Abstract
Purpose
To evaluate cost, outcomes, and incremental cost‐effectiveness of arthroscopic partial meniscectomy comparing visualization using a 1.9 mm distal chip‐on‐tip needlescope versus a standard 4 mm glass rod lens arthroscope.
Methods
We retrospectively reviewed prospectively collected data (from a larger randomized controlled trial) on patients having partial meniscectomy performed by 1 surgeon at 1 facility between February 2023 and February 2025. International Knee Documentation Committee and visual analog scale pain scores at 1‐year minimum follow‐up, costs, cost‐effectiveness (cost/quality‐adjusted life years [QALYs]), and incremental cost‐effectiveness ratio (cost of 1 additional year of life in perfect health) were collected. Sensitivity analyses were assessed for potential variations in cost or effectiveness.
Results
Twenty‐four patients are included in each group; mean follow‐up is 26 months (range 12‐36). Comparing needle versus standard, mean age (years) is 50 versus 46.5 (P = .19); percent male sex is 71 versus 46 (P = .14); improvement in International Knee Documentation Committee is 58.7 versus 48.7 (P = .24); improvement in visual analog scale is 5.4 versus 4.5 (P = .55). Mean cost per case is $17,236.69 versus $16,994.00 (P = .26). Cost‐effectiveness is $1177.32/QALY versus $1215.59/QALY. The incremental cost‐effectiveness ratio is $367.71. Sensitivity analysis shows that if the costs of needle decreased to equal the costs of standard, needle becomes cost‐neutral while providing superior outcomes (dominant), and if the effectiveness of standard arthroscopy increased to equal needle, needle becomes dominated (more expensive, effectiveness neutral).
Conclusions
Arthroscopic partial meniscectomy comparing 1.9 mm distal chip‐on‐tip needlescope versus 4 mm glass rod lens arthroscope results in no significant differences in cost or outcomes at 1‐year minimum follow‐up. Both treatments are highly cost‐effective. Incremental cost‐effectiveness ratio for needlescope compared with arthroscope, $367.71, is more than 2 orders of magnitude lower than the willingness‐to‐pay threshold of $50,000/QALY.
Level of Evidence
Level IV, economic: input data from Level III study and uncertainty as examined by univariate sensitivity analysis.
The foundation of arthroscopic surgery is the camera. The arthroscopic camera has evolved from an endoscope with incandescent light to fiber‐optic “cold” light, to rod lens optics, and to “television cameras…so small that they could be incorporated into the lens…and thus enable all personnel in the operating room to play an informed role.” 1 Although 4.0 mm arthroscopes have been favored for the knee, 2 small‐diameter “needlescopes” have been used for arthroscopy of smaller joints; limitations of needlescopes include diminished image quality, 3 fragility, and higher repair costs. 4
A recent development in imaging is the complementary metal‐oxide‐semiconductor. Complementary metal‐oxide‐semiconductor captures light to create electrical signals that are converted into images made up of photodiodes (pixels arranged in a grid). A sensor reads each photodiode and sends analog signals to the camera's processing unit. Signals are converted into a digital image. 5 Complementary metal‐oxide‐semiconductor sensors are incorporated on a computer chip resulting in a small‐footprint functioning camera. 6 Unlike traditional needlescopes, chip‐on‐tip needlescopes allow high‐definition video and light‐emitting diode illumination and are not fragile, because the sensor can be placed on the distal end of a flexible shaft. 7 , 8 The smaller size of these cameras, compared with 4.0 mm arthroscopes, may result in less pain, faster recovery, and improved outcomes, and these cameras are single‐use, disposable items, which could affect costs.
The purpose of this study was to evaluate cost, outcomes, and incremental cost‐effectiveness of arthroscopic partial meniscectomy comparing visualization using a 1.9 mm distal chip‐on‐tip needlescope versus a standard 4 mm glass rod lens arthroscope. We hypothesized that cost, outcomes, and cost‐effectiveness are similar.
METHODS
This study is a secondary, nested analysis of an Institutional Review Board‐approved (Marshall University), multicenter randomized controlled trial allowing for future research. In this study, patients who underwent arthroscopic partial meniscectomy were retrospectively identified, and prospectively collected data was reviewed. Patients 18 years or older having arthroscopic partial medial and/or lateral meniscectomy using a chip‐on‐tip needle arthroscope (NanoScope 2.0, Arthrex, Naples, FL) or a 4 mm rod lens arthroscope (Arthrex); treated by a single surgeon (C.L.) at a single hospital outpatient surgery center between February 2023 and February 2025; and having a minimum 1‐year follow‐up were evaluated for inclusion. Patients having concomitant chondroplasty are included; patients requiring other procedures, or with Worker's Compensation claims, are excluded. Included patients are part of a larger, Institutional Review Board‐approved multicenter, randomized controlled trial focused on opioid use after arthroscopic partial meniscectomy using a chip‐on‐tip needlescope versus a 4 mm arthroscope, on whom 3‐month outcomes were previously reported. 9 The original trial was designed for purposes other than cost‐effectiveness analysis, and cost‐effectiveness was not evaluated. 9 Randomization was performed using sequentially numbered, opaque, sealed envelopes which were opened on the day of surgery. One of the surgeons who participated in the primary trial changed institutions, and his institution was unable or unwilling to provide cost data and 1 of the 2 institutions where the other surgeon operated was unable or unwilling to provide cost data.
Preoperative demographic data recorded are age, sex, height, weight, body mass index, duration of symptoms, tobacco use, and American Society of Anesthesiologists score. Intraoperatively, Outerbridge chondromalacia grade was recorded for the most involved knee compartment, and meniscal tear location was recorded as medial meniscus, lateral meniscus, or both medial and lateral meniscus. Demographic differences between groups are compared. (Statistical comparisons of demographic data between groups are not often performed for randomized controlled trials. Because this study evaluates a smaller, nested subset of patients from a larger, original trial, demographic differences between groups are evaluated).
The primary outcome measure is the incremental cost‐effectiveness ratio (ICER) comparing needle versus standard arthroscopy integrating change in health‐related quality of life (QoL), life expectancy, and treatment costs. These variables allow calculation of the cost of a quality‐adjusted life year (QALY). 10 One QALY is equivalent to 1 year in “perfect” health. 10 , 11
Additional outcome measures are International Knee Documentation Committee (IKDC)‐Subjective Knee Score and pain visual analog scale (VAS) at 12‐month minimum follow‐up; and Cost/Case (in 2025 US dollars) as the sum of surgeon fee; plus outpatient surgery costs comprised of supply costs (net of needlescope and needlescope sheath costs); time costs (comprised of main operating room time, recovery room time, anesthesia time, and preoperative anesthesia evaluation time); drug costs; miscellaneous costs (lab, radiology, electrocardiogram, and physical therapy evaluation); and needlescope and needlescope sheath costs or 4.0 mm arthroscope and fiber‐optic light cord reprocessing costs (as applicable, as the needlescope and sheath are single use items, and the arthroscope and fiber‐optic light cord are reusable items). Cost data was provided by the hospital Finance Coordinator of Perioperative Services. Of note, surgeon fee plus outpatient surgery facility costs remained stable over the timeframe of the study (2023‐2025).
Statistical Analysis
Outcomes are reported as mean and standard deviation (SD) for each group and disaggregated by sex. 12 Minimal clinically important difference (MCID) is calculated as 0.5 × SD IKDC baseline (preoperative); the percentage of patients improving >MCID for each group is reported.
Continuous variables (age, height, weight, body mass index, symptom duration, American Society of Anesthesiologists score, Outerbridge score, and time to follow‐up) are compared using independent samples t test. Categorical variables (sex and current tobacco use) are compared using Fisher's exact test to account for small cell counts. Categorical demographics for meniscus tear location are compared using the Fisher‐Freeman‐Halton extension of Fisher's exact test to accommodate the 3‐level nominal variable (medial, lateral, and both) in the presence of small cell counts and 0‐frequency cells. Within‐group differences in patient‐reported outcome measures (IKDC and VAS) are compared using the Wilcoxon signed‐rank test, because the postoperative scores are not normally distributed, and the test is robust in cases of floor (VAS) and ceiling (IKDC) effects in the postop data. Between‐group differences in improvement in IKDC and VAS scores and differences in costs are compared using the Mann‐Whitney U test for non‐normally distributed values. Statistical significance is defined as P < .05.
In health economics, QoL is quantitated as a “utility” measuring usefulness of “treatments based on desired and expected benefits versus potential risks.” 13 We report QoL using the EuroQoL‐5D (EQ‐5D) score. IKDC is converted to EQ‐5D utility value per Sripada et al.: EQ‐5D (United Kingdom) = (IKDC × 0.013) − 0.015. 14 To modify for a US partial meniscectomy population (noting that Sripada et al. studied UK patients waiting for anterior cruciate ligament reconstruction), we multiply the algorithm by 0.64. This is required because health utility scores should be no greater than 1 (representing perfect health) and because the IKDC has a high ceiling effect such that patients with excellent outcomes after partial meniscectomy achieve the maximum score. 15 We derive (reverse engineer) the modification (multiply by 0.64) based on Lubowitz and Appleby 10 who reported postoperative QoL after standard knee arthroscopy of 0.704, such that we obtain the same postoperative utility value (0.704) for postoperative standard arthroscopy in the current study. In summary, the algorithm for converting IKDC for US patients having partial meniscectomy to EQ‐5D (United States) = [(IKDC × 0.013) − 0.015] × 0.64.
QALYs are calculated as the change in mean health‐related QoL before and after treatment × mean life expectancy = [(postoperative EQ‐5D (United States) − preoperative EQ‐5D (United States)) × life expectancy]. Life expectancy is calculated using the US Social Security Administration Actuarial Life Table 16 based on subgroup mean age.
Cost per QALY (Cost/QALY) is calculated and reported in US dollars per QALY. ICER is determined as follows: ICER = [(needlescope cost − standard cost)/(QALY needlescope × QALY standard)]. 11
To ensure generalizability, 1‐way sensitivity analysis is performed to adjust for quantitative variation in costs. To ensure against sampling bias undermining changes in QoL scores after surgery, and/or variations in life expectancy, 1‐way sensitivity analysis is performed to adjust for quantitative variation in effectiveness. 10 , 11
RESULTS
Fifty patients (25 needlescope; 25 arthroscope) are included (Figure 1). One needlescope patient (Worker's Compensation claim) and 1 arthroscope patient (meniscus repair) were excluded, leaving 24 patients in each group. No patients were lost to 12‐month follow‐up, and mean time to follow‐up for the 48 patients studied is 26 months (range 12‐36) (Figure 1). Comparing needlescope versus arthroscope, mean age is 50 versus 46.5 years (P = .19), male sex (%) is 71 versus 45 (P = .14), and mean time to follow‐up (months) is 27 versus 25 (P = .43). Groups were balanced (no significant difference) for all demographics measured and recorded, with the exception of a significant difference (P = .024) in meniscus tear location where needlescope patients are almost exclusively medial meniscus tears (96%), whereas arthroscope patients included 21% lateral meniscus tears and 12.5% tears of both medial and lateral menisci. Complete demographic results are summarized in Table 1.
FIGURE 1.
Consort flow diagram illustrating the number of patients enrolled, allocated to treatment groups, lost to follow‐up, and analyzed.
TABLE 1.
Demographics by Subgroup and Disaggregated by Sex
| Needlescope (n = 24) | Arthroscope (n = 24) | P Value |
|---|---|---|
| Mean age in yr (range; SD) = 50.0 (31‐64; 9.5) | Mean age in yr (range; SD) = 46.5 (30‐63; 8.9) | .19 |
| Sex: male = 17/female = 7 | Sex: male = 11/female = 13 | .14 |
| Mean height in cm (range; SD) = 176.2 (158‐193; 9.3) | Mean height in cm (range; SD) = 171.8 (154‐190; 10.2) | .13 |
| Mean weight (kg) = 100.1 (67.4‐126.9; 18.1) | Mean weight (kg) = 102.4 (60.7‐201.1; 29.9) | .75 |
| Mean BMI (range; SD) = 32.2 (24‐44; 5.5) | Mean BMI (range; SD) = 34.5 (21‐62; 9.2) | .30 |
| Mean duration of symptoms (mo) = 15.0 (1‐123; 30.2) | Mean duration of symptoms (mo) = 7.7 (1‐62; 12.2) | .28 |
| Tobacco use current (quit) = 5/24 patients (3 patients) | Tobacco use current (quit) = 1/24 patients (3 patients) | .19 (current use) |
| Mean ASA score (range; SD) = 2.3 (1‐3; 0.6) | Mean ASA score (range; SD) = 2.0 (1‐3; 0.5) | .07 |
| Mean Outerbridge score (range; SD) = 3.1 (1‐4; 1.0) | Mean Outerbridge score (range; SD) = 2.5 (0‐4; 1.35) | .09 |
| Outerbridge 0 = 0 | Outerbridge 0 = 3 | |
| Outerbridge 1 = 3 | Outerbridge 1 = 3 | |
| Outerbridge 2 = 3 | Outerbridge 2 = 4 | |
| Outerbridge 3 = 9 | Outerbridge 3 = 7 | |
| Outerbridge 4 = 9 | Outerbridge 4 = 7 | |
| Meniscus tear location | Meniscus tear location | .02 |
| Medial = 23 | Medial = 16 | |
| Lateral = 1 | Lateral = 5 | |
| Both medial and lateral = 0 | Both medial and lateral = 3 | |
| Follow‐up (mo) (mean; range; SD) = 12 (27; 12‐36; 8.8) | Follow‐up (mo) (mean; range; SD) = 12 (25; 12‐36; 8.6) | .43 |
| Men | Women |
|---|---|
| Needlescope (n = 17) | Needlescope (n = 7) |
| Mean age in yr (range; SD) = 49.5 (31‐64; 10.3) | Mean age in yr (range; SD) = 51.1 (39‐58; 6.7) |
| Mean height in cm (range; SD) = 180.5 (172‐193; 6.5) | Mean height in cm (range; SD) = 165.7 (158‐177; 6.1) |
| Mean weight (kg) = 104.4 (80.2‐126.9; 17.2) | Mean weight (kg) = 89.6 (67.4‐118.5; 18.6) |
| Mean BMI (range; SD) = 32.0 (24‐40; 5.0) | Mean BMI (range; SD) = 32.7 (26‐44; 6.8) |
| Mean duration of symptoms (mo) = 19.6 (1‐123; 35.1) | Mean duration of symptoms (mo) = 4 (2‐7; 1.8) |
| Tobacco use current (quit) = 5/17 patients (3 patients) | Tobacco use current (quit) = 0/7 patients (0 patients) |
| Mean ASA score (range; SD) = 2.3 (2‐3; 0.5) | Mean ASA score (range; SD) = 2.3 (1‐3; 0.8) |
| Mean Outerbridge score (range; SD) = 2.9 (1‐4; 1.1) | Mean Outerbridge score (range; SD) = 3.2 (2‐4; 0.76) |
| Outerbridge 0 = 0 | Outerbridge 0 = 0 |
| Outerbridge 1 = 3 | Outerbridge 1 = 0 |
| Outerbridge 2 = 2 | Outerbridge 2 = 1 |
| Outerbridge 3 = 6 | Outerbridge 3 = 3 |
| Outerbridge 4 = 6 | Outerbridge 4 = 3 |
| Follow‐up (mo) (mean; range; SD) = 12 (25; 12‐36; 9.6) | Follow‐up (mo) (mean; range; SD) = 12 (29; 17‐35; 6.4) |
| Arthroscope (n = 11) | Arthroscope (n = 13) |
|---|---|
| Mean age in yr (range; SD) = 47.3 (34‐57; 7.8) | Mean age in yr (range; SD) = 45.8 (30‐63; 9.9) |
| Mean height in cm (range; SD) = 180.7 (175‐190.5; 5.4) | Mean height in cm (range; SD) = 164 (154‐177; 5.8) |
| Mean weight (kg) = 122.1 (86.4‐201.1; 38.9) | Mean weight (kg) = 87.8 (60.7‐130.6; 22.0) |
| Mean BMI (range; SD) = 37.4 (26‐62; 11.7) | Mean BMI (range; SD) = 32.8 (21‐51; 8.78) |
| Mean duration of symptoms (mo) = 6 (2‐13; 4.1) | Mean duration of symptoms (mo) = 9.15 (1‐62; 16.3) |
| Tobacco use current (quit) = 1/11 patients (2 patients) | Tobacco use current (quit) = 0/13 patients (1 patients) |
| Mean ASA score (range; SD) = 2.2 (1‐3; 0.6) | Mean ASA score (range; SD) = 1.9 (1‐2; 0.28) |
| Mean Outerbridge score (range; SD) = 2.5 (0‐4; 1.4) | Mean Outerbridge score (range; SD) = 2.5 (0‐4; 1.4) |
| Outerbridge 0 = 1 | Outerbridge 0 = 2 |
| Outerbridge 1 = 2 | Outerbridge 1 = 1 |
| Outerbridge 2 = 3 | Outerbridge 2 = 1 |
| Outerbridge 3 = 1 | Outerbridge 3 = 6 |
| Outerbridge 4 = 4 | Outerbridge 4 = 3 |
| Follow‐up (mo) (mean; range; SD) = 12 (25; 12‐35; 8.4) | Follow‐up (mo) (mean; range; SD) = 12 (24; 12‐36; 8.7) |
ASA, American Society of Anesthesiologists; BMI, body mass index; mo, months; SD, standard deviation; yr, years.
Patient‐Reported Outcome Measures
For needlescope, the mean preoperative IKDC score is 33.9 (range 16‐76; SD 13.2), and the mean postoperative IKDC is 92.6 (range 48‐100; SD 13.7). The improvement is significant (P < .001). The mean preoperative pain VAS score is 6.4 (range 0‐10, SD 2.4), and the mean postoperative pain VAS score is 1.0 (range 0‐10; SD 2.2). The decrease in pain is significant (P < .001) (Table 2).
TABLE 2.
Patient‐Reported Outcome Measures by Subgroup and Disaggregated by Sex
| Needlescope (n = 24) | Arthroscope (n = 24) |
|---|---|
| IKDC‐SKS | IKDC‐SKS |
| Pre mean (range; SD) = 33.9 (16‐76; 13.2) | Pre mean (range; SD) = 36.8 (12‐81; 17.0) |
| Post mean (range; SD) = 92.6 (48‐100; 13.7) | Post mean (range; SD) = 85.6 (36‐100; 13.7) |
| Mean improvement = 58.7 (P < .001) | Mean improvement = 48.7 (P < .001) |
| % whose improvement exceeds MCID of 7.5 = 100% | % whose improvement exceed MCID of 7.5 = 92% |
| VAS | VAS |
| Pre mean (range; SD) = 6.4 (0‐10; 2.4) | Pre mean (range; SD) = 6.3 (3‐10; 2.2) |
| Post mean (range; SD) = 1.0 (0‐10; 2.2) | Post mean (range; SD) = 1.8 (0‐7; 1.9) |
| Mean improvement = 5.4 (P < .001) | Mean improvement = 4.5 (P < .001) |
| Needlescope Versus Arthroscope | P Value |
|---|---|
| Difference in mean improvement in IKDC = 10 | P = .24 |
| Difference in mean improvement in VAS = 0.9 | P = .55 |
| Men | Women |
|---|---|
| Needlescope (n = 17) | Needlescope (n = 7) |
| IKDC‐SKS | IKDC‐SKS |
| Pre mean (range; SD; MCID) = 36.6 (17‐76; 14.6) | Pre mean (range; SD; MCID) = 27.3 (16‐32; 5.2) |
| Post mean (range; SD) = 93.2 (48‐100; 14.2) | Post mean (range; SD) = 91.0 (71‐100; 11.1) |
| Mean improvement = 56.6 | Mean improvement = 63.7 |
| % whose improvement exceeds MCID = 100% | % whose improvement exceeds MCID = 100% |
| VAS | VAS |
| Pre mean (range; SD) = 5.9 (0‐10; 2.6) | Pre mean (range; SD) = 7.1 (5‐8; 1.2) |
| Post mean (range; SD) = 1.2 (0‐10; 2.5) | Post mean (range; SD) = 0.7 (0‐3; 1.3) |
| Mean improvement = 4.7 | Mean improvement = 6.4 |
| Arthroscope (n = 11) | Arthroscope (n = 13) |
|---|---|
| IKDC‐SKS | IKDC‐SKS |
| Pre mean (range; SD; MCID) = 39.6 (23‐70; 15.8) | Pre mean (range; SD; MCID) = 34.6 (12‐81; 18.2) |
| Post mean (range; SD) = 90.9 (62‐100; 13.2) | Post mean (range; SD) = 81.2 (36‐100; 19.3) |
| Mean improvement = 51.3 | Mean improvement = 46.6 |
| % whose improvement exceeds MCID = 100% | % whose improvement exceeds MCID = 85% |
| VAS | VAS |
| Pre mean (range; SD) = 5.2 (3‐7; 1.4) | Pre mean (range; SD) = 7.2 (3‐10; 2.3) |
| Post mean (range; SD) = 1.4 (0‐4; 1.6) | Post mean (range; SD) = 2.2 (0‐7; 2.0) |
| Mean improvement = 3.8 | Mean improvement = 5.0 |
IKDC‐SKS, International Knee Documentation Committee‐Subjective Knee Score; MCID, minimal clinically important difference; Post, postoperative; Pre, preoperative; SD, standard deviation; VAS, visual analog scale.
For arthroscope, the mean preoperative IKDC score is 36.8 (range 12‐81; SD 17.0), and the mean postoperative IKDC is 85.6 (range 36‐100; SD 13.7). The improvement is significant (P < .001). The mean preoperative pain VAS score is 6.3 (range 3‐10; SD 2.2), and the mean postoperative pain VAS score is 1.8 (range 0‐7; SD 1.9) (P < .001).
Mean improvement in IKDC shows no significant difference between groups (58.7 for needlescope versus 48.7 for arthroscope; P = .24). Mean improvement in pain VAS shows no significant difference between groups (5.4 for needlescope vs 4.5 for arthroscope; P = .55).
The study‐specific MCID for IKDC = 7.5. For needlescope, improvement in 24/24 patients (100%) exceeded the threshold for MCID. For arthroscope, improvement in 22/24 (92%) exceeded the threshold.
Health‐Related QoL
Health‐related QoL is expressed as a utility score (EQ‐5D [United States]), a preference‐based measurement ranging from 0 (death) to 1 (perfect health). 11 For needlescope, preoperative EQ‐5D = 0.28 and postoperative EQ‐5D = 0.76. In the arthroscope group, preoperative EQ‐5D = 0.29 and postoperative EQ‐5D = 0.70. For needlescope, improvement =0.48. For arthroscope, improvement = 0.41 (Table 3).
TABLE 3.
Improvement in Health‐Related QoL, Life Expectancy, and Effectiveness by Subgroup and Disaggregated by Sex
| Needlescope (n = 24) | Arthroscope (n = 24) |
|---|---|
| Improvement in health‐related QoL (EQ‐5D) = 0.48 | Improvement in health‐related QoL (EQ‐5D) = 0.41 |
| Life remaining (yr) = 30.5 | Life remaining (yr) = 34.1 |
| Effectiveness = 14.64 QALYs | Effectiveness = 13.98 QALYs |
| Men | Women |
|---|---|
| Needlescope (n = 17) | Needlescope (n = 7) |
| Improvement in health‐related QoL (EQ‐5D) = 0.48 | Improvement in health‐related QoL (EQ‐5D) = 0.47 |
| Life remaining (yr) = 29.1 | Life remaining (yr) = 31.8 |
| Effectiveness = 13.97 QALYs | Effectiveness = 14.95 QALYs |
| Arthroscope (n = 11) | Arthroscope (n = 13) |
|---|---|
| Improvement in health‐related QoL (EQ‐5D) = 0.43 | Improvement in health‐related QoL (EQ‐5D) = 0.40 |
| Life remaining (yr) = 31.6 | Life remaining (yr) = 37.3 |
| Effectiveness = 13.59 QALYs | Effectiveness = 14.92 QALYs |
EQ‐5D, EuroQoL‐5D; QALYs, quality‐adjusted life years; QoL, quality of life; yr, years.
Life Expectancy
Expected years of life remaining for needlescope is 30.5, based on subgroup mean age of 50.0 years. 16 Expected years of life remaining for arthroscope is 34.1, based on subgroup mean age of 46.5 (Table 3). 16
Effectiveness
Effectiveness, the benefit of medical treatment, combines life expectancy with improvement in QoL and is quantified in QALYs (gain of years of life in perfect health). 10 , 11 Needlescope results in 14.64 QALYs. Arthroscope results in 13.98 QALYs (Table 3).
Costs
Mean cost per case shows no significant difference between groups ($17,236.69 for needlescope vs $16,994.00 for arthroscope; P = .26). Categorical cost details are reported in Table 4.
TABLE 4.
Mean Cost per Case, Mean Cost per Case by Category, Cost‐Effectiveness∗, and ICER† by Subgroup and Disaggregated by Sex
| Needlescope (n = 24) | Arthroscope (n = 24) |
|---|---|
| Mean cost per case = $17,236.69 | Mean cost per case = $16,994.00 |
| Cost per case range; SD = $14,576.12‐21,224.24; $1489.10 | Cost per case range; SD = $13,773.48‐26,652.94; $2478.62 |
| Mean cost per case by category | Mean cost per case by category |
| Surgeon fee = $1600.00 | Surgeon fee = $1605.00 |
| Needlescope plus needlescope sheath = $640.00 | Needlescope plus needlescope sheath‡ = N/A |
| Supplies = $460.20 | Supplies = $535.90 |
| Time$ = $12,948.01 | Time$ = $13,175.30 |
| Drug = $1439.73 | Drug = $1341.69 |
| Miscellaneous‖ = $148.75 | Miscellaneous‖ = $231.11 |
| Reprocessing (4.0 mm arthroscope) = N/A | Reprocessing¶ (4.0 mm arthroscope) = $105 |
| Cost‐effectiveness = $1177.32 per QALY | Cost‐effectiveness = $1215.59 per QALY |
| Difference in mean cost per case | P = .26 |
| ICER | $367.71/QALY (needle arthroscopy results in 1 additional year of “perfect health” at an additional cost of $367.71) |
| Men | Women |
|---|---|
| Needlescope (n = 17) | Needlescope (n = 7) |
| Mean cost per case = $17,848.41 | Mean cost per case = $15,751.10 |
| Mean cost per case by category | Mean cost per case by category |
| Surgeon fee = $1600.00 | Surgeon fee = $1600.00 |
| Needlescope plus needlescope sheath = $640.00 | Needlescope plus needlescope sheath = $640.00 |
| Supplies = $558.27 | Supplies = $222.05 |
| Time$ = $13,470.67 | Time$ = $11,678.69 |
| Drug = $1451.65 | Drug = $1410.78 |
| Miscellaneous‖ = $127.82 | Miscellaneous‖ = $199.58 |
| Reprocessing (4.0 mm arthroscope) = N/A | Reprocessing (4.0 mm arthroscope) = N/A |
| Cost‐effectiveness = $1227.62 per QALY | Cost‐effectiveness = $1053.59 per QALY |
| Arthroscope (n = 11) | Arthroscope (n = 13) |
|---|---|
| Mean cost per case = $16,956.58 | Mean cost per case = $17,030.18 |
| Mean cost per case by category | Mean cost per case by category |
| Surgeon fee = $1610.90 | Surgeon fee = $1600.00 |
| Needlescope plus needlescope sheath‡ = N/A | Needlescope plus needlescope sheath‡ = N/A |
| Supplies = $711.09 | Supplies = $387.67 |
| Time$ = $12,970.34 | Time$ = $13,350.27 |
| Drug = $1269.71 | Drug = $1402.59 |
| Miscellaneous‖ = $286.00 | Miscellaneous‖ = $184.65 |
| Reprocessing¶ (4.0 mm arthroscope) = $105 | Reprocessing¶ (4.0 mm arthroscope) = $105 |
| Cost‐effectiveness = $1247.72 per QALY | Cost‐effectiveness = $1141.43 per QALY |
Note: Supplies = supplies (net of needlescope plus needlescope sheath).
ICER, incremental cost‐effectiveness ratio; N/A, not applicable; QALY, quality‐adjusted life year; SD, standard deviation.
Cost to gain 1 additional year of life in “perfect” health (Cost/QALY).
Cost to gain 1 additional year of life in “perfect” health as a result of treatment using needlescope as compared with arthroscope.
The chip‐on‐tip needlescope and needlescope sheath are single‐use disposable items.
Time is comprised of main operating room time, recovery room time, anesthesia time, and preoperative anesthesia evaluation time.
Miscellaneous costs include lab, radiology, electrocardiogram, and physical therapy evaluation.
Reprocessing costs of $105 are comprised of $33 for labor (technologist salary plus benefits); $35 for single‐use disposable items (Sterrad Cartridge [Advanced Sterilization Products, Irvine, CA], tray wrap, tray liner, sterile indicators, and corner protectors); and $37 for maintenance and depreciation (per case for arthroscope, light cord, and Sterrad).
Cost‐Effectiveness and ICER
Cost‐effectiveness (i.e., cost to gain 1 additional year of life in perfect health) = $1177.32/QALY for needlescope and $1215.59/QALY for arthroscope (Table 4). ICER is $367.71/QALY. The cost for 1 additional year of life in perfect health, resulting from having needlescope instead of arthroscope, is $367.71.
Sensitivity Analysis: Cost
To determine the effect of variation of needlescope cost, a 1‐way sensitivity analysis is performed. As needlescope costs decrease, the ICER of needlescope (cost of 1 additional life year in perfect health) decreases, because the incremental benefit of needlescope becomes larger. If needlescope costs increase, the ICER of needlescope increases. The relation is linear (Figure 2).
FIGURE 2.
One‐way sensitivity analysis showing ICER of needle arthroscopy as compared with standard arthroscopy (y‐axis) if the cost of needle arthroscopy were to vary (x‐axis). The result (base case: needle arthroscopy cost = $17,237; ICER = $368.74 representing the price to pay for 1 additional year of life in perfect health resulting from having needle arthroscopy instead of standard arthroscopy) is illustrated by a red dot. Sensitivity analysis shows that as the cost of needle arthroscopy increases, the ICER of needle arthroscopy increases; as the cost of needle arthroscopy decreases, the ICER of needle arthroscopy decreases. The relation is linear (solid line). If the cost of needle arthroscopy were decreased to equal the cost of standard arthroscopy ($16,994), needle arthroscopy would become cost‐neutral. This “break‐even point” (where the solid line crosses the dotted line) results in an ICER of 0 (y‐axis). (ICER, incremental cost‐effectiveness ratio.)
To determine the effect of variation in effectiveness of the standard arthroscopy (arthroscope), 1‐way sensitivity analysis is performed. As the effectiveness of arthroscope increases, the ICER of needlescope increases, because the incremental benefit of needlescope becomes smaller. As the effectiveness of arthroscope approaches the effectiveness of needlescope, the relation is asymptotic (because mathematically, for equally effective treatments, the denominator of the ICER becomes 0). If the effectiveness of arthroscope decreases, the ICER of needlescope decreases (Figure 3).
FIGURE 3.
One‐way sensitivity analysis showing ICER of needle arthroscopy as compared with standard arthroscopy (y‐axis) if the effectiveness (QALYs) of standard arthroscopy were to vary (x‐axis). The result (base case: standard arthroscopy effectiveness = 13.98 QALYs; ICER = $368.74 representing the price to pay for 1 additional year of life in perfect health resulting from having needle arthroscopy instead of standard arthroscopy) is illustrated by a red dot. Sensitivity analysis shows that as the effectiveness of standard arthroscopy increases, the ICER of needle arthroscopy increases; as the effectiveness of standard arthroscopy decreases, the ICER of needle arthroscopy decreases. As the effectiveness of standard arthroscopy approaches the effectiveness of needle arthroscopy (14.64 QALYs), the relation is asymptotic, because mathematically, if the treatments are equally effective, the ICER denominator (difference in effectiveness) becomes 0, and at the asymptotic break‐even point (equal effectiveness), the ICER would become infinite. (ICER, incremental cost‐effectiveness ratio; QALYs, quality‐adjusted life years.)
DISCUSSION
The most important finding of this study is that compared with standard arthroscopy, needle arthroscopy results in no significant differences in cost or outcomes at 1‐year minimum follow‐up after partial meniscectomy. Both treatments are highly cost‐effective. ICER for needlescope versus arthroscope is $367.71.
Two prior publications show faster recovery rate, less pain, and decreased opioid consumption (at 2 and 6 weeks, respectively) after partial meniscectomy using needlescope compared with arthroscope. 9 , 17 The first study did not report IKDC; 17 the second, which includes shorter‐term outcomes of the patients included in our study, shows IKDC improvement favoring needlescope at 2 and 6 weeks, whereas, at 12 weeks, significant differences in IKDC scores were not maintained. 9 This finding (no significant difference in knee scores at 3 months) is supported by our study showing no significant difference in knee scores (P = .24) at a minimum of 1 year. Regarding partial meniscectomy after standard arthroscopy, a recent review 18 reports a pooled mean IKDC score of 46.7 ± 15.2 preoperatively to 76.2 ± 18.3 postoperatively. The results of our study (mean preoperative IKDC = 36.8 and mean postoperative IKDC = 85.6 for standard arthroscopy) fall within this range. In addition, sensitivity analysis improves the generalizability of our findings by reporting the effect of variations in outcomes.
Effectiveness and Cost
In health economic terms, QALYs quantify the benefit of treatment by combining life expectancy with QoL (utility) scores. The product of QoL × life expectancy results in an effectiveness of 14.64 QALYs for needlescope and 13.98 QALYs for arthroscope. Needlescope yields an additional 0.66 QALYs over the course of the needle arthroscopy group's mean life expectancy, at an incremental cost increase of $242.69 as compared with standard arthroscopy.
Cost‐Effectiveness
In health economic terms, cost‐effectiveness is defined as Cost/QALY. Cost/QALY of needle arthroscopy is $1177.32 per QALY. Cost/QALY of standard arthroscopy is $1215.59. Needlescope is more cost‐effective (i.e., lower Cost/QALY) than standard arthroscopy. Both treatments are highly cost‐effective relative to a Cost/QALY of $50,000, bearing in mind that “$50,000 per quality‐adjusted life‐year (QALY) gained by using a given health care intervention has long served as a benchmark for the value of U.S. health care…(and) might best be thought of as a…lower boundary.” 19
Prior studies report cost of knee needlescope, 20 cost comparisons between knee needlescope versus MRI, 21 , 22 and cost comparisons between knee needlescope in an office versus standard arthroscopy in an operating room 22 , 23 but do not report cost‐effectiveness (COST/QALY) of chip‐on‐tip needle arthroscopy for knee partial meniscectomy. In contrast, cost‐effectiveness of arthroscopic partial meniscectomy using standard arthroscopy has been reported as ranging from $2585 to $10,448 (in US dollars/QALY). 24 , 25 , 26 , 27 Our Cost/QALY for standard arthroscopy is similar but lower ($1215.59); this may be because we determine health utility (EQ‐5D) based on IKDC, and IKDC has a high ceiling effect in patients having arthroscopic partial meniscectomy. 15 Sensitivity analysis improves the generalizability of our findings by reporting the effect of variations in costs. Finally, by using a ratio (ICER) to compare groups, we normalize potential variations in both costs and outcomes.
Incremental Cost‐Effectiveness Ratio
In health economic terms, ICER is used to compare the cost‐effectiveness of a new treatment compared with a reference treatment based on the incremental cost of the new treatment divided by the incremental measure of benefit. When the measure of benefit is expressed in QALYs, ICER is measured in cost per QALY gained. 11 Quantitatively, QALY gained “indicates the additional cost required to gain 1 QALY using the new treatment strategy when compared with the reference strategy,” where 1 QALY represents 1 additional year of life in excellent (or perfect) health. 11
In health economics, ICER is often interpreted in terms of “willingness to pay” (WTP). 28 , 29 , 30 , 31 , 32 In our analysis, needlescope may be considered cost‐effective relative to standard arthroscopy, because, in terms of WTP, $367.71 is considered a small price to pay for 1 additional year of life in perfect health.
This is illustrated using a cost‐effectiveness plane (Figure 4). The x‐axis represents incremental effectiveness (difference in QALYs); the y‐axis represents incremental costs (difference in price). The origin represents the reference strategy (standard arthroscopy), and the ICER of the new treatment is measured as an “incremental” change from the origin; the ICER of needle arthroscopy, as compared with standard arthroscopy, is plotted using a red dot.
FIGURE 4.
Cost‐effectiveness plane comparing needle arthroscopy versus standard arthroscopy. The x‐axis represents incremental effectiveness in terms of the difference in QALYs comparing needle arthroscopy and standard arthroscopy; the y‐axis represents the difference in price between needle arthroscopy and standard arthroscopy (incremental costs in dollars). The origin represents the reference strategy (standard arthroscopy). ICER is measured as an incremental change from the origin, and the ICER of needle arthroscopy as compared with standard arthroscopy ($368.74/QALY) is plotted as a red dot. In the cost‐effectiveness plane, the upper left quadrant reflects treatments that are more costly and less effective, thus economically unfavorable (dominated), whereas the upper right quadrant reflects treatments that are more costly but more effective (a trade‐off). Treatments in the lower left quadrant are less costly but less effective (also a trade‐off). Treatments in the lower right quadrant are less costly and more effective, thus economically favorable (dominant). The ICER (red dot) for chip‐on‐tip needle arthroscopy versus standard arthroscopy for partial meniscectomy, like most new treatment strategies (11), falls in the upper right quadrant (more costly and more effective). In such cases, the ICER is considered relative to the WTP threshold (blue dotted line). Because the ICER of needle arthroscopy ($368.72/QALY) is more than 2 orders of magnitude lower than the WTP threshold of $50,000/QALY (18), the red dot falls far below the blue dotted line on the y‐axis. This indicates that in the context of health care economics, needle arthroscopy is highly cost‐effective, or “near dominant,” compared with standard arthroscopy. (ICER, incremental cost‐effectiveness ratio; QALYs, quality‐adjusted life years; WTP, willingness to pay.)
In the cost‐effectiveness plane, the upper left quadrant reflects treatments that are more costly and less effective, thus economically unfavorable (“dominated”), whereas the upper right quadrant reflects treatments that are more costly but more effective (a trade‐off). Treatments in the lower left quadrant are less costly but less effective (also a trade‐off), and treatments in the lower right quadrant are less costly and more effective, thus economically favorable (“dominant”). 11
The ICER (red dot) for chip‐on‐tip needle arthroscopy versus standard arthroscopy for partial meniscectomy, like most new treatment strategies, 11 falls in the upper right quadrant (more costly and more effective; Figure 4). In such cases, the ICER is considered relative to the WTP threshold plotted as a blue dotted line. Because the ICER of needle arthroscopy ($368.72/QALY) is more than 2 orders of magnitude lower than the WTP threshold of $50,000/QALY, 18 the red dot falls far below the blue dotted line. This indicates that in the context of health care economics, needle arthroscopy is cost‐effective, or “near dominant,” compared with standard arthroscopy.
Sensitivity Analysis
“The ICER should not be viewed only as a single number, as there is uncertainty to both the measure of the cost and the measure of effectiveness. Thus, cost‐effectiveness analyses generally include sensitivity analyses in which the input variables for assessing both cost and effectiveness are varied.” 33
Sensitivity Analysis: Costs
Different surgeons, treating different patients, at different facilities (or our surgeon operating under different circumstances), could result in different costs. One‐way sensitivity analysis illustrates that if the costs of needle arthroscopy were increased, ICER would increase, that is, the cost of a gain of 1 QALY as a result of needle arthroscopy, as compared with standard arthroscopy, would be greater. If the cost of needle arthroscopy were increased to $20,000, ICER remains more than an order of magnitude below the WTP threshold of $50,000/QALY, 19 indicating minimal sensitivity to price fluctuations within a realistic range of cost of surgery (Figure 2).
In contrast, if the costs of needle arthroscopy were decreased to equal the costs of standard arthroscopy, needle arthroscopy would become cost‐neutral while providing superior outcomes. The “break‐even point” is illustrated by an ICER of 0 on the y‐axis. At, or below, the cost‐neutral break‐even point, needle arthroscopy would be considered the dominant strategy, offering greater health gains at no additional incremental cost (ICER less than or equal to 0).
Sensitivity Analysis: Effectiveness
Different surgeons (or our surgeon operating under different circumstances), treating different patients, at different facilities, using different QoL outcome measures, could result in different effectiveness. One‐way sensitivity analysis illustrates that if effectiveness (QALYs) after standard arthroscopy were increased, the ICER of needle arthroscopy would increase. As the QALY of standard arthroscopy continues to increase (moving to the right on the x‐axis), we reach a break‐even point, at which point, because needle arthroscopy remains the more expensive intervention, needle arthroscopy becomes dominated by standard arthroscopy, that is, standard provides the same utility at a lower cost. At exactly equal QALYs, the ICER denominator becomes 0, mathematically resulting in an asymptote tending toward infinity, and moving even further to the right (not illustrated), as needle arthroscopy is further dominated, the ICER would become negative (Figure 3).
In contrast, as the effectiveness of standard arthroscopy decreases, the ICER of needle arthroscopy will decrease. In the end, needle arthroscopy remains the preferred treatment strategy under health economic benchmarks until effectiveness parity is reached.
Health Economic Societal and Ethical Perspectives
Articles evaluating costs and cost‐effectiveness are becoming more common in the arthroscopic literature. 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 As a result, it is important to consider societal and ethical implications of cost‐effectiveness analyses because although dominant strategies (lower cost, more effective) are obviously economically favorable and dominated strategies (higher cost, less effective) are obviously unfavorable, many new treatments are both more costly and more effective. 11
On one hand, we want what is best for patients, regardless of cost. On the other hand, economic resources are finite, and “healthcare budgets increasingly threaten other parts of the economy.” 11 As health care costs increase, achieving good value is paramount. 33
In the United States, the cost‐effectiveness WTP threshold is traditionally set at $50,000/QALY, and an ICER of <$50,000 is considered to represent “high value.” 19 In contrast, “willingness‐to‐pay thresholds are not set in stone…The threshold is formed by a balance between the ability‐to‐pay and willingness‐to‐pay with societal and political factors playing a role.” 11
“(T)he optimal threshold for cost‐effectiveness is more a sociopolitical decision than a medical or scientific one,” and although cost‐effectiveness analysis cannot resolve major societal decisions, it can help find value in health, given whatever resources are available for medical care. From an ethical standpoint, the $50,000 WTP figure could be used as a guide for understanding value rather than as presenting a barrier 33 or providing clearance.
Some payers or facilities may prioritize profit above all else, without consideration of what may be best for patients. Such an approach is ethically inappropriate.
Thus, despite its limitations, cost‐effectiveness analysis offers the best opportunity to evaluate not only the possible greater effectiveness of new treatment strategies but also its value for money. 11 Ultimately, thoughtful consideration and discerning judgment is required to determine the value 13 (outcomes/costs) of a medical intervention.
Limitations
This study is not without limitations. Because of the small sample size, we are unable to rule out type II (beta) error regarding statistically nonsignificant findings. We retrospectively review prospectively collected data on patients who participated in a larger randomized trial. The trial was primarily designed for purposes other than cost‐effectiveness analysis. In addition, the groups are unbalanced in terms of meniscus tear location. We recorded patient‐reported outcomes using IKDC and used this outcome measure to derive QoL (EQ‐5D [US]) scores. A prospective study could allow direct measurement of EQ‐5D (US) which is preferred. Moreover, IKDC has a high ceiling effect for patients having arthroscopic partial meniscectomy. 15 Our mean time to follow‐up is 26 months, but the minimum time to follow‐up is only 12 months. Although it has recently been reported that a minimum 2‐year follow‐up is likely to be unnecessarily long to evaluate the results of arthroscopic partial meniscectomy, 48 a longer minimum follow‐up is preferred. In terms of health economics, as above, the WTP threshold of the ICER <$50,000 is arbitrary, 11 and “ICER should not be viewed only as a single number, as there is uncertainty to both the measure of the cost and the measure of effectiveness.” 34 Also, our ICER result represents a trade‐off in the cost‐effectiveness plane. Finally, we measured direct medical costs and do not consider the costs of loss of patient productivity, caregiver burden, or travel expenses that could be associated with different rates of recovery, and although our patients did not experience complications, inclusion of larger numbers of patients could result in complication‐related expenses.
CONCLUSIONS
Arthroscopic partial meniscectomy comparing 1.9 mm distal chip‐on‐tip needlescope versus 4 mm glass rod lens arthroscope results in no significant differences in cost or outcomes at 1‐year minimum follow‐up. Both treatments are highly cost‐effective. ICER for needlescope, $367.71, is more than 2 orders of magnitude lower than the WTP threshold of $50,000/QALY.
DECLARATION OF GENERATIVE AI AND AI‐ASSISTED TECHNOLOGIES IN THE WRITING PROCESS
During the preparation of this work, the authors used Google Gemini to assist with the statistical analyses and the creation of sensitivity analysis and cost‐effectiveness plane figures and to assist the authors in understanding and explaining the figures. After using Google Gemini, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
DISCLOSURES
The authors (J.H.L., C.L.) declare the following financial interests/personal relationships which may be considered as potential competing interests: J.H.L. receives support for the present manuscript (i.e., article processing charges) payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events, consulting fees, and support for attending meetings and/or travel from Arthrex, and has a leadership or fiduciary role in other board, society, committee, or advocacy group, unpaid, with Arthroscopy journal. C.L. receives support for the present manuscript (i.e., payments for the original RCT); royalties or licenses; consulting fees; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events; and support for attending meetings and/or travel from Arthrex.
ACKNOWLEDGMENTS
The authors acknowledge John Zach Johnson, LAT, ATC, for his help in collecting and organizing their patient‐reported outcome data.
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