Early ACL surgery is less costly, more effective than rehabilitation and delayed reconstruction

“Fix it Now” Best for ACL tears.

Former Dallas Texans player Christina Gordon (wearing brace) gave up club soccer after breaking her femur and tearing the ACL in both knees over a three-year span with the Texans. Dallas Morning News

Jonathan S. Batchelor, Medscape Orthopedics August 10, 2012

Benefits of Early Action

Early anterior cruciate ligament (ACL) reconstruction demonstrated it was both less costly and more effective than rehabilitation and optional delayed reconstruction, according to work presented during the 2012 American Orthopaedic Society for Sports Medicine conference in Baltimore, Maryland this July.

“The significance of our study is that early surgical intervention actually may be less costly,” said Richard C. Mather III MD, commenting on the research, which was also a sports medicine/arthroscopy poster award winner at the American Academy of Orthopaedic Surgeons meeting in February.

The inspiration for the team’s work was the KANON (Knee Anterior Cruciate Ligament, Nonsurgical versus Surgical Treatment) study,[B,F] said Dr. Mather, an Associate Professor in the Division of Sports Medicine, Department of Orthopaedic Surgery at Duke University Medical Center in Durham, North Carolina.

The primary outcome in the KANON trial was the change from baseline to 2 years in the average score on 4 subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) — pain, symptoms, function in sports and recreation, and knee-related quality of life.

The randomized controlled trial [1] (compared early ACL reconstruction with rehabilitation and optional delayed reconstruction and found no difference in outcome, by an intention-to-treat analysis of KOOS.

“That conclusion has a lot of implications for healthcare delivery and access to care,” Mather said. “I felt that it was incomplete because there was no economic analysis of those two interventions.”

Mather’s group used a Markov decision model to conduct a cost-utility analysis of early ACL reconstruction vs rehabilitation and optional delayed ACL reconstruction, using data from the KANON study [B,C] (121 young, active adults with acute ACL injury) and the Multicenter Orthopaedic Outcomes Network (MOON).[H,I,K,L,M]

The MOON project follows patients after ACL reconstruction. The National Institutes of Health-funded consortium consists of sports medicine physicians across 7 sites and has been able to attain over 85% follow-up, at both 2 and 6 years after surgery, from more than 2500 enrolled patients since 2002.

Estimating Costs

Mather’s team estimated costs, from a societal perspective, using the national average Medicare reimbursement for the procedures in 2011 US dollars. ACL reconstruction plus postoperative rehabilitation averaged $8200; nonoperative rehabilitation as outlined in the KANON trial cost $3800.

Researchers measured utility by the SF-6D — a classification used for describing health that allows an analyst to obtain quality-adjusted life years (QALYs) for use in cost-utility analyses. The team examined symptomatic instability, whether patients’ knees were reported stable, delayed ACL reconstruction 10 weeks to 2 years after injury, delayed ACL reconstruction performed 2-6 years after injury, and disutility of ACL reconstruction as their SF-6D utility set.

The principal outcome measures of the analysis were average incremental costs, incremental effectiveness, incremental QALYs, and net health benefits. Mather said that willingness to pay was set at $50,000, the currently accepted US standard.

The researchers reported that, in their base case, early ACL reconstruction resulted in an incremental gain of 0.32 QALYs over rehabilitation and delayed ACL reconstruction and at a lower overall cost to society of $1006. Using only data from the MOON project, they found that effectiveness gains were driven by the low utility of an unstable knee and the lower utility of a delayed ACL reconstruction vs an early ACL reconstruction.

“The decreased cost of early ACL reconstruction was driven largely by the cost of rehabilitation, 37% of patients choosing the optional delay reconstruction and 38 other surgeries for the 60 patients in the delayed ACL reconstruction [arm] of the KANON trial,” the researchers wrote.

Mather noted that the most influential variable was the rate of knee instability (71% probability) after rehabilitation.

Damage From Inaction

“I’ve seen patients who have chronic ACL tears who either decide not to have them fixed — for whatever reason — and decide to wait, or they had to wait because they just couldn’t get it fixed at the present time and they had a significant increase in incidence of meniscal and cartilage injury as a result of instability,” said Matthew J. Matava MD, commenting on the study.

Matava has seen a number of ACL tears, both in his work as Professor of Orthopedic Surgery and Physical Therapy at Washington University School of Medicine in St. Louis, Missouri, as well as team physician for the National Football League’s St. Louis Rams and National Hockey League’s St. Louis Blues.

“It’s sort of one of those ‘pay me now or pay me later’ scenarios that we hear from a car mechanic,” he noted. “Either we pay up front by having surgery with the goal to save further damage down the line or you can decide to wait and take your chances. Unfortunately, a significant number of people [in this group] are still going to need surgery.”

Early ACL reconstruction is “not an all-or-nothing proposition,” Mather said. Although he and his colleagues found it to be both less costly and more effective than rehabilitation and optional delayed ACL reconstruction, he does not advocate a one-size-fits-all treatment paradigm for ACL tears.

“Early ACL reconstruction is an excellent treatment option, but it also calls for flexible decision making,” he stated. “There are patients that will do well with delayed reconstruction and there are a lot that will do well with earlier reconstruction.”

Source Medscape

  1. A randomized trial of treatment for acute anterior cruciate ligament tears, Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. N Engl J Med. 2010 Jul 22;363(4):331-42. doi: 10.1056/NEJMoa0907797. Erratum in: N Engl J Med. 2010 Aug 26;363(9):893. Full text
  Further reading
  1. Impact of treatment strategy and physical performance on future knee-related self-efficacy in individuals with ACL injury, Flosadottir V, Frobell R, Roos EM, Ageberg E. BMC Musculoskelet Disord. 2018 Feb 13;19(1):50. doi: 10.1186/s12891-018-1973-2. Full text
  2. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial, Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Br J Sports Med. 2017 Nov;51(22):1622-1629. doi: 10.1136/bjsports-2016-097124. Epub 2017 May 17. Full text
  3. Lower extremity performance following ACL rehabilitation in the KANON-trial: impact of reconstruction and predictive value at 2 and 5 years, Ericsson YB, Roos EM, Frobell RB. Br J Sports Med. 2013 Oct;47(15):980-5. doi: 10.1136/bjsports-2013-092642. Full text
  4. No economic benefit of early knee reconstruction over optional delayed reconstruction for ACL tears: registry enriched randomised controlled trial data, Kiadaliri AA, Englund M, Lohmander LS, Carlsson KS, Frobell RB. Br J Sports Med. 2016 May;50(9):558-63. doi: 10.1136/bjsports-2015-095308. Epub 2016 Mar 2.
  5. Surgical versus conservative interventions for treating anterior cruciate ligament injuries, Monk AP, Davies LJ, Hopewell S, Harris K, Beard DJ, Price AJ. Cochrane Database Syst Rev. 2016 Apr 3;4:CD011166. doi: 10.1002/14651858.CD011166.pub2. Review. Full text
  6. Cost-Effectiveness Analysis of Early Reconstruction Versus Rehabilitation and Delayed Reconstruction for Anterior Cruciate Ligament Tears, Mather RC 3rd, Hettrich CM, Dunn WR, Cole BJ, Bach BR Jr, Huston LJ, Reinke EK, Spindler KP. Am J Sports Med. 2014 Jul;42(7):1583-91. doi: 10.1177/0363546514530866. Epub 2014 May 6. Full text
  7. Preoperative patient and injury factors of successful rehabilitation after anterior cruciate ligament reconstruction with single-bundle techniques, de Valk EJ, Moen MH, Winters M, Bakker EW, Tamminga R, van der Hoeven H. Arthroscopy. 2013 Nov;29(11):1879-95. doi: 10.1016/j.arthro.2013.07.273. Review.
  8. Societal and economic impact of anterior cruciate ligament tears, Mather RC 3rd, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, Bach BR Jr, Spindler KP; MOON Knee Group. J Bone Joint Surg Am. 2013 Oct 2;95(19):1751-9. doi: 10.2106/JBJS.L.01705. Full text
  9. The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort, Hettrich CM, Dunn WR, Reinke EK; MOON Group, Spindler KP. Am J Sports Med. 2013 Jul;41(7):1534-40. doi: 10.1177/0363546513490277. Epub 2013 May 30. Full text
  10. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial, Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. BMJ. 2013 Jan 24;346:f232. doi: 10.1136/bmj.f232. Full text
  11. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction? A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts, Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, Huston LJ, Spindler KP, Snyder-Mackler L. Am J Sports Med. 2016 Oct;44(10):2608-2614. Epub 2016 Jul 14. Erratum in: Am J Sports Med. 2017 Apr;45(5):NP9. Full text
  12. Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR Cohort Study, Dunn WR, Spindler KP, Amendola A, Andrish JT, Kaeding CC, Marx RG, McCarty EC, Parker RD, Harrell FE Jr, An AQ, Wright RW, Brophy RH, Matava MJ, Flanigan DC, Huston LJ, Jones MH, Wolcott ML, Vidal AF, Wolf BR; MOON ACL Investigation. Am J Sports Med. 2010 Sep;38(9):1778-87. doi: 10.1177/0363546510370279. Epub 2010 Jul 1. Full text
  13. Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study, Dunn WR, Spindler KP; MOON Consortium. Am J Sports Med. 2010 Oct;38(10):2040-50. doi: 10.1177/0363546510370280. Epub 2010 Aug 13. Full text

Also see
Cost-benefit data support reconstruction of ACL tears in Lower Extremity Review
Long-term Data Reveal Rate and Risk Factors for Subsequent Surgeries Following Initial ACL Reconstruction in National Institute of Arthritis and Musculoskeletal and Skin Diseases NIAMS

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