Abstract
Background
The decision whether to treat conservatively or reconstruct surgically a torn anterior cruciate ligament (ACL) is an ongoing subject of debate. The high prevalence and associated public health burden of torn ACL has led to continuous efforts to determine the best therapeutic approach. A critical evaluation of benefits and expenditures of both treatment options as in a cost effectiveness analysis seems well-suited to provide valuable information for treating physicians and healthcare policymakers.
Methods
A literature review identified four of 7410 searched articles providing sufficient outcome probabilities for the two treatment options for modeling. A transformation key based on the expert opinions of 25 orthopaedic surgeons was used to derive utilities from available evidence. The cost data for both treatment strategies were based on average figures compiled by Orthopaedic University Hospital Balgrist and reinforced by Swiss national statistics. A decision tree was constructed to derive the cost-effectiveness of each strategy, which was then tested for robustness using Monte Carlo simulation.
Results
Decision tree analysis revealed a cost effectiveness of 16,038 USD/0.78 QALY for ACL reconstruction and 15,466 USD/0.66 QALY for conservative treatment, implying an incremental cost effectiveness of 4,890 USD/QALY for ACL reconstruction. Sensitivity analysis of utilities did not change the trend.
Conclusion
ACL reconstruction for reestablishment of knee stability seems cost effective in the Swiss setting based on currently available evidence. This, however, should be reinforced with randomised controlled trials comparing the two treatment strategies.
Background
Rupture of the anterior cruciate ligament (ACL) changes the kinematics of the knee1 and often results in instability with accompanying functional disability and pain2-22. Although there are more than 2000 scientific articles in the literature23 illuminating several aspects of ACL rupture, there is no consensus on the optimal treatment. Whereas some authors reported adequate outcomes after operative treatment using various techniques8,13,24-44, others documented sufficient clinical results after conservative treatment with various protocols of immobilisation and physiotherapy4,45-64. Although several instruments and scoring systems65-69 have been developed to facilitate standardised reporting and comparison of differently treated patients, decision towards one or the other, namely, conservative or surgical treatment seems currently challenging14 due to lack of randomised controlled trials with information on long-term results70.
Most surgeons advocate ACL reconstruction for patients with ACL rupture associated with subjective instability whereas some orthopaedic surgeons routinely favor conservative treatment of ACL ruptures. Thus there is still controversy on this common injury with an estimated incidence of approximately 1500/100,000 person-years in Switzerland, 1200/100,000 person-years in New Zealand71, and 3000/100,000 person-years in the United States23. The occurrence of ACL ruptures depends on sex, age, and sports activities of those affected72. The Swiss National Insurance System for Injuries (UVG), which covers half the Swiss population, provides around 200-250 million US dollars equivalent yearly for patients with ACL injuries, including 40% of direct treatment costs.
A critical evaluation of benefits and expenditures of the two treatment options so as to provide valuable information for treating physicians and healthcare policymakers is in progress. T