Background: The optimal therapeutic approach for people suffering with unstable Charcot arthropathy of the midfoot is unclear. The purpose of this study was to examine the cost-effectiveness of three competing treatment strategies for adults suffering with unstable, midfoot Charcot arthropathy.
Methods: A Markov model was utilized to compare Charcot reconstruction (CR), primary transtibial amputation (TTA) and lifetime bracing in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated ulcer, and infected ulcer. Data regarding costs and probabilities were obtained from available literature. Primary outcomes included long-term costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Willingness-to-pay was set at $100,000 USD.
Results: TTA failed to show cost-effectiveness in comparison to other strategies available. Lifetime bracing was cost-effective in all clinical scenarios, with ICERs ranging from $6,970 to $15,010. CR was also cost-effective in the non-ulcerated and ulcerated scenarios, and offered the greatest potential for maximal QALYs gained, but failed to show value in the infected ulcer scenario. For CR to be cost-effective in the infected ulcer scenario, costs of surgery would need to lessen to $40,000 or complication rates would need to remain under 50%. The results in the non-ulcerated and ulcerated cohorts were robust to multiple sensitivity analyses.
Conclusion: Bracing is a cost-effective option in all stages of Charcot arthropathy while CR appears to be only cost-effective when performed early (i.e., in the non-ulcerated and uncomplicated ulcerated patient). An opportunity for shared-decision making exists in the early stages of Charcot arthropathy, where patient goals and expectations may be assessed while multiple cost-effective options are still available.
A.E. Fleischer: None. R.H. Albright: None. D.G. Armstrong: None. D. Wukich: Consultant; Self; Orthofix, Wright Medical. Other Relationship; Self; Arthrex.