Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review
Saltzman BM, Cvetanovich GL, Nwachukwu BU, Mall NA, Bush-Joseph CA, and Bach BR. American Journal of Sports Medicine. 2015; E pub ahead of print. April 30, 2015.
Take Home Message: Anterior cruciate ligament reconstruction (ACLR) using an autograft appears to have the best outcomes and minimal costs per year of improved quality of life in comparison to allograft or conservative management.
The number of anterior cruciate ligament reconstruction (ACLR) surgeries increased by 150% in the United States over a 12 year period (1994 to 2006). With rising healthcare costs, there is an increasing emphasis on the evidence behind medical procedures like ACLR and their cost-effectiveness. The authors of this systematic review investigated the factors that influence the cost of ACLR among studies published up to October 2014. Twenty-four studies were included in the analysis, including 6 directly comparing allo- versus auto-graft, 2 directly comparing hamstring versus patellar tendon autografts, 3 directly comparing double versus single bundle ACLR techniques, and 3 directly comparing ACLR versus conservative (rehab only). Five out of 6 studies indicated that allograft ACLR costs were generally higher than autograft – mostly because of higher operating room supply costs. There were inconsistent findings regarding costs affiliated with hamstring versus patellar tendon autograft costs. Single-bundle ACLR costs were lower than double-bundle ACLR with similar outcomes. All 3 studies found ACLR to be more cost-effective than conservative management providing $4890 per quality-adjusted life year (life year in good health added from intervention).
The authors of this study found that ACLR is cost-effective. This is especially true for autografts, which is largely driven by the lower operating room supply costs for autografts compared with allografts and previous research showing good patient outcomes. The authors also concluded that a double-bundle technique provided a better cost benefit over a single-bundle technique; however, this could be offset eventually if the number of ACLR revision surgeries decrease after double-bundle ACLR or if more studies find that a double-bundle ACLR offers better outcomes than a single-bundle ACLR. Over time, surgeons may become more effective/efficient with existing surgeries, which could lead to surgical choices, like the double-bundle ACLR, to become more cost effective. Furthermore, as technology continues to advance, there may be other options that prove to be highly cost-effective; however, at this point; an autograft ACLR surgery appears to have the best cost-benefit analysis. It would be interesting to see what the authors defined as successful in patient-reported outcomes for non-surgical/conservative management. Previously authors have reported that osteoarthritis rates are the same whether patients pursue non-surgical/conservative or ACLR management. It may be interesting to eventually consider the costs to a patient over his/her lifetime when we consider the long-term costs associated with work-related disability and treatment for chronic knee pain that many patients may experience 5-20 years after surgery. In the meantime, clinicians should educate their patients about the benefits/risks and be able to answer any questions that patients may have surrounding the many available ACLR options.
Questions for Discussion: Are there other factors that you think should be included in this analysis? Do you think that single bundle autograft ACLR is the best option for all strictly based on costs?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
ACL Graft Type May Not Matter When Attempting to Improve Patient Reported Outcomes 2 Years Post Surgery
Saltzman, B., Cvetanovich, G., Nwachukwu, B., Mall, N., Bush-Joseph, C., & Bach, B. (2015). Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review The American Journal of Sports Medicine DOI: 10.1177/0363546515581470