The Costs Associated With The Perioperative Management Of Articular Cartilage Lesions In The United States

OBJECTIVES: There is a large and increasing U.S. population with symptomatic focal chondral/osteochondral lesions of the knee. The use of cartilage repair and restoration procedures has increased over the past decade due to significant improvements in diagnosis, surgical indications/technique, and graft resources. While clinical evidence supports utilization of these procedures, the costs associated with the perioperative management of these patients and the specific procedures are unknown. Given current challenges in healthcare costs, the purpose of this study was to examine the perioperative costs associated with the evaluation and surgical management of symptomatic focal cartilage lesions of the knee. METHODS: We performed a retrospective review of a national private insurance database (PearlDiver) using Current Procedural Terminology codes to identify all patients who underwent a cartilage repair procedure between 2008 and 2010: (1) microfracture (2) osteochondral autograft (OAT) (3) osteochondral (OC) allograft and (4) autologous chondrocyte implantation (ACI). The associated charge codes for the 1-year preoperative and 1-year postoperative periods for each patient were categorized as imaging, outpatient visits, rehabilitation, joint injections, and repeat procedures for postoperative complications. The charges for each of these categories were calculated and the per-patient average charge (PPAC) was calculated by dividing charges by the total number of patients in each cohort. RESULTS: We identified 41,191 patients (38,444 microfracture, 1,130 OATs, 1,071 OC allograft, 546 ACI) who underwent a cartilage procedure. The PPAC was $3,989.65 for microfracture, $6,110.46 for OATs, $6,671.42 for OC allograft, and $10,195.16 for ACI. When the overall perioperative and surgical costs were consolidated, the PPAC for ACI remained the highest ($16,016.70) and the PPAC for microfracture was the lowest ($7,258.51). For all cartilage repair procedures, diagnostic imaging represented the largest proportion of preoperative costs while rehabilitation was highest out of postoperative costs. The costs for secondary procedures performed to address postoperative complications were highest for ACI patients ($730.00) and lowest for microfracture patients ($231.16). Repeat procedures for ACI were primarily performed for knee stiffness (11%) and cartilage hypertrophy (10%), while no microfracture patients had such additional procedures. CONCLUSION: The overall cost associated with the perioperative management of patients with focal cartilage lesions is substantial. The significant variability in cost for each procedure should be considered along with current clinical outcomes data to support surgical decision-making and determine the most cost-effective solutions for each patient. Based on currently available data, microfracture is a cost effective treatment, thereby lending support to its role as the “gold standard” in the management of chondral defects.