Economic Analyses in Anterior Cruciate Ligament Reconstruction: A Qualitative and Systematic Review

Effects of preoperative treatment on healthcare utilization and return to work for anterior cruciate ligament injuries: a real-world study using the French healthcare database

OBJECTIVE

To compare healthcare use and the number of days of sickness benefits between people with anterior cruciate ligament (ACL) injury who received physiotherapy before and after ACL reconstruction (ACLR) and those who received physiotherapy after ACLR only. Secondary aim: to measure the association between the volume of preoperative healthcare and post-ACLR recovery.

METHODS

Each individual's care pathway was extracted from a section of the French National Health Data System (SNDS) database (province: Pays de La Loire). The database was queried for the codes related to sickness benefits and healthcare utilization, including physiotherapy, medical and paramedical visits and procedures, medication, and medical equipment provided up to six months before and eighteen months after the ACLR. (Registry/number: ClinicalTrials.gov/NCT05737719).

RESULTS

Based on the timing of physiotherapy, two subcohorts were created from the database: 'prehabilitation' (n = 513) for those receiving physiotherapy before and after ACLR; 'no prehabilitation' (n = 630) for those only receiving physiotherapy after ACLR. Before ACLR, healthcare use was higher for the 'prehabilitation' group, including the number of medical visits (3.9 ± 2.3 vs. 3.0 ± 1.9 univariate p < 0.001), analgesia (mild opioids 60.4% vs. 49.8% univariate p < 0.001), dispensing of medical equipment (85.0% vs. 68.9% univariate p < 0.001) and sickness benefit days (52.7 ± 45.6 days vs. 33.2 ± 35.8 days, univariate p < 0.001). After ACLR, the 'prehabilitation' group underwent a higher number of physiotherapy sessions (46.8 ± 21.9 sessions vs 35.8 ± 19.0 sessions, p < 0.001) but had a similar number of sickness benefit days (94.7 ± 77.8 days vs 87.1 ± 69.9 days, p = 0.092). From the multivariate analysis (n = 1143): age, comorbidities, the preoperative number of sickness benefit days, and the number of physiotherapy sessions before ACLR explained 24% of the variance in days of sickness benefits after ACLR.

CONCLUSION

Prehabilitation was associated with higher healthcare utilization before and after ACLR. Prehabilitation, and other preoperative variables, explained only a part of the number of days of sickness benefits after ACLR.

One-stage revision anterior cruciate ligament reconstruction: Preoperative evaluation, planning and surgical techniques. A review of current concepts

The increased rate of anterior cruciate ligament (ACL) tears has led to a greater number of revisions. Revision surgery can be performed in one or two stages. Single-stage revision ACL reconstruction (ssRACLR) may be performed when prior tunnels can be re-used or bypassed whereas a two-stage procedure is indicated when bone grafting of dilated tunnels prior to revision is necessary. While both approaches have shown similar functional outcomes and failure risk, ssRACLR is preferred, when possible, to avoid the increased morbidity, inconvenience and cost associated with two-stage RACLR. In adequately planning for RACLR, a surgeon should investigate the mechanism and timing of injury as well as the previous graft selection, associated pathology and the tunnel placement and size. It is especially important to obtain radiographs and three-dimensional imaging including magnetic resonance imaging (MRI) and computed tomography (CT), which allow the surgeon to accurately evaluate the entire tunnel architecture to determine surgical staging. Following a detailed assessment of the pathoanatomy, the surgeon may determine graft and hardware type, tunnel placement and utilization of lateral extra-articular tenodesis (LET) and other procedures. In our experience, ssRACLR can be carried out for over 90% of revision cases with creative pre-operative planning using autograft with bone plug(s), divergent tunnel creation on the femur (when necessary) and convergent tunnel creation on the tibia (when appropriate) and suspensory or interference fixation as needed. In revision scenarios, we believe that autografts with bone plugs provide the best opportunity for graft healing and incorporation and that LET can be a useful adjunct to reduce re-tear rates. The purpose of this review is to report on the preoperative considerations and surgical techniques for performing ssRACLR, as well as the outcomes.

Level of Evidence

Level V expert opinion.

Increased Visual Attentional Demands Alter Lower Extremity Sidestep Cutting Kinematics in Male Basketball Players

Background

In basketball, changing direction is one of the primary mechanisms of anterior cruciate ligament (ACL) injury, often occurring within complex game situations with high cognitive demands. It is unknown how visual attention affects sidestep cutting kinematics during the entire energy absorption phase of the cut in an ecologically valid environment.

Purpose

The purpose of this research was to study the effect of added cognitive load, in the form of increased visual attentional demands, on sidestep cutting kinematics during the energy absorption phase of the cut in an ecologically valid environment.

Study Design

Crossover Study.

Methods

Fifteen male basketball players (aged 22.1 ± 2.3) performed ten sidestep cutting movements without (BASE) and with (VIS) a visual attention dual task. 3D kinematics of the hip, knee and ankle were recorded utilizing Xsens IMU motion capture. Temporal kinematics were analyzed using Statistical Parametric Mapping. Discrete time point kinematics were additionally analyzed at initial contact (IC) and at peak knee flexion utilizing paired t-tests. Effect sizes were calculated.

Results

Hip flexion was significantly reduced in the VIS condition compared to the BASE condition (p<0.01), including at IC (VIS 35.0° ± 7.2°, BASE 40.7° ± 4.9°, p=0.02, d=0.92) and peak (VIS 37.8° ± 9.7°, BASE 45.5° ± 6.9°, p=0.001, d=0.90). Knee flexion was significantly reduced in the VIS condition, in comparison to the BASE condition (p<0.01), at peak (VIS 59.9° ± 7.5°, BASE 64.1° ± 7.4°, p=0.001, d=0.55).

Conclusion

The addition of visual attention during sidestep cutting altered lower limb kinematics, which may increase ACL injury risk. It is suggested that ACL injury risk screening and prevention should include sidestep cutting with visual attentional demands, in order to mimic the cognitive demands of the sports environment.

Level of Evidence

3.

The Posteromedial Approach for Harvesting Hamstring Autografts Results in Fewer Incidents of Saphenous Nerve Injury Compared to the Conventional Anteromedial Approach: A Systematic Review and Meta-Analysis

Background

The hamstring autograft can be harvested using various skin incisions, such as vertical, transverse, and oblique incisions, and from different localizations, including anteromedial and posteromedial harvest sites. The aim of this study was to compare studies on the anteromedial and posteromedial approaches for hamstring autograft harvest in terms of clinical outcomes, saphenous nerve injury, infection, operative time, graft length, incision length, range of motion, and patient satisfaction.

Methods

Following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a search was conducted in PubMed and Scopus, focusing on studies comparing anteromedial and posterior approaches for hamstring harvest. This study was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42023450249). Methodological quality was evaluated using the Modified Coleman Methodology Score. Odds ratios (ORs) and mean differences (MDs) quantified dichotomous and continuous outcomes, respectively.

Results

Five articles, involving 405 knees, underwent analysis. Four studies were level 3 evidence, while 1 was level 1. The anteromedial hamstring harvest showed higher rates of saphenous nerve injury (OR, 9.77; 95% confidence interval [CI], 2.19-43.65; p = 0.003) and longer operative times, with an MD of about 13 minutes (MD, 13.33; 95% CI, 0.68-25.97; p = 0.04), compared to the posteromedial approach. The anteromedial method yielded a longer semitendinosus graft, with an MD of about 17 mm (MD, 17.57; 95% CI, 7.17-27.98; p = 0.0009). However, no significant differences existed in range of motion, flexion contracture, unintentional graft harvest, infection rates, and patient-reported outcomes. Notably, the posteromedial group reported higher cosmetic satisfaction, with 92% being very satisfied, compared to the anteromedial group with 80% (p = 0.005). However, overall satisfaction levels were similar between the 2 groups (p = 0.35), with a very satisfied rate of 72% for the anteromedial group and 78% for the posteromedial group.

Conclusions

The anteromedial hamstring harvest showed greater saphenous nerve injury and longer operative times compared to the posteromedial approach, along with a longer graft. However, no significant differences were observed in the range of motion, flexion contracture, graft harvest, infection, or patient outcomes.

Value-Based, Environmentally Sustainable Anterior Cruciate Ligament Surgery

Orthopedic surgeons are increasingly recognizing the broader societal impact of their clinical decisions, which includes value-based and environmentally sustainable care. Within anterior cruciate ligament reconstruction, value-based care-or most cost-effective care-includes an outpatient surgical setting with regional anesthesia, use of autograft, meniscus repair when indicated, and use of traditional metal implants such as interference screws and staples. Environmentally sustainable care includes slimming down surgical packs and trays to avoid opening unnecessary equipment, avoiding desflurane as an inhaled anesthetic agent, and minimizing waste in the operating room-a priority that addresses both cost and environmental impact.

The Role of Artificial Intelligence in Anterior Cruciate Ligament Injuries: Current Concepts and Future Perspectives

The remarkable progress in data aggregation and deep learning algorithms has positioned artificial intelligence (AI) and machine learning (ML) to revolutionize the field of medicine. AI is becoming more and more prevalent in the healthcare sector, and its impact on orthopedic surgery is already evident in several fields. This review aims to examine the literature that explores the comprehensive clinical relevance of AI-based tools utilized before, during, and after anterior cruciate ligament (ACL) reconstruction. The review focuses on current clinical applications and future prospects in preoperative management, encompassing risk prediction and diagnostics; intraoperative tools, specifically navigation, identifying complex anatomic landmarks during surgery; and postoperative applications in terms of postoperative care and rehabilitation. Additionally, AI tools in educational and training settings are presented. Orthopedic surgeons are showing a growing interest in AI, as evidenced by the applications discussed in this review, particularly those related to ACL injury. The exponential increase in studies on AI tools applicable to the management of ACL tears promises a significant future impact in its clinical application, with growing attention from orthopedic surgeons.

Autograft patellar bone-tendon-bone use does not increase operative time in anterior cruciate ligament reconstruction

Background

Anterior cruciate ligament reconstruction (ACLR) is a common procedure that has been shown to have relatively good outcomes amongst various graft types. Operative time in ACLR has been found to influence outcomes and cost. The purpose of this study was to evaluate the association of operative time in primary arthroscopically performed anterior cruciate ligament reconstruction (ACLR) and graft type while controlling for confounders that influence time.

Methods

All patients who received ACLR between 2018 and 2022 were included in this retrospective cohort study. Exclusion criteria consisted of age (≤16 years), revisions, concomitant ligament reconstruction or tendon repairs, or other simultaneously performed procedures that could potentially add substantial variation in operative time. The primary outcome was operative time. Graft types included allograft, bone-tendon-bone (BTB) autograft, hamstring tendon (HS) autograft and quadriceps tendon (QT) autograft.

Results

A total of 1813 primary ACLRs were included. The average operative time was 98.9 ± 33.0 min. Graft utilization varies considerably among surgeons. The most used graft type was BTB autograft (42.6%) followed by HS autograft (32.3%) and allograft (21.4%). Only 68 cases (3.8%) used a QT autograft. Seven of the 15 included surgeons primarily used BTB autograft. One surgeon predominately used QT autograft. No difference in operative time was observed among the autograft types (p = 0.342). Allograft ACLR was significantly faster by 27-33 min compared to using BTB autograft, HS autograft, or QT autograft (p < 0.001).

Conclusion

Operative time did not vary by type of autograft selected. Allograft ACLR was performed approximately 30 min faster than autograft ACLR. Further studies examining the effect on patient outcomes of reduced operative time and minimizing graft harvest morbidity in ACLR is important to more accurately determine the cost-effectiveness of allograft ACLR.

Management of Bone Loss and Tunnel Widening in Revision ACL Reconstruction

➤ Both mechanical and biological factors can contribute to bone loss and tunnel widening following primary anterior cruciate ligament (ACL) reconstruction.➤ Revision ACL surgery success is dependent on graft position, fixation, and biological incorporation.➤ Both 1-stage and 2-stage revision ACL reconstructions can be successful in correctly indicated patients.➤ Potential future solutions may involve the incorporation of biological agents to enhance revision ACL surgery, including the use of bone marrow aspirate concentrate, platelet-rich plasma, and bone morphogenetic protein-2.

Can Wearable Sensors Provide Accurate and Reliable 3D Tibiofemoral Angle Estimates during Dynamic Actions?

The ability to accurately measure tibiofemoral angles during various dynamic activities is of clinical interest. The purpose of this study was to determine if inertial measurement units (IMUs) can provide accurate and reliable angle estimates during dynamic actions. A tuned quaternion conversion (TQC) method tuned to dynamics actions was used to calculate Euler angles based on IMU data, and these calculated angles were compared to a motion capture system (our "gold" standard) and a commercially available sensor fusion algorithm. Nine healthy athletes were instrumented with APDM Opal IMUs and asked to perform nine dynamic actions; five participants were used in training the parameters of the TQC method, with the remaining four being used to test validity. Accuracy was based on the root mean square error (RMSE) and reliability was based on the Bland-Altman limits of agreement (LoA). Improvement across all three orthogonal angles was observed as the TQC method was able to more accurately (lower RMSE) and more reliably (smaller LoA) estimate an angle than the commercially available algorithm. No significant difference was observed between the TQC method and the motion capture system in any of the three angles (p < 0.05). It may be feasible to use this method to track tibiofemoral angles with higher accuracy and reliability than the commercially available sensor fusion algorithm.

Lower donor site morbidity with hamstring and quadriceps tendon autograft compared with bone-patellar tendon-bone autograft after anterior cruciate ligament reconstruction: a systematic review and network meta-analysis of randomized controlled trials

PURPOSE

To perform a meta-analysis of RCTs evaluating donor site morbidity after bone-patellar tendon-bone (BTB), hamstring tendon (HT) and quadriceps tendon (QT) autograft harvest for anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, OVID/Medline and Cochrane databases were queried in July 2022. All level one articles reporting the frequency of specific donor-site morbidity were included. Frequentist model network meta-analyses with P-scores were conducted to compare the prevalence of donor-site morbidity, complications, all-cause reoperations and revision ACLR among the three treatment groups.

RESULTS

Twenty-one RCTs comprising the outcomes of 1726 patients were included. The overall pooled rate of donor-site morbidity (defined as anterior knee pain, difficulty/impossibility kneeling, or combination) was 47.3% (range, 3.8-86.7%). A 69% (95% confidence interval [95% CI]: 0.18-0.56) and 88% (95% CI: 0.04-0.33) lower odds of incurring donor-site morbidity was observed with HT and QT autografts, respectively (p < 0.0001, both), when compared to BTB autograft. QT autograft was associated with a non-statistically significant reduction in donor-site morbidity compared with HT autograft (OR: 0.37, 95% CI: 0.14-1.03, n.s.). Treatment rankings (ordered from best-to-worst autograft choice with respect to donor-site morbidity) were as follows: (1) QT (P-score = 0.99), (2) HT (P-score = 0.51) and (3) BTB (P-score = 0.00). No statistically significant associations were observed between autograft and complications (n.s.), reoperations (n.s.) or revision ACLR (n.s.).

CONCLUSION

ACLR using HT and QT autograft tissue was associated with a significant reduction in donor-site morbidity compared to BTB autograft. Autograft selection was not associated with complications, all-cause reoperations, or revision ACLR. Based on the current data, there is sufficient evidence to recommend that autograft selection should be personalized through considering differential rates of donor-site morbidity in the context of patient expectations and activity level without concern for a clinically important change in the rate of adverse events.

LEVEL OF EVIDENCE

Level I.

Meniscus Work and Implant Selection Are Major Cost Drivers of Anterior Cruciate Ligament Reconstruction

Background The current study examines the financial charges associated with primary anterior cruciate ligament reconstruction (ACLR), specifically the contribution of graft choice, graft type, and concomitant meniscus surgery, in the outpatient hospital setting. Methods A retrospective financial billing review was performed on patients who underwent ACLR at a single academic medical center from January to December 2019. Age, BMI, insurance, length of operation, regional block, implants, meniscus surgery, graft type, and graft choice were extracted from hospital electronic patient records. Charges attributed with graft, anesthesia services, supplies, implants, surgeon fees, radiology charges, and total charges were collected. Total amount that insurance and patient paid were also obtained. Descriptive and quantitative statistics were performed. Results A total of 28 patients were studied (18 males, 10 females). The average age was 23.8 years. There were 20 concomitant meniscus surgeries. Six allografts and 22 autografts were used [eight bone-patellar tendon-bone (BPTB), eight hamstrings, six quadriceps]. The average and median total charge was $61,004 and $60,390, respectively (range: $31,403 to $97,914). The average insurance paid was $26,045 while out-of-pocket costs were $402. The average paid by private insurance was higher compared to government insurance ($31,111 vs. $11,066, p<0.001). Graft choice such as allograft vs. autograft (p=0.035) and meniscus surgery (p=0.048) were significant factors to the overall cost. Conclusions Graft choice, specifically the quadrupled hamstring autograft, and concomitant meniscal surgery are major contributors to variations in ACLR charges. Decreasing implant and graft costs and limiting surgical time can decrease charges associated with ACLR. We hope these findings can help guide surgeon financial decisions, by demonstrating the need to take into account the increased total charges and amount paid associated with specific grafts, meniscus surgery, and prolonged OR time.

Navigation in anterior cruciate ligament reconstruction: State of the art

Computer navigation (CN) for anterior cruciate ligament (ACL) surgery has been used mainly for two purposes: to enhance the accuracy of tunnel position and to evaluate the kinematics of the ACL reconstruction (ACLR) and the stability achieved by different surgical techniques. Many studies have shown that navigation may improve the accuracy of anatomical tunnel orientation and position during ACL reconstructive surgery compared with normal arthroscopic tunnel placement, especially regarding the femoral side. At the same time, it has become the gold-standard method for intraoperative knee kinematic assessment, as it permits a quantitative multidirectional knee joint laxity evaluation. CN in ACL surgery has been associated with diverse problems. First, in most optic systems additional skin incisions and drill holes in the femoral bone are required for fixation of a reference frame to the femur. Second, additional radiation exposure and extra medical cost to the patient for preoperative planning are usually needed. Third, CN, due to additional steps, has more opportunities for error during preoperative planning, intraoperative registration, and operation. Fourth, soft tissues, including the skin and subcutaneous tissues, are usually not considered during the preoperative planning, which can be a problem for kinematic and stability assessment. Many studies have concluded that ACLR using a CN system is more expensive than conventional surgery, it adds extra time to the surgery and it is not mitigated by better clinical outcomes. This, combined with costs and invasiveness, has limited the use of CN to research-related cases. Future technology should prioritize less invasive intra-operative surgical navigation.

Ambulatory Surgery Centers Significantly Decrease Total Health Care Expenditures in Primary Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described.

PURPOSE

To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement.

RESULTS

There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all).

CONCLUSION

Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

"Cost-effectiveness of ACL treatment is dependent on age and activity level: a systematic review"

PURPOSE

To systematically review the literature on health-economic evaluations of anterior cruciate ligament (ACL) injury between reconstruction surgery (ACLR) and non-operative treatment (NO) and suggest the most cost-effective strategy between the two.

METHODS

All economic studies related to ACLR versus NO post-ACL injury, either trial based or model based, published until April 2022, were identified using PubMed and Embase. The methodology of the health-economic analysis for each included study was categorized according to the four approaches: cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list.

RESULTS

Of the seven included studies, two compared the strategies of early ACLR and NO alone, and five compared early ACLR and NO with optional delayed ACLR. All studies performed a CUA, and one study performed a CBA additionally. The CHEC scores of the included studies can be considered good, ranging from 15 to 18 from a maximum of 19. Applying the common standard threshold of $50,000 per QALY, six studies in young people with high-activity levels or athletes showed that early ACLR would be preferred over either NO alone or delayed ACLR. Of six studies, two even showed early ACLR to be the dominant strategy over either NO alone or delayed ACLR, with per-patient cost savings of $5,164 and $1,803 and incremental per-patient QALY gains of 0.18 and 0.28, respectively. The one study in the middle-aged people with a moderate activity level showed that early ACLR was not more cost-effective than delayed ACLR, with ICER $101,939/QALY using the societal perspective and ICER $63,188/QALY using the healthcare system perspective.

CONCLUSION

Early ACLR is likely the more cost-effective strategy for ACL injury cases in athletes and young populations with high-activity levels. On the other hand, non-operative treatment with optional delayed ACLR may be the more cost-effective strategy in the middle age population with moderate activity levels.

LEVEL OF EVIDENCE

Systematic review of level III studies.

Cost and Cost Driver Analysis of Anterior Cruciate Ligament Reconstruction Using Time-Driven Activity-Based Costing: Bone-Tendon-Bone Autograft Versus Hamstring Autograft

As health care transitions toward value-based care, orthopaedics has started to implement time-driven activity-based costing (TDABC) to understand costs and cost drivers. TDABC has not previously been used to study cost drivers in anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to use TDABC to (1) calculate bone-tendon-bone (BTB) and hamstring ACLR total costs of care and (2) evaluate the impact of graft choice and other factors on ACLR costs.

Methods

Data were collected from electronic medical records for primary ACLR from the institutional patient-reported outcome registry between 2009 and 2016 in 1 ambulatory surgery center. Patients receiving allograft, revision ACLR, or concomitant meniscal repair or ligament reconstruction were excluded. The total cost of care was determined using TDABC. Multivariate regression analysis was conducted between ACLR cost and group characteristics.

Results

A total of 328 patients were included; 211 (64.3%) received BTB autograft and 117 (35.7%) received hamstring autograft. The mean cost was $2,865.01 ± $263.45 (95% confidence interval: $2,829.26, $2,900.77) for BTB ACLR versus $3,377.44 ± $320.12 ($3,318.82, $3,436.05) for hamstring ACLR (p < 0.001). Operative time was 103.1 ± 25.1 (99.7, 106.5) minutes for BTB ACLR versus 113.1 ± 27.9 (108.0, 118.2) minutes for hamstring ACLR (p = 0.001). The total implant cost was $270.32 ± $97.08 ($257.15, $283.50) for BTB ACLR versus $587.36 ± $108.78 ($567.44, $607.28) for hamstring ACLR (p < 0.001). Hamstring graft (p = 0.006) and suspensory fixation on the femoral side (p = 0.011) were associated with increased costs.

Conclusions

The mean cost of care and operative time for BTB autograft ACLR are less than those for hamstring autograft ACLR. Operative time, implant choice, and graft choice were identified as modifiable cost drivers that can empower surgeons to manage primary ACLR costs while maximizing the value of the procedure.

Level of Evidence

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

No Difference in Knee Kinematics Between Anterior Cruciate Ligament-First and Posterior Cruciate Ligament-First Fixation During Single-Stage Multiligament Knee Reconstruction: A Biomechanical Study

Background:

For combined reconstruction of both the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL), there is no consensus regarding which graft should be tensioned and fixed first.

Purpose:

The purpose of this study was to determine which sequence of graft tensioning and fixation better restores normal knee kinematics. The hypothesis was that ACL-first fixation would more closely restore normal knee kinematics, graft force, and the tibiofemoral orientation in the neutral (resting) position compared with PCL-first fixation.

Study Design:

Controlled laboratory study.

Methods:

A total of 15 unpaired human cadaveric knees were examined using a robotic testing system under the following 4 conditions: (1) 89.0-N anterior tibial load at different knee angles; (2) 89.0-N posterior tibial load at different knee angles; (3) combined rotational 7.0-N·m valgus and 5.0-N·m internal rotation load (simulated pivot shift) at 0°, 15°, and 30° of flexion; and (4) 5.0-N·m external rotation load at 0°, 15°, and 30° of flexion. The 4 evaluated knee states were (1) intact ACL and PCL (intact), (2) ACL and PCL deficient (deficient), (3) combined anatomic ACL-PCL reconstruction fixing the ACL first (ACL-first), and (4) combined anatomic ACL-PCL reconstruction fixing the PCL first (PCL-first). A 9.0 mm–diameter quadriceps tendon autograft was used for the ACL graft, tensioned with 40.0 N at 30° of flexion. A 9.5 mm–diameter hamstring tendon autograft (gracilis and semitendinosus, quadrupled loop, and augmented with an additional allograft strand if needed), tensioned with 40.0 N at 90° of flexion, was used for the PCL graft.

Results:

There were no statistically significant differences between ACL-first and PCL-first fixation regarding knee kinematics. ACL-first fixation restored anterior tibial translation to the intact state at all tested knee angles, while PCL-first fixation showed higher anterior tibial translation than the intact state at 90° of flexion (9.05 ± 3.05 and 5.87 ± 2.40 mm, respectively; P = .018). Neither sequence restored posterior tibial translation to the intact state at 30°, 60°, and 90° of flexion. At 15° of flexion, PCL-first fixation restored posterior tibial translation to the intact state, whereas ACL-first fixation did not.

Conclusion:

There were no differences in knee laxity between ACL-first and PCL-first fixation with the ACL graft fixed at 30° and the PCL graft fixed at 90°.

Clinical Relevance:

This study showed that there was no evidence to support the use of one tensioning sequence over the other in single-stage multiligament knee reconstruction.

Trends in Health Care Expenditures and Patient Out-of-Pocket Expenses in Primary Anterior Cruciate Ligament Reconstruction

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure.

PURPOSE

To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients' out-of-pocket expenditures? (2) How are reimbursements from payers and patients' out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients?

STUDY DESIGN

Economic and decision analysis study; Level of evidence, 4.

METHODS

A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars.

RESULTS

Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11.

CONCLUSION

Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.

Muscle Force Contributions to Anterior Cruciate Ligament Loading

Anterior cruciate ligament (ACL) injuries are one of the most common knee pathologies sustained during athletic participation and are characterised by long convalescence periods and associated financial burden. Muscles have the ability to increase or decrease the mechanical loads on the ACL, and thus are viable targets for preventative interventions. However, the relationship between muscle forces and ACL loading has been investigated by many different studies, often with differing methods and conclusions. Subsequently, this review aimed to summarise the evidence of the relationship between muscle force and ACL loading. A range of studies were found that investigated muscle and ACL loading during controlled knee flexion, as well as a range of weightbearing tasks such as walking, lunging, sidestep cutting, landing and jumping. The quadriceps and the gastrocnemius were found to increase load on the ACL by inducing anterior shear forces at the tibia, particularly when the knee is extended. The hamstrings and soleus appeared to unload the ACL by generating posterior tibial shear force; however, for the hamstrings, this effect was contingent on the knee being flexed greater than ~ 20° to 30°. The gluteus medius was consistently shown to oppose the knee valgus moment (thus unloading the ACL) to a magnitude greater than any other muscle. Very little evidence was found for other muscle groups with respect to their contribution to the loading or unloading of the ACL. It is recommended that interventions aiming to reduce the risk of ACL injury consider specifically targeting the function of the hamstrings, soleus and gluteus medius.

One-Stage ACL Revision Using a Bone Allograft Plug for a Semianatomic Tibial Tunnel That Is Too Anterior

Revision of an anterior cruciate ligament (ACL) reconstruction can be performed as a one-stage or two-stage surgery. Several factors must be taken into consideration when making this choice, especially the size and position of the existing tunnels. When the tibial tunnel is semianatomic, it is difficult to make a new tunnel in the correct position without overlapping the existing tunnel. For this reason, we have developed a one-stage ACL revision surgery that uses a bone allograft plug. When it comes to choosing a reconstruction technique, we believe that combined intra-articular and extra-articular reconstruction with the iliotibial band is suitable when the hamstring tendons are not available, combined with clinical findings of translational and rotational instability. Because the existing tunnels require reorientation, a new femoral tunnel can be created by outside-in drilling to eliminate the risk of overlap, while an allograft bone plug can be used to fill the overly anterior tibial tunnel and allow us to drill the correct tibial tunnel right away. In our hands, this is a safe and effective technique, but longer follow-up is needed to validate its indications.

The Relationship Between Lateral Femoral Condyle Index and Noncontact Anterior Cruciate Ligament Rupture

Purpose

The purpose of this study was to examine the relationship between distal femoral morphology and noncontact anterior cruciate ligament (ACL) rupture and the differences between digital X-ray imaging systems (DR) and magnetic resonance imaging (MRI) to evaluate distal femoral morphology.

Methods

A retrospective case-control study was performed on 120 patients. Two age- and sex-matched cohorts (each n = 60) were analyzed: primary ACL ruptures and a control group consisting of isolated meniscal tears. The lateral femoral condyle index (LFCI) was measured by DR and by MRI to quantify femoral sphericity. Differences among two groups were compared, and diagnostic performance of the risk factors was assessed. In addition, differences between DR and MRI to evaluate LFCI were examined.

Results

The LFCI by MRI was smaller in the knees with primary ACL rupture (median, 0.71; range, 0.62–0.78) than that of the control group (median, 0.77; range, 0.66–0.85) (p < 0.01). The LFCI was also significantly smaller in the knees with primary ACL rupture (median, 0.72; range, 0.63–0.77) than that of the control group (median, 0.79; range, 0.65–0.84) (p < 0.01) by DR. A cutoff of 0.74 of MRI yielded a sensitivity of 77% and a specificity of 78% to predict an ACL rupture, and of 0.75 of DR yield a sensitivity of 87% and a specificity of 77% to predict an ACL rupture.

Conclusion

This study showed that a decreased LFCI is associated with an ACL rupture, and both DR and MRI measurements can effectively predict the risk of ACL rupture. This helps expand the scope of the application of the LFCI and helps clinicians identify susceptible individuals who may benefit from targeted ACL rupture prevention counseling and intervention.

Predictors of patient satisfaction after primary hamstring anterior cruciate ligament reconstruction

BACKGROUND

Predictors of patient satisfaction (PS) after anterior cruciate ligament (ACL) reconstruction are not well known. This study investigated predictors of PS and whether PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life after ACL reconstruction.

METHODS

Patients who underwent primary hamstring ACL reconstruction between January 2015 and December 2017 were retrospectively evaluated. An online survey was used to evaluate PS (yes = satisfied, no = unsatisfied), duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport, pre-injury level of sport participation, patient reported knee function and quality of life. Preoperative, operative and postoperative variables were collected from the medical records.

RESULTS

A total of 183 patients completed the survey at a median of 3.6 (1.5) years after ACL surgery. At final follow-up, 82% of patients were satisfied with the outcome. Preoperative (e.g. age) and operative (e.g. meniscal tear) variables were not predictors of PS (p > 0.05). Duration of supervised postoperative rehabilitation, timing of return to pre-injury level of sport and postoperative ACL injury were predictors of PS (p = 0.018, p = 0.016 and p < 0.001, respectively). Pre-injury level of sport participation was significantly higher in satisfied compared to unsatisfied patients: 44.7% (n = 67) versus 18.2% (n = 6) (p = 0.005). In addition, satisfied patients reported significantly higher patient reported knee function and quality of life compared to unsatisfied patients (p < 0.001).

CONCLUSION

This study provided data on predictors of PS after primary ACL reconstruction. Furthermore, PS was associated with pre-injury level of sport participation, patient reported knee function and quality of life.

Correlation among Knee Muscle Strength and Self-Reported Outcomes Score, Anterior Tibial Displacement, and Time Post-Injury in Non-Coper Anterior Cruciate Ligament Deficient Patients: A Cross-Sectional Study

Little attention has been paid to knee muscle strength after ACL rupture and its effect on prognostic outcomes and treatment decisions. We studied hamstrings (H) and quadriceps (Q) strength correlation with a patient-reported outcome measures score (International Knee Documentation Committee, IKDC), anterior tibial translation (ATT), and time post-injury in 194 anterior cruciate ligament deficient patients (ACLD) who required surgery after a failed rehabilitation program (non-copers). The correlation between knee muscle strength and ATT was also studied in 53 non-injured controls. ACLD patients showed decreased knee muscle strength of both the injured and non-injured limbs. The median (interquartile range) values of the H/Q ratio were 0.61 (0.52-0.81) for patients' injured side and 0.65 (0.57-0.8) for the non-injured side (p = 0.010). The median H/Q ratio for the controls was 0.52 (0.45-0.66) on both knees (p < 0.001, compared with the non-injured side of patients). The H/Q, ATT, and time post-injury were not significantly correlated with the IKDC score. ATT was significantly correlated with the H/Q of the injured and non-injured knees of patients, but not in the knees of the controls. Quadriceps strength and H/Q ratio were significantly correlated with ATT for both limbs of the patients. IKDC score correlated significantly with the quadriceps and hamstrings strengths of the injured limb but not with the H/Q ratio, ATT or time passed after injury.

Delaying ACL reconstruction beyond 6 months from injury impacts likelihood for clinically significant outcome improvement

BACKGROUND

The effect of surgical latency on outcomes of anterior cruciate ligament reconstruction (ACLR) is a topic that is heavily debated. Some studies report increased benefit when time from injury to surgery is decreased while other studies report no benefit. The purpose of our analysis was to compare achievement of clinically significant outcomes (CSOs) in patients with greater than six months of time from injury to ACLR to those with less than or equal to six months of time to surgery.

METHODS

Patients undergoing primary ACLR between January 2017 and January 2018 with minimum one year follow-up were included. International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcomes Score (KOOS) were collected. Multivariate logistic regression was performed for outcome achievement and risk of revision ACLR and Weibull parametric survival analysis was performed for relative time to outcome achievement. The level of significance was set at α = 0.05.

RESULTS

379 patients were included of which, 140 patients sustained ACL injury greater than six months prior to surgery. This group of patients experienced reduced likelihood to achieve patient-acceptable symptomatic state (PASS) on the IKDC (p = 0.03), KOOS Pain (p = 0.01) and a greater likelihood to undergo revision ACLR (p = 0.001). There was no impact of surgical timing on minimal clinically important difference (MCID).

CONCLUSION

Patients with greater than 6 months from injury to ACLR reported reduced likelihood to achieve CSOs, delayed achievement of CSOs, and increased rates of revision surgery.

Early cost estimating model for new bioabsorbable orthopedic implant candidates: A theoretical study

An early health technology assessment (HTA) study was performed to assess the need for developing a new bioabsorbable implant for the treatment of specific orthopedic injuries. The Anterior Cruciate Ligament Reconstruction (ACLR) procedure was selected based on the need and potential impact of bioabsorbable implants in the treatment of ACL injuries. The economic model considers the possible health events after an ACLR (failures and other complications such as stiffness and pain). A decision tree approach was used, and several sensitivity analyses were performed using a Monte Carlo simulation. A cost estimating model was applied comparatively for currently available metal and bioabsorbable implants against a potential new bioabsorbable implant with improved performance. A reduction in stiffness and pain symptoms were considered as targets for these new implants performance, with reduced inflammation resulting from the use of materials with appropriate biological and mechanical properties. The current study estimates that, under the assumptions made, the introduction of a new bioabsorbable implant in ACLR surgeries may generate yearly cost savings. The model estimates positive cost-benefits of the new implant when it reduces the probability of failure by more than 30%, or reduces at least 14% the probability of complications of an inflammatory nature. The development of a new bioabsorbable orthopedic implant for ACLR is encouraged by this study identifying the need for new bioabsorbable implants with improved biological and mechanical performance. The results of this early HTA have made it possible to anticipate design needs and objectives for the research and development of new orthopedic bioabsorbable implants.

Machine learning can reliably identify patients at risk of overnight hospital admission following anterior cruciate ligament reconstruction

PURPOSE

Overnight admission following anterior cruciate ligament reconstruction has implications on clinical outcomes as well as cost benefit, yet there are few validated risk calculators for reliable identification of appropriate candidates. The purpose of this study is to develop and validate a machine learning algorithm that can effectively identify patients requiring admission following elective anterior cruciate ligament (ACL) reconstruction.

METHODS

A retrospective review of a national surgical outcomes database was performed to identify patients who underwent elective ACL reconstruction from 2006 to 2018. Patients admitted overnight postoperatively were identified as those with length of stay of 1 or more days. Models were generated using random forest (RF), extreme gradient boosting (XGBoost), linear discriminant classifier (LDA), and adaptive boosting algorithms (AdaBoost), and an additional model was produced as a weighted ensemble of the four final algorithms.

RESULTS

Overall, of the 4,709 patients included, 531 patients (11.3%) required at least one overnight stay following ACL reconstruction. The factors determined most important for identification of candidates for inpatient admission were operative time, anesthesia type, age, gender, and BMI. Smoking history, history of COPD, and history of coagulopathy were identified as less important variables. The following factors supported overnight admission: operative time > 200 min, age < 35.8 or > 53.5 years, male gender, BMI < 25 or > 31.2 kg/m², positive smoking history, history of COPD and the presence of preoperative coagulopathy. The ensemble model achieved the best performance based on discrimination assessed via internal validation (AUC = 0.76), calibration, and decision curve analysis. The model was integrated into a web-based open-access application able to provide both predictions and explanations.

CONCLUSION

Modifiable risk factors identified by the model such as increased BMI, operative time, anesthesia type, and comorbidities can help clinicians optimize preoperative status to prevent costs associated with unnecessary admissions. If externally validated in independent populations, this algorithm could use these inputs to guide preoperative screening and risk stratification to identify patients requiring overnight admission for observation following ACL reconstruction.

LEVEL OF EVIDENCE

IV.

Influence of Preoperative Tunnel Widening On the Outcomes of a Single Stage-Only Approach to Every Revision Anterior Cruciate Ligament Reconstruction: An Analysis of 409 Consecutive Patients From the SANTI Study Group

BACKGROUND

Preoperative tunnel widening is a frequently reported indication for performing a 2-stage revision anterior cruciate ligament reconstruction (ACLR) instead of a single-stage procedure. However, the strength of the available evidence to support a 2-stage strategy is low.

PURPOSE/HYPOTHESIS

The purpose was to evaluate the clinical outcomes of a single stage-only approach to revision ACLR. It was hypothesized that this approach would be associated with significant improvements from baseline in patient-reported outcome measures (PROMs) and knee stability and that there would be no significant differences in any postoperative outcomes between patients with and without preoperative tunnel widening.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective analysis was conducted of a large series of consecutive patients undergoing revision ACLR with a minimum follow-up of 2 years. Preoperative tunnel widening was assessed using digital radiographs. All patients underwent single-stage surgery with an outside-in technique, regardless of the degree of tunnel widening. Clinical outcomes were compared according to whether tunnel widening was present (either tunnel ≥12 mm) or not (both tunnels <12 mm).

RESULTS

The study included 409 patients with a mean ± SD follow-up of 69.6 ± 29.0 months. After revision ACLR, there was a significant reduction in the side-to-side anteroposterior laxity difference, from 7.7 ± 2.2 mm preoperatively to 1.2 ± 1.1 mm at 2 years (P < .001). The mean International Knee Documentation Committee (IKDC) and all subscales of the Knee injury and Osteoarthritis Outcome Score (KOOS) exceeded the thresholds for the Patient Acceptable Symptom State defined for primary ACLR. An overall 358 patients had retrievable preoperative radiographs. According to the tunnel diameter measurements, 111 patients were allocated to group A (both tunnels <12 mm) and 247 patients to group B (either/both tunnels ≥12 mm). There were no significant differences between groups with respect to anteroposterior side-to-side laxity difference, graft rupture rates, non-graft rupture related reoperations, or contralateral anterior cruciate ligament injury rates. There was also no significant difference between groups that exceeded minimal detectable change thresholds for any of the PROMs recorded (ACL-RSI [Anterior Cruciate Ligament-Return to Sports After Injury], Lysholm, Tegner, IKDC, KOOS).

CONCLUSION

A single-stage approach to revision ACLR is associated with excellent clinical results when an outside-in drilling technique is utilized. The presence of preoperative tunnel widening does not significantly influence PROMs, knee stability, graft rupture rates, or non-graft rupture related reoperation rates.

Decline in Racial Disparities for United States Hospital Admissions After Anterior Cruciate Ligament Reconstruction From 2007 to 2015

Background

Racial disparities in perioperative complications have been shown to exist for many procedures in orthopaedic surgery. Although anterior cruciate ligament reconstruction (ACLR) is commonly performed as an outpatient procedure, the rate of admission to the hospital postoperatively is not insignificant. Hispanic patients have been shown to have higher odds of admission compared with non-Hispanic patients.

Hypothesis

We hypothesized that racial disparities would decrease from 2007 to 2015, resulting in lower rates of hospital admission for Black and Hispanic patients.

Study Design

Descriptive epidemiology study.

Methods

This study represents a retrospective analysis of the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ACLR between 2007 and 2015. We performed bivariate analysis as well as binary logistic regression, with postoperative admission as the primary outcome. Previously identified risk factors for admission were used as predictors in addition to a term for the statistical interaction between year of surgery and ethnicity.

Results

A total of 7542 patients undergoing ACLR were assessed. The logistic regression model showed that Hispanic patients had higher overall odds of admission (odds ratio [OR], 3.320; P < .001) than White patients; Black patients also had higher odds compared with White patients (OR, 1.929; P = .009). However, there was a significant interaction between year of surgery and both Black ethnicity (OR, 0.907; P = .026) and Hispanic ethnicity (OR, 0.835; P = .002), indicating a significant decrease in the admission rates for these minority patients compared with White patients over time. Other risk factors for admission were the use of regional anesthesia (OR, 3.482; P < .001), bleeding disorders (OR, 5.064; P = .002), a higher body mass index (OR, 1.029; P < .001), and longer operative times (OR, 1.012; P < .001). More recent surgery was associated with lower odds of admission (OR, 0.826; P < .001).

Conclusion

Admission rates after ACLR declined from 2007 to 2015. Black and Hispanic patients were more likely to be admitted overall, but they also saw a greater decrease in the odds of admission than White patients. This represents a reduction in disparity between the 2 groups and is a reassuring improvement in racial disparity trends after a common sports procedure.

Inpatient admission following anterior cruciate ligament reconstruction is associated with higher postoperative complications

PURPOSE

To compare the occurrence of short-term postoperative complications between inpatient and outpatient anterior cruciate ligament reconstruction.

METHODS

The ACS National Surgical Quality Improvement Program (NSQIP) database was utilized to identify patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR) from 2007 to 2017. A total of 18,052 patients were available for analysis following application of exclusion criteria. Patients were categorized based on location of surgery. Inpatients and outpatient ACLR groups were matched by demographics and preoperative laboratory values and differences in 30-day complication rates following surgery were assessed. Significance was set with alpha < 0.05.

RESULTS

From 2007 to 2017, there was an increasing frequency for outpatient ACLR (p < 0.001), while the incidence of inpatient ACLR remained largely constant (n.s). Groups were matched to include 1818 patients in each cohort. Within the first 30 days of surgery, patients in the inpatient ACLR group experienced significantly greater rates of superficial incisional SSI (0.6% vs 0.1%, p = 0.026) and composite surgical complications (0.6% vs 0.2%, p = 0.019), as well as a greater rate of reoperation (0.7% vs 0.2%, p = 0.029). Inpatient procedures also demonstrated a greater rate of deep surgical incisional SSI (0.2% vs 0.0%, n.s) and readmission to hospital (0.8% vs 0.7%, n.s).Outpatient ACLR procedures were also associated with a significantly greater relative value unit (RVU)/h compared with inpatient ACLRs (0.17 vs 0.14, p < 0.001).

CONCLUSIONS

Inpatient ACLR may have an increased risk of postoperative complications compared to outpatient ACLR during the short-term postoperative period. Although some patients may require admission post-operatively for medical and/or pain management, doing so is not necessarily without a degree of risk.

LEVEL OF EVIDENCE

III.

Outcomes After Arthroscopic Hip Labral Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

The acetabular labrum is critical to maintenance of hip stability and has been found to play a key role in preservation of the hip fluid seal. For irreparable labral damage, arthroscopic labral reconstruction is an evolving technique that has been shown to decrease hip pain and restore function.

PURPOSE

To provide a comprehensive review of current literature for arthroscopic hip labral reconstruction, with a focus on determining if outcomes differ between autograft or allograft tissue.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed and Scopus online databases were searched with the key terms "hip,""labrum,""reconstruction," and "graft" in varying combinations. Procedures performed, complications, failures, and functional outcome measures were included in this analysis. The inverse variance method was used to calculate pooled estimates and 95% CIs.

RESULTS

Eight studies with 537 hips were included. Mean age was 37.4 years (95% CI, 34.5-40.4 years), and mean follow-up time was 29 months (95% CI, 26-33 months). Survivorship after autograft reconstruction ranged from 75.7% to 100%, as compared with 86.3% to 90.0% in the allograft cohort. In the autograft cohort, failures included 0% to 13.2% conversion to total hip arthroplasty and 0% to 11.0% revision hip arthroscopy. Failures in the allograft cohort included 0% to 12.9% total hip arthroplasty conversion, 0% to 10.0% revision arthroscopy, and 0% to 0.8% open revision surgery. Based on 6 studies, the modified Harris Hip Score improved by a mean 29.0 points after labral reconstruction (P < .0001).

CONCLUSION

Arthroscopic hip labral reconstruction results in clinically significant improvements in patient-reported outcomes. Our analysis indicates that there are no significant differences in outcomes based on graft type alone. A number of factors may determine graft choice, including patient preference, surgeon experience, operative time, morbidity, and cost. Proper patient selection based on age and severity of degenerative joint disease will also optimize outcomes after labral reconstruction.

Cost Analysis in Shoulder Surgery: A Systematic Review

BACKGROUND

Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently.

PURPOSE

To analyze the current state of cost-effectiveness analyses in shoulder surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument).

RESULTS

A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7).

CONCLUSION

Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.

Cost-effectiveness of Operative Versus Non-operative Management of Acute Achilles Tendon Ruptures

BACKGROUND

The management of acute Achilles tendon ruptures is controversial, and most injuries are treated with surgery in the USA. The cost utility of operative versus non-operative treatment of acute Achilles tendon injury is unclear.

QUESTIONS/PURPOSES

The purpose of this study was to compare the cost-effectiveness of operative versus functional non-operative treatment of acute Achilles tendon ruptures.

METHODS

A Markov cost-utility analysis was conducted from the societal perspective using a 2-year time horizon. Hospital costs were derived from New York State billing data, and physician and rehabilitation costs were derived from the Medicare physician fee schedule. Indirect costs of missed work were calculated using estimates from the US Bureau of Labor Statistics. Rates of re-rupture, major and minor complications, and the associated costs were obtained from the literature. Effectiveness was expressed in quality-adjusted life years (QALYs). For the base-case analysis, operative and non-operative patients were assumed to have the same utilities (quality of life) following surgery. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the robustness of model assumptions.

RESULTS

In the base-case model, non-operative management of acute Achilles tendon ruptures dominated operative management, resulting in both lower costs and greater QALY gains. The differences in costs and effectiveness were relatively small. The benefit of non-operative treatment was 1.69 QALYs, and the benefit of operative treatment was 1.67 QALYs. Similarly, the total cost of operative and non-operative management was $13,936 versus $13,413, respectively. In sensitivity analyses, surgical costs and days of missed work were important drivers of cost-effectiveness. If hospitalization costs dropped below $2621 (compared with $3145) or the hourly wage rose above $29 (compared with $24), then operative treatment became a cost-effective strategy at the willingness-to-pay threshold of $50,000/QALY. The model results were also highly sensitive to the relative utilities for operative versus non-operative treatment. If non-operative utilities decreased relative to operative utilities by just 2%, then operative management became the dominant treatment strategy.

CONCLUSION

For acute Achilles tendon ruptures, non-operative treatment provided greater benefits and lower costs than operative management in the base case; however, surgical costs and the economic impact associated with return to work are important determinants of the preferred cost-effective strategy.

Acute reconstruction results in less sick-leave days and as such fewer indirect costs to the individual and society compared to delayed reconstruction for ACL injuries

PURPOSE

To compare the total number of sick-leave days caused by the knee injury from the day of injury and over the first year between acute (within 8 days) and delayed (6-10 weeks) anterior cruciate ligament reconstruction (ACLR) and also assess other clinical outcomes during this period.

METHODS

Seventy patients with an acute ACL injury and Tegner level of 6 or more were randomized to acute (within 8 days) or delayed (after 6-10 weeks) ACLR. Patient-reported outcomes; objective IKDC and manual stability measurements were assessed at 6 and 12 months. With data from the Swedish Social Insurance Agency (Försäkringskassan) information about the number of sick-leave days due to the knee injury over the following 12 months was collected and compared between the two groups.

RESULTS

Seventy-one percent received compensation for sick leave (26 in the acute versus 23 in the delayed group). The mean number of sick-leave days for the acute group was significantly lower (M = 56.9, SD = 36.4) compared to the delayed group (M = 88.5, SD = 50.2), p < 0.05. The acute group was also significantly stronger in flexion in both slow and fast angle velocities according to Biodex^®. No other differences were found between the groups in other clinical assessments or in terms of associated injuries.

CONCLUSION

Acute and delayed ACLR provided comparable clinical outcomes after 12 months. Acute reconstruction resulted in less sick-leave days and as such fewer indirect costs to the individual and society. These findings suggest that if patients requiring ACLR can be identified early and ACLR can be performed in the acute phase, socioeconomic costs can potentially be reduced by minimizing time off work.

LEVEL OF EVIDENCE

II.

Acute ACL reconstruction shows superior clinical results and can be performed safely without an increased risk of developing arthrofibrosis

PURPOSE

To compare acute ACL reconstruction (ACLR) within 8 days of injury with delayed reconstruction after normalized range of motion (ROM), 6-10 weeks after injury. It was hypothesized that acute ACL reconstruction with modern techniques is safe and can be beneficial in terms of patient-reported outcomes and range of motion.

METHODS

The effect of acute and delayed ACLR was randomized studied on 70 patients with high recreational activity level, Tegner level 6 or more, between 2006 and 2013. Patient-reported outcomes, objective IKDC, KOOS, and manual stability measurements were documented during the 24-month follow-up period.

RESULTS

The acute ACLR group did not result in increased stiffness and showed superior outcome regarding strength and how the patient felt their knee functioning at 24 months. In addition, the acute group was not inferior to the delayed group in any assessment. Regarding patient-related outcomes in KOOS, both groups showed significant improvements in all subscales, but no difference was found between the groups. Functional return (FR) rate was almost double compared to the Swedish knee ligament register and treatment failure (TF) rate was reduced by half, no significant difference between the groups. No difference regarding cyclops removal, re-injury of ACL or meniscus was found between the two surgical timing groups.

CONCLUSION

Acute ACLR within 8 days of injury does not appear to adversely affect ROM or result in increased stiffness in the knee joint and was not inferior to the delayed group in any assessment when compared to delayed surgery.

LEVEL OF EVIDENCE

I.

ACL reconstruction using a bone patellar tendon bone (BPTB) allograft or a hamstring tendon autograft (GST): a single-center comparative study

Background and aim of the work: There is still debate on which graft is better indicated for anterior cruciate ligament (ACL) surgical reconstruction. The objective of this study was to evaluate the medium-term clinical outcomes of ACL reconstruction comparing patients managed with bone patellar tendon bone allograft (BPTB) versus patients treated with hamstring autograft (GST). Methods: Patients enrolled during the period 2013-2016 underwent a personal interview with the use of specific evaluation questionnaires (Tegner e Lyshom, Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee), a clinical evaluation with the use of objective functional tests (Lachman test, pivot-shift) and a physical examination of the knee. Results: In this study 43 patients were enrolled: 21 patients were treated by autograft and 22 patients by allograft. Patients who received allograft ACL reconstruction returned to normal sport activity earlier than patients operated on using autograft (11.7±10.3 vs 17.9±14.6 weeks, p<0.05). Data obtained with subjective tests, clinical and physical examination were positive overall, with no differences observed between the two groups. Finally, 15 allograft patients and 12 autograft patients accepted to perform the proprioceptive tests: no difference was found between the two groups. Conclusions: At follow-up evaluation after ACL reconstruction, both BPTB allograft and GST autograft patient groups showed similar results at subjective, objective clinical evaluation and proprioceptive properties of the limb. In particular, the use of allogenic BPTB allowed the patients to return earlier to normal activities of daily-living and sport activity. (www.actabiomedica.it)

Income change after cruciate ligament injury - A population-based study

OBJECTIVES

To investigate the association between choice of treatment and patients' income after cruciate ligament (CL) injury and assess the effect of different covariates such as sex, age, comorbidities and type of work.

METHODS

This entire-population cohort study in Sweden included working patients with a diagnosed CL injury between 2002 and 2005, identified in The National Swedish Patient Register (n = 13,662). The exposure was the treatment choice (operative or non-operative treatment). The main outcome measure was average yearly income five years after CL diagnosis, adjusted for the following covariates: sex, age, comorbidities, type of work, region, calendar year, education and income.

RESULTS

Relative to non-operative treatment, operative treatment was associated with greater average yearly incomes (nine to 15%) after injury among patients between 20 and 50 years, patients with partial university education, patients living in large cities and patients with one comorbidity, despite no overall significant association in the national cohort. Delayed operative treatment (>1 year) had no significant association with income change, whereas early operative treatment (<1 year) was associated with higher average yearly incomes (11 to 16%) among females, patients between 20 and 50 years, patients living in large cities and patients with one comorbidity.

CONCLUSIONS

In a broad sense, treatment choice was not associated with changes in income five years after CL injuries among patients in the workforce, however earlier operative treatment was associated with higher average incomes among patients with ages between 20 and 50, females, living in large cities, with one comorbidity and with a high level of education.

Autograft or allograft for reconstruction of anterior cruciate ligament: a health economics perspective

PURPOSE

To assess the clinical and cost-effectiveness of allografts versus autografts in the reconstruction of anterior cruciate ligaments.

METHODS

Systematic review of comparative clinical effectiveness and cost-effectiveness analysis.

RESULTS

Both autograft and allograft reconstruction are highly effective. Recent studies show little difference in failure rates between autografts and allografts (about 6% and 7%, respectively). In cost-effectiveness analysis, the price differential is the main factor, making autografts the first choice. However, there will be situations, particularly in revision ACL reconstruction, where an allograft may be preferred, or may be the only reasonable option available.

CONCLUSION

In ACL reconstruction, clinical results with autografts are as good as or slightly better than with allografts. Allografts cost more, indicating that autografts are more cost-effective and should usually be first choice.

LEVEL OF EVIDENCE

II.

Cost Comparison of Surgically Treated Ankle Fractures Managed in an Inpatient Versus Outpatient Setting

INTRODUCTION

Although choices physicians make profoundly affect the cost of health care, few surgeons know relative costs associated with the setting in which care is provided. Without valid cost information, surgeons cannot understand how their choices affect the total cost of care.

METHODS

Actual costs for all isolated, surgically treated ankle fractures at a level I trauma hospital and affiliated outpatient surgery center were determined using a validated episode of care costing system and analyzed using multivariate regression analysis in this retrospective cohort study.

RESULTS

One hundred forty-eight patients (ie, 61 inpatients and 87 outpatients) with isolated, surgically treated ankle fractures were included. After controlling for confounding variables, outpatient care was associated with 31.6% lower costs compared with inpatient care. Obese patients had 21.6% higher costs compared with patients who were not obese. No difference was noted in revision surgery, readmission, or return visits to the emergency department for patients treated on an inpatient or outpatient basis.

CONCLUSION

Where medically/socially appropriate, this analysis suggests that ankle fracture surgery should be provided in an outpatient surgical facility to provide the greatest value to the patient and society.

LEVEL OF EVIDENCE

Level III.

Anterolateral Complex Reconstruction: Another Fad or Method to Improve ACL Outcomes?

Anterolateral rotational laxity of the knee is a persistent problem following anterior cruciate ligament reconstruction (ACLR) that can lead to increased rates of graft failure. Renewed interest in the anterolateral complex of the knee has led to a resurgence in the use of adjunctive techniques such as lateral extra-articular tenodesis and anterolateral ligament reconstruction. Use of these techniques can restore normal knee kinematics and potentially thereby reduce the rate of graft failure. Historically, experience with modified ACLR techniques such as the double-bundle ACLR have shown that improved biomechanics is not always reflected in clinical outcome trials. Additional procedures also come with additional costs and further economic analysis needs to be performed to clarify whether these additional costs are offset by improved clinical and societal outcomes in the longer-term.

Contingent Valuation Studies in Orthopaedic Surgery: A Health Economic Review

BACKGROUND

A greater emphasis on providing high-value orthopaedic interventions has resulted in increased health economic reporting. The contingent-valuation method (CVM) is used to determine consumer valuation of the benefits provided by healthcare interventions. CVM is an important value-based health economic tool that is underutilized in orthopaedic surgery.

QUESTIONS/PURPOSES

The purpose of this study was to (1) identify previously published CVM studies in the orthopaedic literature, (2) assess the methodologies used for CVM research, and (3) understand how CVM has been used in the orthopaedic cost-benefit analysis framework.

METHODS

A systematic review of the literature using the MEDLINE database was performed to compile CVM studies. Search terms incorporated the phrase willingness to pay (WTP) or willingness to accept (WTA) in combination with orthopaedic clinical key terms. Study methodology was appraised using previously defined empirical and conceptual criteria for CVM studies.

RESULTS

Of the 160 studies retrieved, 22 (13.8%) met our inclusion criteria. The economics of joint arthroplasty (n = 6, 27.3%) and non-operative osteoarthritis care (n = 4, 18.2%) were the most common topics. Most studies used CVM for pricing and/or demand forecasting (n = 16, 72.7%); very few studies used CVM for program evaluation (n = 6). WTP was used in all included studies, and one study used both WTP and WTA. Otherwise, there was little consistency among included studies in terms of CVM methodology. Open-ended questioning was used by only ten studies (45.5%), a significant number of studies did not perform a sensitivity analysis (n = 9, 40.9%), and none of the studies accounted for the risk preference of subjects. Only two of the included studies applied CVM within a cost-benefit analysis framework.

CONCLUSION

CVM is not commonly reported in orthopaedic surgery and is seldom used in the context of cost-benefit analysis. There is wide variability in the methods used to perform CVM. We propose that CVM is an appropriate and underappreciated method for understanding the value of orthopaedic interventions. Increased attention should be paid to consumer valuations for orthopaedic interventions.

Patient- and Procedure-Specific Variables Driving Total Direct Costs of Outpatient Anterior Cruciate Ligament Reconstruction

Background:

Few studies have investigated the influence of patient-specific variables or procedure-specific factors on the overall cost of anterior cruciate ligament reconstruction (ACLR) in an ambulatory surgery setting.

Purpose:

To determine patient- and procedure-specific factors influencing the overall direct cost of outpatient arthroscopic ACLR utilizing a unique value-driven outcomes (VDO) tool.

Study Design:

Cohort study (economic and decision analysis); Level of evidence, 3.

Methods:

All ACLRs performed by 4 surgeons over 2 years were retrospectively reviewed. Cost data were derived from the VDO tool. Patient-specific variables included age, body mass index, comorbidities, American Society of Anesthesiologists (ASA) classification, smoking status, preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computerized Adaptive Testing (PF-CAT) score, and preoperative Single Assessment Numeric Evaluation (SANE) score. Procedure-specific variables included graft type, revision status, associated injuries and procedures, time from injury to ACLR, surgeon, and operating room (OR) time. Multivariate analysis determined patient- and procedure-related predictors of total direct costs.

Results:

There were 293 autograft reconstructions, 110 allograft reconstructions, and 31 hybrid reconstructions analyzed. Patient-specific factors did not significantly influence the ACLR cost. The mean OR time was shorter for allograft reconstruction (P < .001). Predictors of an increased direct cost included the use of an allograft or hybrid graft (44.5% and 33.1% increase, respectively; P < .001), increased OR time (0.3% increase per minute; P < .001), surgeon 3 or 4 (9.1% or 5.9% increase, respectively; P < .001 or P = .001, respectively), and concomitant meniscus repair (24.4% increase; P < .001). Within the meniscus repair cohort, all-inside, root, and combined repairs correlated with a 15.5%, 31.4%, and 53.2% increased mean direct cost, respectively, compared with inside-out repairs (P < .001).

Conclusion:

This study failed to identify modifiable patient-specific factors influencing direct costs of ACLR. Allografts and hybrid grafts were associated with an increased total direct cost. Meniscus repair independently predicted an increased direct cost, with all-inside, root, and combined repairs being costlier than inside-out repairs. The time-saving potential of all-inside meniscus repair was not realized in this study, making implant use a significant factor in the overall cost of ACLR with meniscus repair.

MRI-Based Assessment of Lower-Extremity Muscle Volumes in Patients Before and After ACL Reconstruction

Context:Study of muscle volumes in patients after anterior cruciate ligament (ACL) injury and reconstruction (ACL-R) is largely limited to cross-sectional assessment of the thigh musculature, which may inadequately describe posttraumatic and postsurgical muscle function. No studies have prospectively examined the influence of ACL injury and reconstruction on lower-extremity muscle volumes.Objective:Assess magnetic resonance imaging-derived lower-extremity muscle volumes, and quantify quadriceps strength and activation in patients following ACL injury and reconstruction.Design:Prospective case series.Setting:Research laboratory and magnetic resonance imaging facility.Patients (or Other Participants):Four patients (2 men and 2 women; age = 27.4 (7.4) y, height = 169.2 (8.1) cm, and mass = 74.3 (18.5) kg) scheduled for ACL-R.Intervention(s):Thirty-five muscle volumes were obtained from a bilateral lower-extremity magnetic resonance imaging before and after ACL-R.Main Outcome Measures:Muscle volumes expressed relative to (1) a normative database presurgery and postsurgery, (2) limb symmetry presurgery and postsurgery, and (3) percentage change presurgery to postsurgery. Quadriceps function was quantified by normalized knee extension maximal voluntary isometric contraction torque and central activation ratio.Results:Involved vastus lateralis and tibialis anterior were consistently smaller than healthy individuals (z < −1 SD) presurgery and postsurgery in all patients. Involved rectus femoris and vastus lateralis were more than 15% smaller than the contralateral limb presurgery, whereas the involved rectus femoris, gracilis, vastus medialis, vastus intermedius, and vastus lateralis muscle volumes exceeded 20% asymmetry postoperatively. Involved gracilis and semitendinosus atrophied more than 30% from presurgery to postsurgery. Involved maximal voluntary isometric contraction torque and central activation ratio increased by 12.7% and 12.5%, respectively, yet strength remained 33.2% asymmetric postsurgery.Conclusions:Adaptations in lower-extremity muscle volumes are present following ACL injury and reconstruction. Anterior thigh and shank muscles were smaller than healthy individuals, and large asymmetries in quadriceps volumes were observed presurgery and postsurgery. Selective atrophy of the semitendinosus and gracilis occurred following surgery. Volumetric deficits of the quadriceps musculature may exist despite improvements in muscle strength and activation.

Hamstring Autograft for Foot and Ankle Applications

BACKGROUND

Hamstring tendon autografts may be used for foot and ankle surgeries, although reports on their effectiveness and morbidity in the foot and ankle literature are limited. We studied a cohort of patients who underwent hamstring harvest for foot and ankle applications, hypothesizing that morbidity to the knee would be limited.

METHODS

We studied a cohort of patients who underwent hamstring autograft for foot or ankle applications by a fellowship-trained sports and foot and ankle surgeon since 2011. Thirty-seven patients underwent isokinetic strength testing using a dynamometer an average of 38 months postoperatively. The average patient age was 45 ± 16 (range, 18-78) years, and 54% were women. Peak flexion and extension torque as well as flexion and extension torque at 30, 70, and 90 degrees of flexion were collected at 2 different testing speeds, 180 and 300 degrees/s. t tests were used for all comparisons.

RESULTS

At follow-up, 32 patients (86%) reported no pain at the harvest site; the remaining 5 patients reported mild to moderate symptoms. No patients were dissatisfied, and all would recommend the surgery to someone else. Flexion strength at higher degrees of flexion was significantly lower compared with extension strength as well as compared with flexion strength at lower degrees of flexion, when testing was performed at lower speed ( P < 0.05).

CONCLUSIONS

When used for foot and ankle surgery, hamstring autografts resulted in high patient satisfaction with minimal donor site morbidity. While knee flexion strength was decreased at higher degrees of flexion, this finding did not appear to be clinically significant.

LEVEL OF EVIDENCE

Level IV, case series.

Similar cost-utility for double- and single-bundle techniques in ACL reconstruction

PURPOSE

The aim was to estimate the cost-utility of the DB technique (n = 53) compared with the SB (n = 50) technique 2 years after ACL reconstruction.

METHODS

One hundred and five patients with an ACL injury were randomised to either the Double-bundle (DB) or the Single-bundle (SB) technique. One hundred and three patients (SBG n = 50, DBG n = 53) attended the 2-year follow-up examination. The mean age was 27.5 (8.4) years in the SBG and 30.1 (9.1) years in the DBG. The cost per quality-adjusted life years (QALYs) was used as the primary outcome. Direct costs were the cost of health care, in this case outpatient procedures. Indirect costs are costs related to reduce work ability for health reasons. The cost-utility analysis was measured in terms of QALY gained.

RESULTS

The groups were comparable in terms of clinical outcome. Operating room time was statistically significantly longer in the DBG (p = 0.001), making the direct costs statistically significantly higher in the DBG (p = 0.005). There was no significant difference in QALYs between groups. In the cost-effectiveness plane, the mean difference in costs and QALYs from the trial data using 1000 bootstrap replicates in order to visualise the uncertainty associated with the mean incremental cost-effectiveness ratio (ICER) estimate showed that the ICERs were spread out over all quadrants. The cost-effectiveness acceptability curve showed that there was a 50% probability of the DB being cost-effective at a threshold of Euro 50,000.

CONCLUSION

The principal findings are that the DB is more expensive from a health-care perspective. This suggests that the physician may choose individualised treatment to match the patients' expectations and requirements.

Hamstring Graft Preparation Techniques for Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction is one of the most commonly performed procedures in orthopaedics, with more than 125,000 performed in the United States per year. There are several reconstruction graft choices that can be used to reconstruct the native anterior cruciate ligament, with autograft hamstring tendons being one of the most commonly used. Preparation of a hamstring autograft varies depending on patient characteristics and physician preference. The purpose of this Technical Note is to describe in detail different variants of hamstring graft preparation techniques that are commonly used in practice.