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Original research
ACL reconstruction for all is not cost-effective after acute ACL rupture
  1. Vincent Eggerding1,
  2. Max Reijman1,
  3. Duncan Edward Meuffels1,
  4. Eline van Es1,
  5. Ewoud van Arkel2,
  6. Igor van den Brand3,
  7. Joost van Linge4,
  8. Jacco Zijl5,
  9. Sita MA Bierma-Zeinstra6,
  10. Marc Koopmanschap7
  1. 1 Orthopedics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
  2. 2 Orthopedics, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
  3. 3 Orthopedics, Elisabeth-TweeSteden Ziekenhuis, Tilburg, Noord-Brabant, The Netherlands
  4. 4 Orthopedics, Reinier de Graaf Gasthuis, Delft, Zuid-Holland, The Netherlands
  5. 5 Department of Orthopaedic Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
  6. 6 Department of General Practice and Orthopedics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
  7. 7 Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, Zuid-Holland, The Netherlands
  1. Correspondence to Dr Vincent Eggerding, Orthopedics, Erasmus Medical Center, Rotterdam 3000 CA, The Netherlands; v.eggerding{at}erasmusmc.nl

Abstract

Objectives To conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator).

Methods Patients aged between 18 and 65 years of age with a recent ACL rupture (<2 months) were randomised between either an early ACL reconstruction (index) or a rehabilitation plus an optional reconstruction in case of persistent instability (comparator) after 3 months of rehabilitation. A cost-utility analysis was performed to compare both treatments over a 2-year follow-up. Cost-effectiveness was calculated as incremental costs per quality-adjusted life year (QALY) gained, using two perspectives: the healthcare system perspective and societal perspective. The uncertainty for costs and health effects was assessed by means of non-parametric bootstrapping.

Results A total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective.

Conclusion Routine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.

  • anterior cruciate ligament
  • knee surgery
  • knee injuries
  • exercise rehabilitation
  • sports rehabilitation programs

Data availability statement

Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. We agree on data sharing to British Journal of Sports Medicine when required according to the World Health Organization and Nordic Trial Alliance declaration about clinical trial transparency.

https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

http://dx.doi.org/10.1136/bjsports-2020-102564

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    Data availability statement

    Data are available upon reasonable request. Data may be obtained from a third party and are not publicly available. We agree on data sharing to British Journal of Sports Medicine when required according to the World Health Organization and Nordic Trial Alliance declaration about clinical trial transparency.

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    Footnotes

    • Correction notice This article has been corrected since it published Online First. Reference 14 has been updated.

    • Contributors VE, SMAB-Z, DEM and MR conceived and designed the study. VE, EvE, DEM, EvA, IvdB, JvL and JZ assisted with recruitment of participants. VE and MK conducted the statistical analysis and interpretation of data. VE drafted the manuscript with input from MK, MR, SMAB-Z, DEM, EvE, EvA, IvdB, JvL, JZ. All authors have read and approved the final manuscript.

    • Funding Supported by ZonMW (grant # 171102006), commissioned by the Dutch Ministry of Health, Welfare, and Sport and the Netherlands Organization for Scientific Research.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

    • Provenance and peer review Not commissioned; externally peer reviewed.