Quality-Adjusted Life Years Gained by Hip and Knee Replacement Surgery and Its Aftercare

Published:January 11, 2016DOI:



      To determine the lifetime quality-adjusted life years (QALYs) gained by total joint arthroplasty (TJA), and assess the QALYs attributed to specific postoperative rehabilitation interventions.


      Secondary analysis of 2 multicenter, randomized controlled trials (RCTs) with 3-, 6-, 12-, and 24-month follow-up.


      Two university hospitals, 2 municipal hospitals, and 1 rural hospital.


      Patients (N=827) who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA).


      RCT A: 465 patients were randomly assigned to receive aquatic therapy (pool exercises aimed at training of proprioception, coordination, and strengthening) 6 versus 14 days after THA or TKA. RCT B: 362 patients were randomly assigned to either perform or not perform ergometer cycling beginning 2 weeks after THA or TKA.

      Main Outcome Measure

      QALYs, based on the Short Form–6 Dimensions utility, measured at baseline and 3, 6, 12, and 24 months' follow-up.


      After hip arthroplasty, the lifetime QALYs increased by 2.35 years in the nonergometer group, and by 2.30 years in the early aquatic therapy group. However, after knee arthroplasty, the lifetime QALYs increased by 1.81 years in the nonergometer group, and by 1.60 years in the early aquatic therapy group. By ergometer cycling, .55 additional QALYs could be gained after hip and .10 additional QALYs after knee arthroplasty, while the additional QALYs attributed to the timing of aquatic therapy were .12 years after hip and .01 years after knee arthroplasty.


      This analysis provides a sound estimate for the determination of the lifetime QALYs gained by THA and TKA. In addition, this analysis demonstrates that specific postoperative rehabilitation can result in an additional mean QALY gain of .55 years, which represents one fourth of the effect of surgery. Even if this is interpreted as a small effect at an individual level, it is important when extrapolated to all patients undergoing TJA. At a national level, these improvements appear to have a similar magnitude of QALY gain when compared with published data regarding medications to lower blood pressure in all persons with arterial hypertension.


      List of abbreviations:

      CI (confidence interval), EQ-5D (EuroQol–5 Dimensions), HRQoL (health-related quality of life), QALY (quality-adjusted life year), RCT (randomized controlled trial), SF-6D (Short Form–6 Dimensions), THA (total hip arthroplasty), TJA (total joint arthroplasty), TKA (total knee arthroplasty)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Barret M.
        • Wilson E.
        • Whalen D.
        Summary 2007 HCUP Nationwide Inpatient Sample (NIS) comparison report.
        Agency for Healthcare Research and Quality, Rockville2010 (Report no. 2010–03)
        • National Joint Registry for England and Wales
        11th annual report 2014.
        NJR Centre, Hernel Hempstead, Hertfordshire2015 (Report no. 11)
        • Schneider E.C.
        • Zaslavsky A.M.
        • Epstein A.M.
        Use of high-cost operative procedures by Medicare beneficiaries enrolled in for-profit and not-for-profit health plans.
        N Engl J Med. 2004; 350: 143-150
        • Moran C.G.
        • Horton T.C.
        Total knee replacement: the joint of the decade. A successful operation, for which there's a large unmet need.
        BMJ. 2000; 320: 820
        • Learmonth I.D.
        • Young C.
        • Rorabeck C.
        The operation of the century: total hip replacement.
        Lancet. 2007; 370: 1508-1519
        • Kim J.
        • Lonner J.H.
        • Nelson C.L.
        • Lotke P.A.
        Response bias: effect on outcomes evaluation by mail surveys after total knee arthroplasty.
        J Bone Joint Surg Am. 2004; 86: 15-21
        • Wright R.J.
        • Sledge C.B.
        • Poss R.
        • Ewald F.C.
        • Walsh M.E.
        • Lingard E.A.
        Patient-reported outcome and survivorship after Kinemax total knee arthroplasty.
        J Bone Joint Surg Am. 2004; 86: 2464-2470
        • Seil R.
        • Pape D.
        Causes of failure and etiology of painful primary total knee arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1418-1432
        • Ruiz Jr., D.
        • Koenig L.
        • Dall T.M.
        • et al.
        The direct and indirect costs to society of treatment for end-stage knee osteoarthritis.
        J Bone Joint Surg Am. 2013; 95: 1473-1480
        • Bozic K.J.
        • Rosenberg A.G.
        • Huckman R.S.
        • Herndon J.H.
        Economic evaluation in orthopaedics.
        J Bone Joint Surg Am. 2003; 85: 129-142
        • Drummond M.F.
        • Sculpher M.J.
        • Torrance G.W.
        • O'Brien B.J.
        • Stoddart G.L.
        Methods for the economic evaluation of health care programmes.
        3rd ed. Oxford Univ Pr, Oxford2005
        • Vavken P.
        • Bianchi T.
        In brief: cost-effectiveness analyses in orthopaedics.
        Clin Orthop Relat Res. 2011; 469: 2395-2398
        • Elmallah R.K.
        • Cherian J.J.
        • Jauregui J.J.
        • Bhowmik-Stoker M.
        • Beaver W.B.
        • Mont M.A.
        Determining health-related quality-of-life outcomes using the SF-6D preference-based measure in patients following total knee arthroplasty.
        J Arthroplasty. 2015; 30: 1150-1153
        • Pennington M.
        • Grieve R.
        • Sekhon J.S.
        • Gregg P.
        • Black N.
        • van der Meulen J.H.
        Cemented, cementless, and hybrid prostheses for total hip replacement: cost effectiveness analysis.
        BMJ. 2013; 346: f1026
        • Jenkins P.J.
        • Clement N.D.
        • Hamilton D.F.
        • Gaston P.
        • Patton J.T.
        • Howie C.R.
        Predicting the cost-effectiveness of total hip and knee replacement: a health economic analysis.
        Bone Joint J. 2013; 95: 115-121
        • Edlin R.
        • Tubeuf S.
        • Achten J.
        • Parsons N.
        • Costa M.
        Cost-effectiveness of total hip arthroplasty versus resurfacing arthroplasty: economic evaluation alongside a clinical trial.
        BMJ Open. 2012; 2: e00162
        • Fordham R.
        • Skinner J.
        • Wang X.
        • Nolan J.
        The economic benefit of hip replacement: a 5-year follow-up of costs and outcomes in the Exeter Primary Outcomes Study.
        BMJ Open. 2012; 2: e000752
        • Chang R.W.
        • Pellisier J.M.
        • Hazen G.B.
        A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip.
        JAMA. 1996; 275: 858-865
        • Pennington M.W.
        • Grieve R.
        • van der Meulen J.H.
        Lifetime cost effectiveness of different brands of prosthesis used for total hip arthroplasty: a study using the NJR dataset.
        Bone Joint J. 2015; 97: 762-770
        • Losina E.
        • Walensky R.P.
        • Kessler C.L.
        • et al.
        Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume.
        Arch Intern Med. 2009; 169: 1113-1121
        • Fineberg H.V.
        Shattuck lecture. A successful and sustainable health system—how to get there from here.
        N Engl J Med. 2012; 366: 1020-1027
        • Lingard E.A.
        • Katz J.N.
        • Wright E.A.
        • Sledge C.B.
        Predicting the outcome of total knee arthroplasty.
        J Bone Joint Surg Am. 2004; 86: 2179-2186
        • NIH Consensus Panel
        NIH consensus statement on total knee replacement Dec 8-10, 2003.
        J Bone Joint Surg Am. 2004; 86: 1328-1335
        • Jones D.L.
        • Westby M.D.
        • Greidanus N.
        • et al.
        Update on hip and knee arthroplasty: current state of evidence.
        Arthritis Rheum. 2005; 53: 772-780
        • Westby M.D.
        • Kennedy D.
        • Carr S.
        • Brander V.
        • Bell M.
        • Backman C.
        Post-acute physiotherapy for primary total hip arthroplasty (Protocol).
        Cochrane Database Syst Rev. 2006; : CD005957
        • Peter W.F.
        • Nelissen R.G.
        • Vliet Vlieland T.P.
        Guideline recommendations for post-acute postoperative physiotherapy in total hip and knee arthroplasty: are they used in daily clinical practice?.
        Musculoskeletal Care. 2014; 12: 125-131
        • Liebs T.R.
        • Herzberg W.
        • Ruther W.
        • Haasters J.
        • Russlies M.
        • Hassenpflug J.
        Ergometer cycling after hip or knee replacement surgery: a randomized controlled trial.
        J Bone Joint Surg Am. 2010; 92: 814-822
        • Liebs T.R.
        • Herzberg W.
        • Ruther W.
        • Haasters J.
        • Russlies M.
        • Hassenpflug J.
        Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty.
        Arch Phys Med Rehabil. 2012; 93: 192-199
        • Liebs T.R.
        • Herzberg W.
        • Gluth J.
        • et al.
        Using the patient's perspective to develop function short forms specific to total hip and knee replacement based on WOMAC function items.
        Bone Joint J. 2013; 95: 239-243
        • Moher D.
        • Schulz K.F.
        • Altman D.G.
        The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials.
        Lancet. 2001; 357: 1191-1194
        • Franklin P.D.
        • Allison J.J.
        • Ayers D.C.
        Beyond joint implant registries: a patient-centered research consortium for comparative effectiveness in total joint replacement.
        JAMA. 2012; 308: 1217-1218
        • Brazier J.
        • Roberts J.
        • Deverill M.
        The estimation of a preference-based measure of health from the SF-36.
        J Health Econ. 2002; 21: 271-292
        • Osnes-Ringen H.
        • Kvamme M.K.
        • Kristiansen I.S.
        • et al.
        Cost-effectiveness analyses of elective orthopaedic surgical procedures in patients with inflammatory arthropathies.
        Scand J Rheumatol. 2011; 40: 108-115
        • Tolley K.
        What are health utilities?.
        Hayward Medical Communications, London2009 (Report no. NPR09/1103)
        • Lawless B.M.
        • Greene M.
        • Slover J.
        • Kwon Y.M.
        • Malchau H.
        Does age or bilateral disease influence the value of hip arthroplasty?.
        Clin Orthop Relat Res. 2012; 470: 1073-1078
        • Sassi F.
        Calculating QALYs, comparing QALY and DALY calculations.
        Health Policy Plan. 2006; 21: 402-408
        • Little R.
        • Yau L.
        Intent-to-treat analysis for longitudinal studies with drop-outs.
        Biometrics. 1996; 52: 1324-1333
        • Saha C.
        • Jones M.P.
        Bias in the last observation carried forward method under informative dropout.
        J Stat Plan Inference. 2009; 139: 246-255
        • Federal Office of Statistics
        Mortality table of Germany 2008/10.
        Federal Office of Statistics, Wiesbaden2011
        • Dall T.M.
        • Gallo P.
        • Koenig L.
        • Gu Q.
        • Ruiz D.
        Modeling the indirect economic implications of musculoskeletal disorders and treatment.
        Cost Eff Resour Alloc. 2013; 11: 5
        • Kurtz S.
        • Ong K.
        • Lau E.
        • Mowat F.
        • Halpern M.
        Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
        J Bone Joint Surg Am. 2007; 89: 780-785
        • Garber A.M.
        • Phelps C.E.
        Economic foundations of cost-effectiveness analysis.
        J Health Econ. 1997; 16: 1-31
        • Detsky A.S.
        • Redelmeier D.A.
        Measuring health outcomes: putting gains into perspective.
        N Engl J Med. 1998; 339: 402-403
        • Bibbins-Domingo K.
        • Chertow G.M.
        • Coxson P.G.
        • et al.
        Projected effect of dietary salt reductions on future cardiovascular disease.
        N Engl J Med. 2010; 362: 590-599
        • Barton G.R.
        • Sach T.H.
        • Avery A.J.
        • Doherty M.
        • Jenkinson C.
        • Muir K.R.
        Comparing the performance of the EQ-5D and SF-6D when measuring the benefits of alleviating knee pain.
        Cost Eff Resour Alloc. 2009; 7: 12
        • Sach T.H.
        • Barton G.R.
        • Jenkinson C.
        • Doherty M.
        • Avery A.J.
        • Muir K.R.
        Comparing cost-utility estimates: does the choice of EQ-5D or SF-6D matter?.
        Med Care. 2009; 47: 889-894