that physicians consider the current DRG system inadequate and unbalanced in favor of the choice of the prosthetic solution. This seems to contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management. Overall, orthopaedic surgeons consider that the reimbursement system affects their choice in the treatment of patients affected by OA.

The reimbursement system is an essential element in the public healthcare context, as it ensures access to medical care for patients with health issues while managing the available resources [39]. The DRG has become an important classification system in the global healthcare frameworks, including Europe, America, Asia, and Australia [54, 58]. Under the DRG system, hospitals are reimbursed a fixed amount based on the patient’s diagnosis and medical procedures, rather than on the actual costs incurred. While this approach offers cost predictability and standardization, it could also create financial pressures for medical facilities, especially when dealing with complex and expensive treatments, such as joint arthroplasty [7, 14, 46, 57]. Previous research suggested that the reimbursement system may influence physicians’ decisions in other fields [8, 31, 47], and this could also hold true for the therapeutic decision-making process of OA. In fact, reimbursements related to joint replacement are higher compared to those for conservative and less invasive options for the management of OA patients, which could lead to a potential preference among healthcare professionals toward the joint replacement option, as demonstrated by this survey.

This could have significantly contributed to the rise in the number of arthroplasty procedures performed in recent years, which goes beyond the increasing prevalence of OA over the years [30, 42]. The current survey confirmed that among orthopaedic surgeons there is a perception of inappropriate utilization of prosthetic implants at the expense of less invasive solutions. Joint arthroplasty should represent the definitive treatment for end-stage OA in patients who no longer respond to conservative and less-invasive procedures [25]. Nevertheless, recent registry analyses underlined that joint arthroplasty indications have been expanded to include patients with less severe forms of OA and at younger age [55, 73]. Large evidence suggested a less favorable outcome of joint replacement in this patient group [17, 34, 37, 41, 55].

It is crucial to balance the potential benefits of an improvement in their quality of life against the potential risk of poor functional outcomes and even more a not negligible risk of revision. A survival analysis on over 100,000 patients undergone total hip or knee replacement investigated the lifetime risks of revision surgery based on increasing age at the time of primary surgery [6]. It has been proven that for patients who are younger than 60 years at primary surgery, their lifetime risk of revision at 20 years increases significantly, reaching up to one in three in those patients aged 50–55 years. In contrast, older patients undergoing hip or knee replacement at or over 70 years of age had a lifetime risk of requiring revision surgery between 1 and 6%. Similarly, a recent study analyzed a regional registry involving 45,488 total knee replacements, finding that at 15 years of follow-up patients under 65 years old had a double risk of implant failure compared to older patients [55].

More than 200,000 revision surgeries are expected in the United States alone in 2030 [66]. Beside the important clinical implications to the affected patients, the costs of revision surgeries are a significant concern for the healthcare system, including the removal of the previous prosthesis, the implantation of a new prosthesis, hospital costs, and post-operative rehabilitation [52, 53]. The complexity of the surgery increases operating room time and hospital stay and entails higher complication rates compared to primary surgeries. Moreover, the removal of the previous prosthesis can lead to substantial loss of bone and soft tissues, making the implantation of a new prosthesis more challenging [4, 12, 65, 70]. There is an increase in the risk of infections, joint instability, misalignment, prosthesis loosening, as well as vascular and neurological complications [23, 60, 62]. Furthermore, patients undergoing revision may experience worsening of pre-existing clinical conditions, increased blood loss during surgery, and a longer and more complex post-operative recovery, further increasing the total costs [38, 49]. Overall, this can cause significant financial pressure on the healthcare system and could result in a negative impact on the resources and quality of the healthcare [57].

These findings are particularly important considering on one side the increasing life expectancy and on the other side the emergence of new joint preserving strategies, which could postpone the need for joint replacement to an older age. Several alternative solutions have been proposed to manage younger patients with early to moderate OA preserving the native joint, reducing the progression of joint damage and delaying the need for joint replacement. Among these, knee osteotomy is an established surgical treatment for young patients with mono-compartmental knee OA and lower limb misalignment [26, 29, 43]. Restoring the correct alignment of the lower limb reduces the overload on the affected compartment improving pain and function, slowing the deterioration of the knee, and delaying or avoiding the need for arthroplasty [9, 48]. A recent case-control study demonstrated a reduced need for prosthetic revision in young patients treated with high tibial osteotomy and then with TKA compared to young patients treated with an early TKA [22]. Therefore, knee osteotomy should be considered as a treatment option to postpone TKA in these patients. Restoring proper lower limb alignment reduces overload on the affected compartment, improving pain, function, and potentially delaying or avoiding the need for arthroplasty [26]. Similarly, some cartilage restoration procedures can represent a solution in young patients with focal chondral or osteochondral lesions in early OA joints [3, 11, 20, 36, 69], with good results reported at mid-term follow-up even for moderate stages of unicompartmental OA addressed with a combined approach of knee osteotomy and cartilage and meniscus scaffold/allograft implantations [15, 45].

Injective solutions show promise to target the whole joint environment, improving joint homeostasis and thus reducing symptoms and delaying the need for arthroplasty. Among the injective options, viscosupplementation is one of the most used in the clinical practice [21, 56], although there is no consensus among different scientific societies on guidelines for its use [10]. The repetitive use of hyaluronic acid has been suggested to postpone joint replacement in OA patients, with several retrospective analyses reporting a higher median time to TKA in patients who received hyaluronic acid injections compared to control groups [2, 75, 76]. Similarly, it has been demonstrated that also intra-articular platelet-rich plasma (PRP) injections are able to delay the need for joint arthroplasty, with a survival analysis on over 1,000 patients with knee OA reporting a median delay of 4 years and a survival rate of 85% at 5 years of follow-up [64]. Considering the lower invasiveness, the safety, and the promising results, these injectable options could be considered in the decision-making process for the management of patients with OA, in order to delay prosthesis. Currently, the reimbursement system does not favor the use of these minimally invasive solutions over total joint replacement, even in young patients with early OA.

Moreover, new applications of orthobiologics are emerging to target the subchondral bone, which is believed to play a role in the pathophysiology and progression of OA disease [74]. Subchondral bone marrow aspirate concentrate (BMAC) injections reported promising results in delaying TKA. In a randomized trial on 30 young patients with bilateral knee OA secondary to osteonecrosis, comparable clinical results up to 12 years have been observed in knees treated either with TKA or a subchondral BMAC injection, but with a lower complication rate and a quicker recovery for knees treated with the injective approach [27]. In a randomized trial on 140 adult patients with bilateral medial knee OA patients were randomly treated with subchondral BMAC injections on one side and TKA on the other side. The injective procedure provided an effect on pain sufficient to postpone or avoid TKA up to 15 years of follow-up, with only 25 patients requesting TKA in joints treated with BMAC injections [28]. Further research should confirm, consolidate, and optimize the promising findings of these studies, as well as investigate new minimally invasive solutions able to delay or avoid prosthetic joint replacement. Efficient alternatives are highly needed to be adopted by the healthcare systems to balance the pressure documented toward prosthetic replacement.

This study has some limitations. The number of participants was a subgroup of all society members, and the sample was not homogeneous in terms of age, professional role, and place of work. In particular, the inclusion of staff with few years of experience may have caused a bias related to the complete understanding of the reimbursement system currently in place. Nevertheless, the heterogeneity allowed the overall group of being representative of the entire physician population, and the sub-analyses based on different age groups, professional role, and place of work allowed to evaluate the response rate in each specific category. Moreover, the analysis performed excluding the youngest resident physicians confirmed the findings for all investigated aspects. Finally, due to the nature of the survey administered to members of a National society, results may be representative of the specific reimbursement system and the conclusions should be generalized with caution to other countries. On the other hand, the DRG systems present similarities in several countries across different continents, with a strong focus on the prosthetic solution which should be investigated critically according to the insights of this survey. The healthcare framework can drive the orthopaedic surgeon’s choice, which warrants caution towards providing a balanced reimbursement system offering the choice of prosthetic replacement not at the expense of less invasive and potentially more suitable solutions for the management of OA patients.

Conclusions

This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Availability of data and materials

Not applicable.

References

  1. Agarwal N, To K, Khan W (2021) Cost effectiveness analyses of total hip arthroplasty for hip osteoarthritis: a PRISMA systematic review. Int J Clin Pract 75(2):e13806

    Article  PubMed  Google Scholar 

  2. Altman R, Lim S, Steen RG, Dasa V (2015) Hyaluronic acid injections are associated with delay of total knee replacement surgery in patients with knee osteoarthritis: evidence from a large U.S. health claims database. PLoS One 10(12):e0145776

    Article  PubMed  PubMed Central  Google Scholar 

  3. Andriolo L, Reale D, Di Martino A, Boffa A, Zaffagnini S, Filardo G (2021) Cell-free scaffolds in cartilage knee surgery: a systematic review and meta-analysis of clinical evidence. Cartilage 12(3):277–292

    Article  PubMed  Google Scholar 

  4. Arthursson AJ, Furnes O, Espehaug B, Havelin LI, Söreide JA (2007) Prosthesis survival after total hip arthroplasty–does surgical approach matter? Analysis of 19,304 Charnley and 6,002 Exeter primary total hip arthroplasties reported to the Norwegian Arthroplasty Register. Acta Orthop 78(6):719–729

    Article  PubMed  Google Scholar 

  5. Artino AR, Durning SJ, Sklar DP (2018) Guidelines for reporting survey-based research submitted to academic medicine. Acad Med 93(3):337–340

    Article  PubMed  Google Scholar 

  6. Bayliss LE, Culliford D, Monk AP, Glyn-Jones S, Prieto-Alhambra D, Judge A, Cooper C, Carr AJ, Arden NK, Beard DJ, Price AJ (2017) The effect of patient age at intervention on risk of implant revision after total replacement of the hip or knee: a population-based cohort study. Lancet 389(10077):1424–1430

    Article  PubMed  PubMed Central  Google Scholar 

  7. Belatti DA, Pugely AJ, Phisitkul P, Amendola A, Callaghan JJ (2014) Total joint arthroplasty: trends in medicare reimbursement and implant prices. J Arthroplasty 29(8):1539–1544

    Article  PubMed  Google Scholar 

  8. Berchi C, Degieux P, Halhol H, Danel B, Bennani M, Philippe C (2016) Impact of falling reimbursement rates on physician preferences regarding drug therapy for osteoarthritis using a discrete choice experiment. Int J Pharm Pract 24(2):114–122

    Article  PubMed  Google Scholar 

  9. Berruto M, Maione A, Tradati D, Ferrua P, Uboldi FM, Usellini E (2020) Closing-wedge high tibial osteotomy, a reliable procedure for osteoarthritic varus knee. Knee Surg Sports Traumatol Arthrosc 28(12):3955–3961

    Article  CAS  PubMed  Google Scholar 

  10. Bichsel D, Liechti FD, Schlapbach JM, Wertli MM (2022) Cross-sectional analysis of recommendations for the treatment of hip and knee osteoarthritis in clinical guidelines. Arch Phys Med Rehabil 103(3):559-569.e5

    Article  PubMed  Google Scholar 

  11. Boffa A, Solaro L, Poggi A, Andriolo L, Reale D, Di Martino A (2021) Multi-layer cell-free scaffolds for osteochondral defects of the knee: a systematic review and meta-analysis of clinical evidence. J Exp Orthop 8(1):56

    Article  PubMed  PubMed Central  Google Scholar 

  12. Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ (2009) The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 91(1):128–133

    Article  PubMed  Google Scholar 

  13. Chen Y-J, Zhang X-Y, Yan J-Q, Xue-Tang, Qian M-C, Ying X-H (2023) Impact of diagnosis-related groups on inpatient quality of health care: a systematic review and meta-analysis. Inquiry 60:469580231167011

    PubMed  Google Scholar 

  14. Cheng E, Lewin A, Churches T, Harris IA, Naylor J (2020) Cost of investigations during the acute hospital stay following total hip or knee arthroplasty, by complication status. BMC Health Serv Res 20(1):1036

    Article  PubMed  PubMed Central  Google Scholar 

  15. Condello V, Filardo G, Madonna V, Andriolo L, Screpis D, Bonomo M, Zappia M, Dei Giudici L, Zorzi C (2018) Use of a biomimetic scaffold for the treatment of osteochondral lesions in early osteoarthritis. Biomed Res Int 2018:7937089

    Article  PubMed  PubMed Central  Google Scholar 

  16. Courtney PM, Ashley BS, Hume EL, Kamath AF (2016) Are bundled payments a viable reimbursement model for revision total joint arthroplasty? Clin Orthop Relat Res 474(12):2714–2721

    Article  PubMed  PubMed Central  Google Scholar 

  17. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR (2012) Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA 308(12):1227–1236

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Cram P, Vaughan-Sarrazin MS, Wolf B, Katz JN, Rosenthal GE (2007) A comparison of total hip and knee replacement in specialty and general hospitals. J Bone Joint Surg Am 89(8):1675–1684

    Article  PubMed  Google Scholar 

  19. Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, Bridgett L, Williams S, Guillemin F, Hill CL, Laslett LL, Jones G, Cicuttini F, Osborne R, Vos T, Buchbinder R, Woolf A, March L (2014) The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis 73(7):1323–1330

    Article  PubMed  Google Scholar 

  20. Di Martino A, Kon E, Perdisa F, Sessa A, Filardo G, Neri MP, Bragonzoni L, Marcacci M (2015) Surgical treatment of early knee osteoarthritis with a cell-free osteochondral scaffold: results at 24 months of follow-up. Injury 46(Suppl 8):S33-38

    Article  PubMed  Google Scholar 

  21. Ebad Ali SM, Farooqui SF, Sahito B, Ali M, Khan AA, Naeem O (2021) Clinical outcomes of intra-articular high molecular weight hyaluronic acid injection for hip osteoarthritis- a systematic review and meta-analysis. J Ayub Med Coll Abbottabad 33(2):315–321

    PubMed  Google Scholar 

  22. Erard J, Schmidt A, Batailler C, Shatrov J, Servien E, Lustig S (2023) Higher knee survivorship in young patients with monocompartmental osteoarthritis and constitutional deformity treated by high tibial osteotomy then total knee arthroplasty compared to an early total knee arthroplasty : a comparative study at a minimum follow-up of ten years. Bone Jt Open 4(2):62–71

    Article  PubMed  PubMed Central  Google Scholar 

  23. Evangelopoulos DS, Ahmad SS, Krismer AM, Albers CE, Hoppe S, Kleer B, Kohl S, Ateschrang A (2019) Periprosthetic infection: major cause of early failure of primary and revision total knee arthroplasty. J Knee Surg 32(10):941–946

    Article  PubMed  Google Scholar 

  24. Finks JF, Osborne NH, Birkmeyer JD (2011) Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 364(22):2128–2137

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Gademan MGJ, Hofstede SN, Vliet Vlieland TPM, Nelissen RGHH, Marang-van de Mheen PJ (2016) Indication criteria for total hip or knee arthroplasty in osteoarthritis: a state-of-the-science overview. BMC Musculoskelet Disord 17(1):463

    Article  PubMed  PubMed Central  Google Scholar 

  26. He M, Zhong X, Li Z, Shen K, Zeng W (2021) Progress in the treatment of knee osteoarthritis with high tibial osteotomy: a systematic review. Syst Rev 10(1):56

    Article  PubMed  PubMed Central  Google Scholar 

  27. Hernigou P, Auregan JC, Dubory A, Flouzat-Lachaniette CH, Chevallier N, Rouard H (2018) Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee. Int Orthop 42(11):2563–2571

    Article  PubMed  Google Scholar 

  28. Hernigou P, Delambre J, Quiennec S, Poignard A (2021) Human bone marrow mesenchymal stem cell injection in subchondral lesions of knee osteoarthritis: a prospective randomized study versus contralateral arthroplasty at a mean fifteen year follow-up. Int Orthop 45(2):365–373

    Article  PubMed  Google Scholar 

  29. Huizinga MR, Gorter J, Demmer A, Bierma-Zeinstra SMA, Brouwer RW (2017) Progression of medial compartmental osteoarthritis 2–8 years after lateral closing-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc 25(12):3679–3686

    Article  CAS  PubMed  Google Scholar 

  30. Hussain SM, Neilly DW, Baliga S, Patil S, Meek R (2016) Knee osteoarthritis: a review of management options. Scott Med J 61(1):7–16

    Article  CAS  PubMed  Google Scholar 

  31. Huttin C, Andral J (2000) How the reimbursement system may influence physicians’ decisions results from focus groups interviews in France. Health Policy 54(2):67–86

    Article  CAS  PubMed  Google Scholar 

  32. Jaffe WL, Dundon JM, Camus T (2018) Alignment and balance methods in total knee arthroplasty. J Am Acad Orthop Surg 26(20):709–716

    Article  PubMed  Google Scholar 

  33. Kamath AF, Courtney PM, Bozic KJ, Mehta S, Parsley BS, Froimson MI (2015) Bundled payment in total joint care: survey of AAHKS membership attitudes and experience with alternative payment models. J Arthroplasty 30(12):2045–2056

    Article  PubMed  Google Scholar 

  34. Keeney JA, Eunice S, Pashos G, Wright RW, Clohisy JC (2011) What is the evidence for total knee arthroplasty in young patients?: a systematic review of the literature. Clin Orthop Relat Res 469(2):574–583

    Article  PubMed  Google Scholar 

  35. Kluyskens L, Debieux P, Wong KL, Krych AJ, Saris DBF (2022) Biomaterials for meniscus and cartilage in knee surgery: state of the art. J ISAKOS 7(2):67–77

    Article  PubMed  Google Scholar 

  36. Kon E, Di Matteo B, Verdonk P, Drobnic M, Dulic O, Gavrilovic G, Patrascu JM, Zaslav K, Kwiatkowski G, Altschuler N, Robinson D (2021) Aragonite-based Scaffold for the treatment of joint surface lesions in mild to moderate osteoarthritic knees: results of a 2-year multicenter prospective study. Am J Sports Med 49(3):588–598

    Article  PubMed  Google Scholar 

  37. Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ (2009) Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 467(10):2606–2612

    Article  PubMed  PubMed Central  Google Scholar 

  38. Kurtz SM, Ong KL, Schmier J, Mowat F, Saleh K, Dybvik E, Kärrholm J, Garellick G, Havelin LI, Furnes O, Malchau H, Lau E (2007) Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am 89(Suppl 3):144–151

    PubMed  Google Scholar 

  39. Lang X, Guo J, Li Y, Yang F, Feng X (2023) A bibliometric analysis of diagnosis related groups from 2013 to 2022. Risk Manag Healthc Policy 16:1215–1228

    Article  PubMed  PubMed Central  Google Scholar 

  40. Learmonth ID, Young C, Rorabeck C (2007) The operation of the century: total hip replacement. Lancet 370(9597):1508–1519

    Article  PubMed  Google Scholar 

  41. Leskinen J, Eskelinen A, Huhtala H, Paavolainen P, Remes V (2012) The incidence of knee arthroplasty for primary osteoarthritis grows rapidly among baby boomers: a population-based study in Finland. Arthritis Rheum 64(2):423–428

    Article  PubMed  Google Scholar 

  42. Litwic A, Edwards MH, Dennison EM, Cooper C (2013) Epidemiology and burden of osteoarthritis. Br Med Bull 105:185–199

    Article  PubMed  Google Scholar 

  43. Ma X-L, Hu Y-C, Wang K-Z, Chinese Hospital Association Clinical Medical Technology Application Committee, Joint Surgery Branch of the Chinese Orthopaedic Association, Subspecialty Group of Osteoarthritis, Chinese Association of Orthopaedic Surgeons (2022) Chinese clinical practice guidelines in treating knee osteoarthritis by periarticular knee osteotomy. Orthop Surg 14(5):789–806

    Article  PubMed  PubMed Central  Google Scholar 

  44. Manley M, Ong K, Lau E, Kurtz SM (2009) Total knee arthroplasty survivorship in the United States Medicare population: effect of hospital and surgeon procedure volume. J Arthroplasty 24(7):1061–1067

    Article  PubMed  Google Scholar 

  45. Marcacci M, Zaffagnini S, Kon E, Marcheggiani Muccioli GM, Di Martino A, Di Matteo B, Bonanzinga T, Iacono F, Filardo G (2013) Unicompartmental osteoarthritis: an integrated biomechanical and biological approach as alternative to metal resurfacing. Knee Surg Sports Traumatol Arthrosc 21(11):2509–2517

    Article  CAS  PubMed  Google Scholar 

  46. Mayfield CK, Haglin JM, Levine B, Della Valle C, Lieberman JR, Heckmann N (2020) Medicare reimbursement for hip and knee arthroplasty from 2000 to 2019: an unsustainable trend. J Arthroplasty 35(5):1174–1178

    Article  PubMed  Google Scholar 

  47. McKoy JM, Tigue CC, Bennett CL (2008) Does reimbursement affect physicians’ decision making? Examples from the use of recombinant erythropoietin. Cancer Treat Res 140:235–251

    Article  PubMed  Google Scholar 

  48. Murray R, Winkler PW, Shaikh HS, Musahl V (2021) High tibial osteotomy for varus deformity of the knee. J Am Acad Orthop Surg Glob Res Rev 5(7):e21.00141

    PubMed  PubMed Central  Google Scholar 

  49. Oduwole KO, Molony DC, Walls RJ, Bashir SP, Mulhall KJ (2010) Increasing financial burden of revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 18(7):945–948

    Article  PubMed  Google Scholar 

  50. Otten R, van Roermund PM, Picavet HSJ (2010) Trends in the number of knee and hip arthroplasties: considerably more knee and hip prostheses due to osteoarthritis in 2030. Ned Tijdschr Geneeskd 154:A1534

    PubMed  Google Scholar 

  51. Pareek A, Parkes CW, Gomoll AH, Krych AJ (2023) Improved 2-year freedom from arthroplasty in patients with high-risk SIFK scores and medial knee osteoarthritis treated with an implantable shock absorber versus non-operative care. Cartilage 14(2):164–171

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Patel A, Oladipo V, Kerzner B, McGlothlin JD, Levine BR (2022) A retrospective review of reimbursement in revision total hip arthroplasty: a disparity between case complexity and RVU compensation. J Arthroplasty 37(8S):S807–S813

    Article  PubMed  Google Scholar 

  53. Patel A, Oladipo VA, Kerzner B, McGlothlin JD, Levine BR (2022) A retrospective review of relative value units in revision total knee arthroplasty: a dichotomy between surgical complexity and reimbursement. J Arthroplasty 37(6S):S44–S49

    Article  PubMed  Google Scholar 

  54. Peltola M, Quentin W (2013) Diagnosis-related groups for stroke in Europe: patient classification and hospital reimbursement in 11 countries. Cerebrovasc Dis 35(2):113–123

    Article  PubMed  Google Scholar 

  55. Perdisa F, Bordini B, Salerno M, Traina F, Zaffagnini S, Filardo G (2023) Total knee arthroplasty (TKA): when do the risks of TKA overcome the benefits? Double risk of failure in patients up to 65 years old. Cartilage 14(3):305–311

    Article  PubMed  PubMed Central  Google Scholar 

  56. Pereira TV, Jüni P, Saadat P, Xing D, Yao L, Bobos P, Agarwal A, Hincapié CA, da Costa BR (2022) Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis. BMJ 378:e069722

    Article  PubMed  PubMed Central  Google Scholar 

  57. Piscitelli P, Iolascon G, Di Tanna G, Bizzi E, Chitano G, Argentiero A, Neglia C, Giolli L, Distante A, Gimigliano R, Brandi ML, Migliore A (2012) Socioeconomic burden of total joint arthroplasty for symptomatic hip and knee osteoarthritis in the Italian population: a 5-year analysis based on hospitalization records. Arthritis Care Res (Hoboken) 64(9):1320–1327

    Article  CAS  PubMed  Google Scholar 

  58. Quentin W, Scheller-Kreinsen D, Blümel M, Geissler A, Busse R (2013) Hospital payment based on diagnosis-related groups differs in Europe and holds lessons for the United States. Health Aff (Millwood) 32(4):713–723

    Article  PubMed  Google Scholar 

  59. Reale D, Feltri P, Franceschini M, de Girolamo L, Laver L, Magalon J, Sanchez M, Tischer T, Filardo G (2023) Biological intra-articular augmentation for osteotomy in knee osteoarthritis: strategies and results: a systematic review of the literature from the ESSKA Orthobiologics Initiative. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-023-07469-x

    Article  PubMed  Google Scholar 

  60. Roman MD, Russu O, Mohor C, Necula R, Boicean A, Todor A, Mohor C, Fleaca SR (2022) Outcomes in revision total knee arthroplasty (Review). Exp Ther Med 23(1):29

    Article  PubMed  Google Scholar 

  61. Romanini E, Decarolis F, Luzi I, Zanoli G, Venosa M, Laricchiuta P, Carrani E, Torre M (2019) Total knee arthroplasty in Italy: reflections from the last fifteen years and projections for the next thirty. Int Orthop 43(1):133–138

    Article  PubMed  Google Scholar 

  62. Rosso F, Cottino U, Dettoni F, Bruzzone M, Bonasia DE, Rossi R (2019) Revision total knee arthroplasty (TKA): mid-term outcomes and bone loss/quality evaluation and treatment. J Orthop Surg Res 14(1):280

    Article  PubMed  PubMed Central  Google Scholar 

  63. Ruiz D, Koenig L, Dall TM, Gallo P, Narzikul A, Parvizi J, Tongue J (2013) The direct and indirect costs to society of treatment for end-stage knee osteoarthritis. J Bone Joint Surg Am 95(16):1473–1480

    Article  PubMed  Google Scholar 

  64. Sánchez M, Jorquera C, Sánchez P, Beitia M, García-Cano B, Guadilla J, Delgado D (2021) Platelet-rich plasma injections delay the need for knee arthroplasty: a retrospective study and survival analysis. Int Orthop 45(2):401–410

    Article  PubMed  Google Scholar 

  65. Schreurs BW, Hannink G (2017) Total joint arthroplasty in younger patients: heading for trouble? Lancet 389(10077):1374–1375

    Article  PubMed  Google Scholar 

  66. Schwartz AM, Farley KX, Guild GN, Bradbury TL (2020) Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. J Arthroplasty 35(6S):S79–S85

    Article  PubMed  PubMed Central  Google Scholar 

  67. Scott CEH, Oliver WM, MacDonald D, Wade FA, Moran M, Breusch SJ (2016) Predicting dissatisfaction following total knee arthroplasty in patients under 55 years of age. Bone Joint J 98-B(12):1625–1634

    Article  CAS  PubMed  Google Scholar 

  68. Seil R, Becker R (2016) Time for a paradigm change in meniscal repair: save the meniscus! Knee Surg Sports Traumatol Arthrosc 24(5):1421–1423

    Article  PubMed  Google Scholar 

  69. Sessa A, Andriolo L, Di Martino A, Romandini I, De Filippis R, Zaffagnini S, Filardo G (2019) Cell-free osteochondral scaffold for the treatment of focal articular cartilage defects in early knee OA: 5 years’ follow-up results. J Clin Med 8(11):1978

    Article  PubMed  PubMed Central  Google Scholar 

  70. Shafaghi R, Rodriguez O, Schemitsch EH, Zalzal P, Waldman SD, Papini M, Towler MR (2019) A review of materials for managing bone loss in revision total knee arthroplasty. Mater Sci Eng C Mater Biol Appl 104:109941

    Article  CAS  PubMed  Google Scholar 

  71. Shemesh M, Shefy-Peleg A, Levy A, Shabshin N, Condello V, Arbel R, Gefen A (2020) Effects of a novel medial meniscus implant on the knee compartments: imaging and biomechanical aspects. Biomech Model Mechanobiol 19(6):2049–2059

    Article  PubMed  Google Scholar 

  72. Shichman I, Roof M, Askew N, Nherera L, Rozell JC, Seyler TM, Schwarzkopf R (2023) Projections and epidemiology of primary hip and knee arthroplasty in Medicare patients to 2040–2060. JB JS Open Access 8(1):e22.00112

    PubMed  PubMed Central  Google Scholar 

  73. Slover J, Zuckerman JD (2012) Increasing use of total knee replacement and revision surgery. JAMA 308(12):1266–1268

    Article  CAS  PubMed  Google Scholar 

  74. Sundaram K, Vargas-Hernández JS, Sanchez TR, Moreu NM, Mont MA, Higuera CA, Piuzzi NS (2019) Are subchondral intraosseous injections effective and safe for the treatment of knee osteoarthritis? A systematic review. J Knee Surg 32(11):1046–1057

    Article  PubMed  Google Scholar 

  75. Waddell DD, Bricker DC (2007) Total knee replacement delayed with Hylan G-F 20 use in patients with grade IV osteoarthritis. J Manag Care Pharm 13(2):113–121

    PubMed  Google Scholar 

  76. Waddell DD, Joseph B (2016) Delayed total knee replacement with Hylan G-F 20. J Knee Surg 29(2):159–168

    PubMed  Google Scholar 

  77. Walker-Santiago R, Tegethoff JD, Ralston WM, Keeney JA (2021) Revision total knee arthroplasty in young patients: higher early reoperation and rerevision. J Arthroplasty 36(2):653–656

    Article  PubMed  Google Scholar 

  78. Worlicek M, Koch M, Daniel P, Freigang V, Angele P, Alt V, Kerschbaum M, Rupp M (2021) A retrospective analysis of trends in primary knee arthroplasty in Germany from 2008 to 2018. Sci Rep 11(1):5225

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

Special thanks to the SIAGASCOT society and the members who have completed the questionnaire.

Funding

No funding was available for the present study.

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Authors and Affiliations

  1. Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, Bologna, 1 - 40136, Italy

    Luca De Marziani, Angelo Boffa, Alessandro Di Martino & Luca Andriolo

  2. Ortopedia e Traumatologia, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

    Davide Reale

  3. Orthopaedics and Traumatology Unit, Department of Public Health, University Federico II of Naples Federico II, Naples, Italy

    Alessio Bernasconi

  4. Foot and Ankle Specialistic Unit, IRCCS Galeazzi Sant’Ambrogio, Milan, Italy

    Valentina Rita Corbo

  5. Department of Orthopaedic Surgery, Istituto Di Cura Città Di Pavia, Pavia, Italy

    Francesca de Caro

  6. Servizio di Ortopedia e Traumatologia dell’Ospedale Regionale di Bellinzona e Valli, Ente Ospedaliero Cantonale, Ticino, Switzerland

    Marco Delcogliano

  7. Division of Orthopedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland

    Giorgio di Laura Frattura

  8. Department of Orthopaedics and Trauma Surgery, Clinica San Michele, Maddaloni, Italy

    Giovanni Di Vico

  9. UOC di Clinica Ortopedica AOU Sassari, Sassari, Italy

    Andrea Fabio Manunta

  10. Humanitas Castelli, Bergamo, Italy

    Arcangelo Russo

  11. Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy

    Giuseppe Filardo

  12. Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland

    Giuseppe Filardo

  13. Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland

    Giuseppe Filardo

Authors
  1. Luca De Marziani
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  2. Angelo Boffa
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  4. Luca Andriolo
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  9. Marco Delcogliano
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  10. Giorgio di Laura Frattura
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  11. Giovanni Di Vico
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  13. Arcangelo Russo
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  14. Giuseppe Filardo
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Contributions

Conceptualization, G.F.; methodology, L.D.M., A.Bo, L.A, A.D.M, and D.R; data curation, L.D.M. and A.Bo.; writing—original draft preparation, L.D.M. and A.Bo.; writing—review and editing, A.D.M, L.A., D.R., A.Be, V.R.C., F.d.C., G.d.L.F., M.D., G.D.V., A.F.M., A.R., and G.F.; supervision, G.F. All authors have read and agreed to the published version of the manuscript.

Corresponding author

Correspondence to Angelo Boffa.

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De Marziani, L., Boffa, A., Di Martino, A. et al. The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis. J EXP ORTOP 10, 146 (2023). https://doi.org/10.1186/s40634-023-00699-5

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