2025 ISAKOS Congress in Munich, Germany

2025 ISAKOS Biennial Congress Paper


Defining Quality of Life and Cost-Effectiveness of Treatment of First Time and Recurrent Patellar Instability: Data From the JUPITER Cohort

Jacqueline M. Brady, MD, Portland, OR UNITED STATES
Haley D. Smith, BS, Portland, Oregon UNITED STATES
Shiv Malhotra, BS, New York, NY UNITED STATES
Natalie K. Pahapill, BS, New York, NY UNITED STATES
Bennett Propp, BS, Westport, CT UNITED STATES
Elizabeth Rose Dennis, MD MS, Brooklyn, NY UNITED STATES
Matthew William Veerkamp, BA, Cincinnati, OH UNITED STATES
Eric J. Wall, MD, Cincinnati, OH UNITED STATES
Daniel W. Green, MD, MS, New York, NY UNITED STATES
Philip Wilson, MD, Dallas, TX UNITED STATES
Shital N. Parikh, MD, Cincinnati, OH UNITED STATES
Beth Ellen Shubin Stein, MD, New York, NY UNITED STATES

Hosptial for Special Surgery, New York, New York, UNITED STATES

FDA Status Not Applicable

Summary

Assigning quality of life adjusted years and cost effectiveness in operatively and nonoperatively treated patients with first- time and recurrent patellar instability revealed that over a two-year period, operative treatment provided the highest utility.

Abstract

Purpose

Quality of life and cost-effectiveness between different treatments for patellofemoral instability remains unclear. The purpose of this study is to evaluate quality of life and cost-effectiveness of nonoperative, immediate operative, and delayed operative treatment for both first-time and recurrent patellar instability, and to evaluate the cost-effectiveness of Medial Patellofemoral Ligament Reconstruction (MPFL-R) with and without a Tibial Tubercle Osteotomy (TTO) in those with first time and recurrent patellar instability.

Methods

Using the Justifying Patellar Instability Treatment by Results (JUPITER) cohort, patients prospectively enrolled from 2017-2022 with 1-year follow-up or more from treatment of patellar instability were included. Patients who underwent previous ipsilateral knee surgery were excluded. Patients were categorized into either first-time or recurrent dislocators group. Each group was then split into three lifestyle alteration states: 1) severe to total, 2) mild to moderate, and 3) none. The Knee Injury and Osteoarthritis Outcome Score (KOOS) Q2 question was used as an anchor to define these states. Each state was then assigned a Quality Adjusted Life Year (QALY) score from 0-1, with 1 representing perfect health, based on the validated Banff Patellofemoral Instrument II (BFII) score for the annual assessment of patellofemoral treatment effectiveness. Transitions between lifestyle states from treatment-to-2 years were modeled using JUPITER derived probabilities, and 2-10 years using literature derived probabilities. A Markov state transition model was constructed to assess the cost-effectiveness of each treatment modality and ran for 10 cycles, representing 10 years. Transition state probabilities from years 2-10 were derived from existing literature. Cost of surgery, physical therapy, parental leave, and bracing were derived from literature and adjusted to inflation. A final ratio was used to compare cost-effectiveness between treatment modalities.

Results

There were 307 First-Time Dislocators and 380 Recurrent Dislocators that met inclusion criteria. For First-time Dislocators, a QALY score of .35 was associated with severe/total lifestyle alterations, .65 was associated with mild/moderate lifestyle alterations, and a score of .85 was associated with no alteration. QALY scores for the Recurrent Dislocators group were 0.35, 0.64, and 0.87. Over a 2-year time-period, operative treatment had the highest QALY accruals out of all treatment modalities for both First-Time and Recurrent Dislocators, whereas delayed treatment had the lowest. Further analysis showed MPFL-R without any concurrent bony procedures having a higher QALY accrual compared to MPRFL-R with a TTO over two years.

Conclusions

Over a two-year period, operative treatment provided the highest utility amongst patients with first-time and recurrent patellar dislocations. Delayed operative treatment led to the lowest utility scores, emphasizing the importance of choosing the correct treatment modality from patients’ initial presentation and avoiding delay of definitive treatment. Lastly, isolated MPFL-R led to higher utility scores than MPFL-R with TTO, proving to be a more cost-effective form of operative treatment, giving providers another metric when ultimately deciding which operative measure to perform. Given that MPFL-R treatment provides the highest utility of all, there is further support for its utilization among both first-time and recurrent patellar dislocations as the standard treatment for patellar instability.