Summary
Lateral extra-articular procedure (LEAP) augmentation of anterior cruciate ligament reconstruction (ACLR) is cost-effective in comparison to its isolated counterpart.
Abstract
Purpose
The purpose of the present investigation is 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 (ALLR).
Methods
A cost-effectiveness analysis (TreeAge Software, Williamstown, MA, USA) was developed using failure rates for ACLR with and without concomitant LEAPs from existing level I-II literature. 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 EQ-5D (European Quality of Life 5 Dimension) from KOOS (Knee Injury and Osteoarthritis Outcome Score) to evaluate improvements in quality-adjusted life years (QALY) over a one-year postoperative period. Cost-effectiveness was determined based on prior literature, considering an intervention cost-effective if the incremental cost-effectiveness ratio (ICER) was below $50,000/QALY. Three, one-way sensitivity analyses were conducted to assess the impact of surgical time, implant cost, and LEAP failure rates on cost-effectiveness.
Results
The total cost of an isolated ACLR was estimated at $12,000, increasing to $12,300 with LEAP augmentation. Cost-effectiveness analysis showed an incremental cost-effectivness ratio (ICER) of $22,544/QALY with LEAP augmentation, remaining below the $50,000/QALY cost-effectiveness threshold. Time sensitivity analysis indicated that for the procedure to remain cost-effective, the maximum allowable operative time is 41 minutes, given an OR cost of $46/minute (Figure 1). Additionally, implant costs could rise to $1,505 while maintaining cost-effectiveness, given an LEAP OR time of 15 minutes (Figure 2). Finally, the failure rate of LEAP-augmented ACLR could increase from 2.9 to 8.0% and still meet cost-effectiveness criteria (Figure 3).
Conclusion
Although lateral extra-articular procedures increase the time and cost of ACL reconstruction, they remain a cost-effective strategy for patients who are suitable candidates for augmentation.