A Cost-Effectiveness Analysis of the Addition of Autograft Lateral Extra-Articular Procedures to Primary Anterior Cruciate Ligament Reconstruction.

BACKGROUND

Multiple clinical studies have highlighted the improved outcomes of ACLR in associated with LEAPs. However, such procedures are associated with increased costs and operating room time, thus questioning their cost-effectiveness.

PURPOSE: To evaluate the cost-effectiveness of augmenting an anterior cruciate ligament reconstruction (ACLR) with autograft lateral extra-articular procedures (LEAP), either a modified Lemaire or anterolateral ligament reconstruction.

STUDY

DESIGN

Economic and decision analysis; Level of evidence, 3.

METHODS

A cost-effectiveness analysis was developed using failure rates for ACLR with and without concomitant autograft LEAPs from existing level 1 and 2 studies. Institutional data were used to estimate costs, including hospital and surgeon fees for ACLR and additional implant costs for LEAP. Utility measures were derived by linear approximation of the European Quality of Life 5 Dimension from the Knee injury and Osteoarthritis Outcome Score to evaluate improvements in quality-adjusted life years (QALY), a standardized metric that combines quantity and quality of life into a single value, over 1 year. Cost-effectiveness was determined based on previous literature, with an intervention considered cost-effective if the incremental cost-effectiveness ratio (ICER) was <$50,000/QALY. Three 1-way sensitivity analyses were conducted to assess the effect of implant cost, LEAP failure rates, and surgical time on cost-effectiveness.

RESULTS

The total cost of an isolated ACLR was estimated at $14,000, increasing to $14,990 with LEAP augmentation. Cost-effectiveness analysis showed an ICER of $25,313/QALY with LEAP augmentation, remaining below the $50,000/QALY cost-effectiveness threshold. Implant costs could rise to $1265 while maintaining cost-effectiveness, given an LEAP operation time (OR) of 15 minutes. Additionally, the failure rate of LEAP-augmented ACLR could increase from 2.9% to 7.7% while still meeting cost-effectiveness criteria. Finally, time sensitivity analysis indicated that for the procedure to remain cost-effective, the maximum allowable additional operative time is 36 minutes, given an OR cost of $46/minute.

CONCLUSION

Although LEAP increases the time and cost of ACLR, it remains a cost-effective strategy for patients who are suitable candidates for augmentation.