The Cost-Effectiveness Of Lateral Extra-Articular Tenodesis In Primary Anterior Cruciate Ligament Reconstruction


Nathan Varady, MD, MBA
UNITED STATES

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The Cost-Effectiveness Of Lateral Extra-Articular Tenodesis In Primary Anterior Cruciate Ligament Reconstruction

Nathan Varady, MD, MBA, UNITED STATES Jacob F. Oeding, MS, UNITED STATES Paul Inclan, UNITED STATES Andrew D. Pearle, MD, UNITED STATES Anil S. Ranawat, MD, UNITED STATES Sabrina M. Strickland, MD, UNITED STATES Scott A. Rodeo, MD, UNITED STATES Riley J. Williams, MD, UNITED STATES

Hospital for Special Surgery, New York, NY, UNITED STATES

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Anatomic Location

Knee

Anatomic Structure

Ligaments

Diagnosis / Condition

Tears Instability

Treatment / Technique

Repair / Reconstruction Autograft Failed

Ligaments

Anterolateral Ligament ACL

Sports Medicine

Economic Analysis Outcome Studies Research

Summary: In this Markov chain Monte Carlo based analysis, lateral extra-articular tenodesis (LET) augmentation to primary anterior cruciate ligament reconstruction was found to be highly cost-effective in the vast majority of clinical scenarios.

Background

Recent data have demonstrated favorable outcomes following anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) augmentation. However, the cost-effectiveness of this procedure compared to ACLR alone is unclear. The purpose of this study was to evaluate the cost-effectiveness of ACLR with LET augmentation in athletes with primary ACL ruptures compared to treatment with ACLR alone.

Methods

A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 athletes undergoing ACLR+LET (iliotibial band) compared to ACLR alone. Costs, utility values, graft failure rates, and transition probabilities were derived from existing literature. Targeted meta-analysis of failure rates and patient reported outcomes was performed. Model outcomes included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Sensitivity analyses assessed the cost-effectiveness of ACLR+LET across a range of clinical scenarios.

Results

Meta-analysis demonstrated a weighted graft failure rate of 5% (95% CI: 3%-9%) for ACLR+LET compared to 11% (95% CI: 7%-18%) for ACLR alone (relative risk 0.39, 95% CI: 0.27-0.57, p<0.001). Across a five-year treatment horizon, the mean total cost of ACLR alone was $68,605 ± $9,472 compared to $56,217 ± $7,349 for ACLR+LET. ACLR+LET was associated with an additional 1.88 ± 0.30 QALYs compared to 1.54 ± 0.30 QALYs for ACLR alone, and ACLR+LET was determined to be the preferred treatment in 98.1% of patients in the microsimulation model. In sensitivity analysis, ACLR+LET remained the most cost-effective treatment strategy with an ACLR+LET failure rate up to 11.3% or an ACLR alone failure rate down to 4.8%.

Conclusion

LET augmentation is a cost-effective treatment option for athletic patients undergoing primary ACLR. The results of this Monte Carlo microsimulation suggest that ACLR+LET yields both superior outcomes and lower overall costs than ACLR alone. In sensitivity analysis, we found that only small improvements in graft failure rates were required for LET augmentation to be the favored treatment, suggesting that LET may be a cost-effective treatment option when used even beyond the highest risk athletes.

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