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In an interesting article by Eggerding et al,1 the authors conducted a cost-utility analysis for two treatment strategies for patients who sustain an anterior cruciate ligament (ACL) tear; early ACL reconstruction versus rehabilitation plus an optional reconstruction in case of persistent instability. The randomised controlled study included patients with ACL tear aged 18–65 years. The authors found that it takes 48460 € from a healthcare perspective and 78179 € from a societal perspective to gain a quality-adjusted life year (QALY) when performing early surgery compared with rehabilitation plus optional reconstruction. How much are we willing to pay to gain a QALY, and what is the best way to use limited resources? Most previous studies have focused on patient function and satisfaction, and with increasing economic burden in most countries, studies such as this one evaluating cost-utility are necessary.
The clinical problem
Anterior cruciate ligament reconstruction (ACL-R) is one of the most commonly performed procedures in orthopaedic sports medicine. Increased sports participation and training load in the youth, and the desire to stay active into old age are among the factors that have contributed to the increased injury burden. The number of ACL-R procedures has increased in the last two decades in most countries in the western world. It is also possible that advances in surgical techniques have led to an increased number of ACL-R. The goal of ACL-R is to restore joint stability and return patients to preinjury physical activities and levels of function. Other arguments for early ACL-R are to protect the menisci and articular cartilage, hence preserving the general joint health and possibly preventing or delaying the development of early osteoarthritis (OA).2 3 However, there is currently no evidence to support that ACL-R prevents the development of early OA.4 5
The evidence for change—why rehabilitation first?
Several studies have demonstrated that up to 40% of patients function well with a torn ACL.6 Determining which patients may have good outcomes without surgery at the time of injury is challenging. Rehabilitation before ACL-R (prehab) has been reported to significantly improve outcomes and rates of return to play compared with no rehabilitation.7 This suggests that rehabilitation after ACL tear may help identify patients who may not need surgery, and also increase the likelihood of good functional outcomes and return to play for patients who ultimately undergo ACL-R. Rehabilitation after ACL tear with the option of ACL-R in cases of persistent instability has been demonstrated to provide good outcomes.8 It is also important to understand that surgery is an intervention associated with complications, including infection, joint stiffness, pain and persistent instability, which are detrimental to joint function and health. Furthermore, it has been reported that only 63% of patient with ACL-R return to preinjury levels after reconstruction.9 In a study based on the Norwegian and Swedish Knee Ligament Registries, Snaebjörnsson et al reported that patients undergoing ACL-R within 3 months of injury had a higher risk of ACL revision.10 This paper by Eggerding et al 1 shows that early surgery is not cost effective, and provides another reason to consider rehabilitation before performing surgery. However, these advantages should be weighed against the risk of sustaining meniscal and chondral injuries due to persistent instability, both of which negatively influence outcomes after ACL surgery.
The argument against change—why early surgery makes sense?
In the study by Eggerding et al, patients were either treated early or underwent 3 months of rehabilitation, with an option to undergo ACL-R if there was persistent instability. Unfortunately, all patients may not have access to the high level rehabilitation and follow-up provided in this study, making it difficult to apply in real life. Whether a patient with ACL tear can undergo rehabilitation first depends also on concomitant injuries, especially meniscus injuries. Meniscus tears have been shown to influence outcomes after ACL-R and are positively correlated to the risk of developing OA.2 3 Early surgery for ACL tears with concomitant displaced bucket-handle meniscus tears, radial tears and meniscal root tears is recommended in order to restore more normal joint loading and stability. Additionally, Eggerding et al 1 found that the patients who fail non-operative treatment and undergo consequential ACL-R have the lowest quality of life and highest costs. Our experience caring for competitive and elite athletes is consistent with this finding and a driver of early surgical intervention in patients who plan to engage in cutting and pivoting sports.
How should we change our practice on anterior cruciate ligament reconstruction?
Shared decision-making on treatment options and managing expectations is important in this era where information is readily available on the internet. The study by Eggerding et al 1 adds valuable information for doctors, patients and policy-makers. By demonstrating a significant cost difference between early ACL-R versus a rehabilitation first approach, we have a better understanding of the cost and value of two different treatment strategies for ACL tears. However, predicting which patient will benefit most from which strategy is difficult, and the identification of patient factors to support one approach over the other is a needed area of future research. To operate early is the most costly but also might enable repair of the menisci and cartilage, and possibly avoid quality of life detriments in patients who try but fail rehabilitation. To rehabilitate and operate late (if needed) can save cost and potentially avoid surgery, but if it fails, this approach is the most expensive and possibly the longest route to restore full function. Through informed decision-making, surgeons must be open to individualise treatment and partner with their patients to select the best option.
Ethics statements
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Footnotes
Twitter @GilbertMoatshe, @larsengebretsen
Contributors All authors (GM, CK, AG and LE) have contributed substantially to this work and meet the ICMJE criteria. They have all made substantial contributions to the conception of the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests GM: editorial board—Journal of Arthroscopy. Committee Member—ISAKOSLE: Acta Orthopaedica: Editorial or governing board, American Orthopaedic Society for Sports Medicine: Board or committee member. Arthrex: IP royalties; paid consultant; research support. Biomet: research support. BJSM: publishing royalties, financial or material support. ESSKA: board or committee member. iBalance: stock or stock options. International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine: board or committee member. Journal of Bone and Joint Surgery—American: editorial or governing board. Knee: editorial or governing board. Knee Surgery, sports traumatology, arthroscopy: editorial or governing board. Smith and Nephew: research support.
Provenance and peer review Commissioned; externally peer reviewed.