Need For Total Knee Replacement Research Articles

A Gender-Bias-Mitigated, Data-Driven Precision Medicine System to Assist in the Selection of Biological Treatments of Grade 3 and 4 Knee Osteoarthritis: Development and Preliminary Validation of precisionKNEE.

Objective To identify key variables predictive of patient responses to microfragmented adipose tissue (MFAT) treatment in knee osteoarthritis (KOA) and evaluate its potential to delay or mitigate the need for total knee replacement (TKR). Methods We utilised a dataset comprising 329 patients treated with MFAT for KOA, incorporating variables such as gender, age, BMI, arthritic aetiology, radiological grade, and Oxford Knee Scores (OKS) pre- and post-treatment. We employed random forest regressors for model training and testing, with gender bias mitigation and outlier detection to enhance prediction accuracy. Model performance was assessed through root mean squared error (RMSE) and mean absolute error (MAE), with further validation in a TKR-suitable patient subset. Results The model achieved a test RMSE of 6.72 and an MAE of 5.38, reflecting moderate predictive accuracy across the patient cohort. Stratification by gender revealed no statistically significant differences between actual and predicted OKS improvements (p-values: males = 0.93, females = 0.92). For the subset of patients suitable for TKR, the model presented an increased RMSE of 9.77 and MAE of 7.81, indicating reduced accuracy in this group. The decision tree analysis identified pre-operative OKS, radiological grade, and gender as significant predictors of post-treatment outcomes, with pre-operative OKS being the most critical determinant. Patients with lower pre-operative OKS showed varying responses based on radiological severity and gender, suggesting a nuanced interaction between these factors in determining treatment efficacy. Conclusion This study highlights the potential of MFAT as a non-surgical alternative for KOA treatment, emphasising the importance of personalised patient assessments. While promising, the predictive model warrants further refinement and validation with a larger, more diverse dataset to improve its utility in clinical decision-making for KOA management.

Carboplasty, a Minimally Invasive Procedure for Knee Osteoarthritis: Surgical Technique and Clinical Evidence

Knee osteoarthritis affects ~16% of adults in the world and is considered one of the most incapacitating diseases. Despite the advances in scientific knowledge and biological treatments in the field of orthopedics, available nonsurgical treatments for knee osteoarthritis are limited and still ineffective in delaying or stopping the progression of arthritis. Biologics such as platelet-rich plasma, bone marrow aspirate, and progenitor cells have emerged as potential treatments for osteoarthritis; however, the results are still not as expected. Carboplasty is a new treatment that involves the application of bone marrow aspirate into the bone-cartilage interface and intra-articularly, with the intention of stopping the progression of osteoarthritis and delaying the need for total knee replacement. By applying bone marrow directly in the bone-cartilage interface, the communication between subchondral bone and articular cartilage may be reestablished, promoting the delivery of nutrients to the cartilage, and it is hoped that preserving, regenerating, and restoring knee cartilage. Thirteen patients with knee osteoarthritis underwent carboplasty. Patients showed a statistically significant improvement in the Veterans RAND 12 Item Health Survey, the visual analog scale for knee pain, the Western Ontario and McMaster University Osteoarthritis Index, and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement at 3 and 6 months postprocedure. No adverse events were reported during the follow-up. Carboplasty is promising and worthy of further research.

NOVEL COMPOSITE ENDPOINT FOR SEVERE KNEE OSTEOARTHRITIS STATUS

Purpose: Knee osteoarthritis (OA) is a degenerative disease associated with pain, loss of function and possible need for total knee replacement (TKR). TKR is driven by disease severity and many other non-clinical factors; consequently, studying TKR endpoints for OA clinical trials has not been optimal. The recent report from Kim et al. (Kim et al., 2020) proposes the use of composite clinical endpoints based on combinations of severe pain and/or functional impairment utilizing WOMAC (Likert version) or the occurrence of TKR.

Rehabilitation Of Knee Osteoarthritis With Varus Deformity: A Case Report

Introduction: Osteoarthritis (OA) is one of the most common causes of chronic disability in the adult and geriatric population. It is known that 10% of the population aged 65 years and over suffer from knee osteoarthritis. Physical Medicine and Rehabilitation Specialist will often deal with cases of osteoarthritis due to the increasing prevalence of osteoarthritis globally, especially in long-term outpatient services. Case: A 58 years old, female, was referred from the Orthopedic department with a diagnosis of right Osteoarthritis knee grade IV and left Osteoarthritis knee grade II need for Total Knee Replacement (TKR). She felt pain in both knees since 5 months ago with a Visual Analog Scale (VAS) is 6. She is psychologically not ready yet for TKR. She stopped working due to her condition. The joint?s range of motion of the right knee joint range was limited in flexion (0-130?). Physical examination revealed a tender point at the medial area of the knee, crepitation in both knees, a positive patellar grinding test in both knees, a positive varus test of the right knee, atrophy on both vastus medialis muscles, and knee varus deformity. We provide rehabilitation programs for the patient such as giving physical modality (SWD), strengthening exercise, aerobic exercise, knee brace, home education, and home exercise program. Following the rehabilitation program for 3 months, the patient felt more fit, full right knee range of motion was obtained. She walked more easily with her knee brace and experienced improvements in physical function parameters. There was an improvement in ADL (Activity of Daily Living) function represented by the Barthel index, and there was a pain decreased. Conclusion: The combination of a knee brace, physical modality, exercise program, home exercise program, and knee joint protection education is provide improvements in pain, function, and some aspects of OA health-related quality of life.

Knee Joint Distraction in a Dog as Treatment for Severe Osteoarthritis

AbstractOsteoarthritis (OA) is the most common joint disease diagnosed in veterinary practice. There is no cure; where conservative treatment fails, a joint prosthesis is the last resort. In human OA patients, temporary distraction is a joint-preserving treatment which provides clinical and structural benefits, and postpones the need for total knee replacement for up to 9 years. In this single case, feasibility of knee joint distraction (KJD) was assessed in a 9-year-old female Dobermann with severe OA. Osteoarthritis of the left stifle joint was diagnosed clinically and radiographically. Knee joint distraction was applied for 7 weeks using a custom-made, hinged, external fixator. Follow-up of 1 year included owner questionnaires, orthopaedic examination, radiography, and force plate analysis. Additionally, synovial fluid biomarkers were assessed. Application and removal of the KJD frame were successfully accomplished without surgical complications. During KJD, the dog tolerated the frame well and maintained the use of the left hindlimb. Mild pin tract infection developed during the distraction period, which responded well to oral antibiotic medications. Owners reported clinical improvement during KJD and the follow-up period. This was confirmed by force plate analysis, demonstrating improvement from 3 months and onward. KJD proved to be a feasible strategy to treat end-stage OA in this single case; clinical efficacy remains to be determined in a larger cohort.

Microfragmented Adipose Tissue Injection (MFAT) May Be a Solution to the Rationing of Total Knee Replacement: A Prospective, Gender-Bias Mitigated, Reproducible Analysis at Two Years.

Background Knee osteoarthritis (KOA) is a significant cause of disability in a globally ageing population. Knee replacement surgery has been shown to improve function and quality of life. Access to this intervention can be limited for a number of reasons including rationing of care, lack of healthcare provision in austere environments, and more recently, due to the cessation of elective orthopaedic care as a result of the COVID pandemic. Referral for knee replacement surgery is often guided by the patient's Oxford Knee Score (OKS). Recent therapies including treatment with microfragmented adipose tissue (MFAT) have emerged as alternatives to relieve pain and improve function in such patients. Method We identified all patients with KOA Kellgren-Lawrence grade 3 and 4 in our dataset of patients treated with a single injection of MFAT and applied published OKS thresholds for referral for TKR to separate them into 3 cohorts according to their functional impairment. 220 patients (95 females, 125 males) with KOA were given one MFAT injection. The function (OKS) and quality of life (EuroQol-5) prior to and 24 months after therapy were compared. Results MFAT injection provided a statistically significant improvement in the quality of life (EQ-5D) at 24 months in patients with a baseline OKS of 39 or less (p value: <0.001) as well as those with OKS of 27 or less who are deemed suitable for a knee replacement (p value: <0.001). Conclusion MFAT injection improves quality of life in patients with KOA who are deemed suitable for the knee replacement. MFAT is a low-morbidity alternative biological treatment and can delay the need for total knee replacement in suitable patients.

The relationship between obesity and primary Total Knee Replacement: A scoping review of the literature

BackgroundPrimary Total Knee Replacement (TKR) is one of the most commonly performed elective orthopaedic procedures globally. Many patients undergoing this type of surgery are overweight or obese. In the UK, clinical commissioning groups have imposed arbitrary Body Mass Index (BMI) thresholds for TKR surgery. Many obese patients undergoing TKR believe they will lose weight following the procedure because of increased mobility. AimThis paper aims to present the findings of a scoping literature review about the relationship between obesity and primary TKR and to make recommendations for clinical practice, education and policy. MethodsA scoping literature review investigated the impact of BMI/body weight on the need for TKR, the impact of body weight and or BMI on patient outcomes following TKR, weight loss/gain following TKR and the implications of obesity on cost of TKR. FindingsSeventy-one papers were included in the review. Seven studies reported statistically significant associations between increased BMI/obesity with the need for TKR. Thirty of the studies reported worse outcomes for obese patients compared to non-obese comparisons. Forty of the studies reported no difference between obese and non-obese participants, including some where outcomes of obese patients were better than non-obese comparisons. Eight studies reported on changes to weight before and after TKR, three of the studies reporting a higher percentage losing weight than gaining weight and four studies reporting that obese patients gained weight. The 8th study reported that morbidly obese patients largely returned to their baseline BMI postoperatively. ConclusionThe findings of the review challenge the legitimacy of setting BMI thresholds to control access to TKR surgery. There is an urgent need to develop evidence based approaches to support weight loss and weight management for this group of patients. Obese patients undergoing TKR should receive specific information regarding potential additional risks of complications and poorer outcomes. There is a need for health promotion regarding the association of being overweight/obese in young adulthood and developing osteoarthritis of the knee joints requiring TKR in middle and older age.

Total knee replacement after high tibial osteotomy: time-to-event analysis and predictors.

BACKGROUND:An important aim of high tibial osteotomy (HTO) is to prevent or delay the need for total knee replacement (TKR). We sought to estimate the frequency and timing of conversion from HTO to TKR and the factors associated with it.METHODS:We prospectively evaluated patients with osteoarthritis (OA) of the knee who underwent medial opening wedge HTO from 2002 to 2014 and analyzed the cumulative incidence of TKR in July 2019. The presence or absence of TKR on the HTO limb was identified from the orthopedic surgery reports and knee radiographs contained in the electronic medical records for each patient at London Health Sciences Centre. We used cumulative incidence curves to evaluate the primary outcome of time to TKR. We used multivariable Cox proportional hazards analysis to assess potential preoperative predictors including radiographic disease severity, malalignment, correction size, pain, sex, age, body mass index (BMI) and year of surgery.RESULTS:Among 556 patients who underwent 643 HTO procedures, the cumulative incidence of TKR was 5% (95% confidence interval [CI] 3%–7%) at 5 years and 21% (95% CI 17%–26%) at 10 years. With the Cox proportional hazards multivariable model, the following preoperative factors were significantly associated with an increased rate of conversion: radiographic OA severity (adjusted hazard ratio [HR] 1.96, 95% CI 1.12–3.45), pain (adjusted HR 0.85, 95% CI 0.75–0.96)], female sex (adjusted HR 1.67, 95% CI 1.08–2.58), age (adjusted HR 1.50 per 10 yr, 95% CI 1.17–1.93) and BMI (adjusted HR 1.31 per 5 kng/m2, 95% CI 1.12–1.53).INTERPRETATION:We found that 79% of knees did not undergo TKR within 10 years after undergoing medial opening wedge HTO. The strongest predictor of conversion to TKR is greater radiographic disease at the time of HTO.

Developing prediction models for total knee replacement surgery in patients with osteoarthritis: Statistical analysis plan

Approximately 12-20% of those with osteoarthritis (OA) in Australia who undergo total knee replacement (TKR) surgery do not report any clinical improvement. There is a need to develop prediction tools for use in general practice that allow early identification of patients likely to undergo TKR and those unlikely to benefit from the surgery. First-line treatment strategies can then be implemented and optimised to delay or prevent the need for TKR. The identification of potential non-responders to TKR may provide the opportunity for new treatment strategies to be developed and help ensure surgery is reserved for those most likely to benefit. This statistical analysis plan (SAP) details the statistical methodology used to develop such prediction tools. To describe in detail the statistical methods used to develop and validate prediction models for TKR surgery in Australian patients with OA for use in general practice. This SAP contains a brief justification for the need for prediction models for TKR surgery in general practice. A description of the data sources that will be linked and used to develop the models, and estimated sample sizes is provided. The planned methodologies for candidate predictor selection, model development, measuring model performance and internal model validation are described in detail. Intended table layouts for presentation of model results are provided. Consistent with best practice guidelines, the statistical methodologies outlined in this SAP have been pre-specified prior to data pre-processing and model development.

Deep Learning Improves Predictions of the Need for Total Knee Replacement

Deep Learning Improves Predictions of the Need for Total Knee Replacement

FRI0426 EMOTIONAL COMPONENTS AND INFLAMMATION ARE HIGHLY RELEVANT IN PAIN REPORTED BY KNEE OSTEOARTHRITIC PATIENTS

Background:Osteoarthritis (OA) is a leading cause of disability in elderly and the most frequent form is knee OA (KOA) (1). Pain is the principal symptom that leads patients to visit clinicians, and it is the main reason, together with functionality, for patients to undergo a total knee replacement (TKR) after apparently unsuccessful conservative (CNV) treatments (2). It is well-known that there is a poor correlation between the radiographic severity (based on Kellgren &amp; Lawrence (KL) score) and the reported pain (3), so other variables may be responsible for the intensity of pain.Objectives:Identifying the leading causes of pain in each patient would improve the management of the disease. In this study we aim to investigate the role of emotional components, nociception process and inflammation in treatment decision, as a global measure of pain suffered by KOA patients, taking into account sex, age and BMI.Methods:KOA patients, carefully selected to be idiopathic, graded 2-3 in KL, were recruited at Hospital del Mar. The following variables were recorded: WOMAC, Hospital Anxiety and Depression Scale (HAD), Pain Catastrophizing Scale (PCS), tender points (TP) (measure with a pressure algometer at points defined in the Arendt-Nielsen extended peripatellar map), synovial hypertrophy (SH) and effusion (SE) (measure by ultrasounds), and PCR and ESR serum levels. Patients were classified according to 4 factors: treatment (CNV/TKR), sex, age (60-67/68-75) and BMI (&lt;30/&gt;30). All groups were balanced. Multivariate and correlations analysis were performed.Results:Eighty-seven patients have been recruited. Patients from the TKR group present significant higher WOMAC (p=0.000), PCS (p=0.002) and SE (p= 0.038) values than CNV ones, without interaction with the other factors, except for SE, that presents interaction with BMI (Fig. 1). Women reported significant upper WOMAC (p=0.001) and HAD rates (p=0.020), but also higher number of TP and ESR levels (p= 0.000 and 0.002, respectively). The level of sensitization was significantly higher in women than in men (p=0.000). Several significant correlations were found, mainly between WOMAC and emotional components, as well as between TP and WOMAC, PCS, and inflammation markers (Table 1).Conclusion:PCS is an emotional component that could explain in part the lack of correlation between joint status and patient’s symptomatology. Working out strategies for pain management could improve this PCS values and therefore reduce the need for TKR. Furthermore, this study also highlights the two mainly types of OA etiology: mechanical and inflammatory. It suggests that inflammation is mostly responsible for OA progression in patients with low BMI, and plays a strong role in women pathology. Finally, specific treatments targeting central pain sensitization could also improve the management of the pathology in women.

Implementing a national first-line management program for moderate-severe knee osteoarthritis in Australia: A budget impact analysis focusing on knee replacement avoidance

To model potential cost savings associated with implementing a first-line management program for moderate-severe knee osteoarthritis (OA) at a national level in Australia. A budget impact analysis was undertaken using published trial data and publically available data. Australian population projections and OA prevalence data were used to forecast likely need for total knee replacement (TKR) surgery for 2019-2029. Published data were sourced on TKR avoidance following a 12-week non-surgical knee OA management program (exercise therapy, education, insoles, dietary advice, analgesia) and cost per TKR in Australia. The cost of providing the first-line program was estimated on a sliding scale ($AUD750-$3000), with a base case of $AUD1,500. These inputs were used to model potential annual savings associated with national implementation of the program. The number of people in Australia with moderate-severe knee OA requiring TKR was estimated to be 56,007 in 2019, rising to 69,038by 2029. Avoidance of TKR by 34%-68% of people after the first-line management program could translate to savings of $AUD303million-690 million in 2019. Successively lowering the proportion of people who avoided TKR demonstrated that only 1 in 12 program recipients would need to avoid surgery for the program to generate savings. National implementation of a first-line OA management program as an alternative to TKR could produce substantial cost savings for the Australian healthcare system. Longer term data on TKR avoidance is needed to establish whether cost savings are realised or simply shifted to later years.

Surgical Treatment of Insufficiency Fractures of the Knee

Bone marrow lesions (BMLs) in the knee represent focal edema caused by subchondral bone attrition and microfractures to the trabecular bone. These lesions are poor prognostic indicators for several orthopaedic procedures but also have been associated with the progression of osteoarthritis. Current research is aimed at treating BMLs with the intent to improve the overall structural integrity of the subchondral bone and delay the need for arthroplasty. The injection of calcium phosphate bone substitute has been proposed to treat BMLs because animal models have shown its potential to stimulate bone repair. This technical note describes the key steps involved in performing percutaneous fixation of BMLs with a hard-setting bone substitute, as well as associated pearls and pitfalls. Although continued research with prospective comparative cohorts and long-term follow-up is needed to determine the efficacy of this procedure, this intervention holds promise in delaying the need for total knee replacement in the arthritic patient with a focal lesion.

Is Total Knee Replacement Justified in the Morbidly Obese? A Systematic Review.

Total knee replacement (TKR) comprises a significant, growing aspect in the management of patients with advanced arthritis of the knee for which conservative medical therapy has failed. Obesity, a rising epidemic, is considered an important independent risk factor in the development of osteoarthritis (OA). An aging population and increasing incidence of obesity contribute to a higher prevalence of OA and a subsequent greater need for TKR. The numbers of morbidly obese (MO) people undergoing TKR has consistently been rising. However, there have been concerns among patients and surgeons about the outcomes and complications of TKR in MO patients, especially given the morbidities associated with obesity. The goal of this systematic review was to assess relevant, up-to-date data on the safety, outcomes, and complications associated with TKR in MO patients.

Safety of Repeated Injections of Sodium Hyaluronate (SUPARTZ) for Knee Osteoarthritis: A Systematic Review and Meta-Analysis.

Though there is no consensus on its efficacy, knee osteoarthritis is symptomatically managed with intra-articular hyaluronic acid (IAHA). Recent reports suggest that IAHA may delay the need for total knee replacement, with the magnitude of delay proportional to the number of injection series. However, the safety of repeated injection series is reported to vary between commercial products. This report describes a systematic review of safety data on repeated treatment courses of SUPARTZ. We performed a systematic search of MEDLINE, Cochrane database, EMBASE, Web of Science, Google Scholar, and unpublished data. We included all human randomized controlled trials or observational studies with adverse event (AE) data for SUPARTZ in knee osteoarthritis. Two independent reviewers extracted data and evaluated study quality. Data were analyzed separately for the first and subsequent series of injections. The primary sources for repeated-injection data on SUPARTZ were a postmarket registry (N = 7404), 4 prospective studies (N = 127 total), and a retrospective study (N = 220). None of the sources reported increased frequency or severity of AEs with repeated injections. In the registry, 95% of multiple-injection-series patients who reported an AE did so during the first series. None of the AEs was serious, and most resolved spontaneously without medical intervention. The overall adverse event rate after repeat courses of SUPARTZ was 0.008 (95% confidence interval: 0.001-0.055). Multiple courses of SUPARTZ injections appear to be at least as safe, and probably safer, than the first course. This study supports the safety of repeat courses of SUPARTZ injections for knee osteoarthritis.

Efficacy and safety of hyaluronic acid in the management of osteoarthritis: Evidence from real-life setting trials and surveys.

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) treatment algorithm recommends intra-articular (IA) hyaluronic acid (HA) for management of knee osteoarthritis (OA) as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs (NSAIDs). This recommendation is based upon accumulating evidence that IA HA provides a significant benefit in knee OA. There is good evidence that IA HA injections reduce pain and increase function in knee OA, and the benefits are long-lasting as compared with IA corticosteroids. Evidence from real-life studies of repeat courses of IA HA demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement (TKR) of around 2 years. The clinical benefit of IA HA on knee OA may be 2-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and (ii) the re-establishment of joint homeostasis through induction of endogenous HA production, which continues long after the exogenous injection has left the joint. The magnitude of the clinical effect may be different for different HA products, but this has not been proven so far and requires further investigation. IA HA injections are generally considered to be safe, although a slightly higher number of cases of local reactions and post-injection non-septic arthritis has been reported with high molecular weight cross-linked HAs. The use of IA HA in knee OA patients with mild-moderate disease, and for more severe patients wishing to delay TKR surgery, is recommended by the ESCEO task force. Further investigation into the OA patient types most likely to benefit from IA HA is warranted. Viscosupplementation with IA HA is a safe and effective component of the multi-modal management of knee OA.

In patients with known knee OA, do viscous injections decrease or delay the need for total knee replacement?

Evidence-Based Answer The use of intraarticular hyaluronic acid (IA-HA) injections in patients with knee osteoarthritis (OA) decreases symptoms and may delay or prevent total knee replacement (TKR), especially in patients younger than 50 years or older than 80 years (SOR: B, metaanalysis of RCTs and case series).

Changes in knee pain, perceived need for surgery, physical function and quality of life after dietary weight loss in obese women diagnosed with knee osteoarthritis

Objectives: This pilot study had two main objectives, the first aimed to investigate whether weight loss is associated with a reduction in perceived need for Total Knee Replacement (TKR) surgery due to decrease in knee pain and improvement in function. The second aimed to identify whether change in body weight would directly affect reduction in knee pain to a point where the need for surgery could be prolonged or alleviated. 34 subjects were recruited into the study. Design: Women between 40 and 65 years old with morbid obesity (BMI ≥ 35 kg/m2) and osteoarthritis of he knee were pre-selected. If participants passed study criteria the Western Ontario McMaster University questionnaire (WOMAC), Item -36 Short Form Health Survey (SF-36), 6 Minute Walk Test (6MWT) and Timed Up And Go (TUG) were obtained from baseline and subjects were enrolled into a weight loss program, with no exercises included, for a 6 month period. Results: Repeated measures analysis of variance (ANOVA) revealed that at 6 weeks of diet the mean body weight reduction of 9.5%, was followed by a significant reduction (p=.015) in WOMAC scores and (p=.038) SF-36 sub score of physical function. At 3 months of diet a significant reduction of 16.5% in body weight contributed to a significant decrease of 37% in knee pain and 56% of participants perceived not to have surgery. Conclusions: These results suggest that an initial loss of 16.5% of body weight for obese individuals was significant enough to reduce pain and postpone patient’s intent to have surgery in 56%.

Surgical Considerations in Total Knee Replacement for the Obese Patient

Total knee replacement (TKR) is one of the most commonly performed and successful orthopedic surgeries in the modern era. The rising prevalence of obesity has contributed to the need for TKR, but the anatomy of obese patients presents unique challenges during surgery. In this article, we will focus on surgical techniques and tools to maximize the success of TKR in this patient population. We will also cover the relationship between obesity and the development of knee osteoarthritis, postoperative care, and prosthetic outcomes.

Disease-modifying drugs for knee osteoarthritis: can they be cost-effective?

Disease-modifying osteoarthritis drugs (DMOADs) are under development. Our goal was to determine efficacy, toxicity, and cost thresholds under which DMOADs would be a cost-effective knee OA treatment. We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to compare guideline-concordant care to strategies that insert DMOADs into the care sequence. The guideline-concordant care sequence included conservative pain management, corticosteroid injections, total knee replacement (TKR), and revision TKR. Base case DMOAD characteristics included: 50% chance of suspending progression in the first year (resumption rate of 10% thereafter) and 30% pain relief among those with suspended progression; 0.5%/year risk of major toxicity; and costs of $1,000/year. In sensitivity analyses, we varied suspended progression (20-100%), pain relief (10-100%), major toxicity (0.1-2%), and cost ($1,000-$7,000). Outcomes included costs, quality-adjusted life expectancy, incremental cost-effectiveness ratios (ICERs), and TKR utilization. Base case DMOADs added 4.00 quality-adjusted life years (QALYs) and $230,000 per 100 persons, with an ICER of $57,500/QALY. DMOADs reduced need for TKR by 15%. Cost-effectiveness was most sensitive to likelihoods of suspended progression and pain relief. DMOADs costing $3,000/year achieved ICERs below $100,000/QALY if the likelihoods of suspended progression and pain relief were 20% and 70%. At a cost of $5,000, these ICERs were attained if the likelihoods of suspended progression and pain relief were both 60%. Cost, suspended progression, and pain relief are key drivers of value for DMOADs. Plausible combinations of these factors could reduce need for TKR and satisfy commonly cited cost-effectiveness criteria.