Economic Analyses in Anterior
Cruciate Ligament Reconstruction: A Qualitative and Systematic Review

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. 

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?

Nicole Cattano
by: Jeffrey Driban

Related Posts:

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