Surgery for early structural osteoarthritis of the hip and knee: the SCORE evidence synthesis and economic evaluation.

RESEARCH QUESTION: Is surgery for early hip or knee osteoarthritis clinically effective and cost-effective? BACKGROUND: Osteoarthritis is the most common joint disease worldwide costing between 1% and 2.5% of gross domestic product in developed countries. Once a hip or knee develops end-stage disease, arthroplasty surgery is highly successful in most patients. Treatment options are limited for early disease, and patients may fall into a 'treatment gap', despite having severe symptoms. Many surgical procedures are used to treat early osteoarthritis of the hip and knee, but the clinical and cost-effectiveness of these techniques remains unclear. OVERALL AIM: To investigate the role of surgery in the management of early hip or knee osteoarthritis? OBJECTIVES: Use systematic review and evidence synthesis to determine the clinical effectiveness of current surgical interventions for early hip and knee osteoarthritis. Estimate the cost-effectiveness of these procedures using decision model analytic modelling. Create clinical treatment guidance and identify areas where new clinical research is required. METHODS: The programme of work consisted of systematic review, evidence synthesis and health economic modelling for surgical treatments used for early hip and knee osteoarthritis. We divided treatments into four groups: (1) non-regenerative procedures, (2) regenerative procedures, (3) load-modifying procedures and (4) arthroplasty procedures. They were compared with non-surgical treatment following National Institute for Health and Care Excellence guidance. We used outcome measures that satisfied the Outcome Measures in Rheumatoid Arthritis Clinical Trials and Osteoarthritis Research Society International core outcome set for hip and knee osteoarthritis. Decision-analytic models were developed to assess the cost-effectiveness of treatment alternatives expressed as cost per quality-adjusted life-year gained. RESULTS: The systematic review identified 61,098 studies, and our evidence synthesis identified a number of surgical techniques that have been used to treat early hip and knee osteoarthritis. However, we found very little meaningful evidence of the clinical efficacy for the majority of the surgical procedures. We only found seven randomised controlled trials and three non-randomised studies that compared a surgical technique to non-operative treatment. There were two surgical treatments that had limited but supportive evidence. Femoro-acetabular impingement is an early stage of hip osteoarthritis, and there is some evidence that arthroscopic chondroplasty provides patients with clinical relief of symptoms, above that seen with non-operative measures. In the knee, weaker evidence suggests arthroscopic debridement of osteoarthritic articular cartilage fragments may be of benefit, above non-operative measures. Health economic analysis suggests that both procedures may be cost-effective, but the evidence is again of low quality. LIMITATIONS: The original updated searches completed in January 2021, with a further search for randomised controlled studies completed in January 2025. CONCLUSIONS: There is a significant gap in the evidence base supporting surgical interventions in early hip and knee osteoarthritis. Limited evidence suggests that arthroscopic chondroplasty procedures may be effective in treating hip femoro-acetabular impingement and early knee osteoarthritis. A small number of randomised studies are in progress, but these studies do not encompass all procedures that are in use. FUTURE WORK: The key recommendation for future work is that more high-quality comparative studies are required to establish if the surgical interventions that are currently used are effective. STUDY REGISTRATION: This study is registered as PROSPERO CRD42019156444. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127398) and is published in full in Health Technology Assessment; Vol. 30, No. 56. See the NIHR Funding and Awards website for further award information.