ACL Surgery - Worth the Price?

ACL reconstruction found to be more cost effective over rehab alone

/ Author:  / Reviewed by: Joseph V. Madia, MD Beth Bolt, RPh

Pain and cost are two big concerns when people think about knee surgery for a torn knee ligament. Is surgery worth the high cost or can physical therapy help?

Surgery to reconstruct the ACL in the knee is more cost effective and efficient compared to doing rehab alone, a new study found. Over a long period of time, ACL surgery saved society more than $50,000 on average versus participating in only rehab.

The cost of an ACL tear over a patient's lifetime is substantial, according to the researchers of the study. They said that people should focus on strategies that prevent injury.

"Talk with your doctor about ACL surgery benefits."

Richard Mather, III, MD, from Duke Orthopaedic Surgery in Durham, North Carolina, led a team of researchers that examined the cost effectiveness of having anterior cruciate ligament (ACL) reconstruction surgery compared to having structured rehabilitation only. The ACL is one of the ligaments inside the knee joint.

The researchers compared the average costs for both procedures from previous studies on ACL surgery and rehab, including the KANON study and the Multicenter Orthopaedic Outcomes Network.

The first study involved 121 patients who were followed for at least two years after surgery. The second study included 988 primary ACL tears with patients followed at least six years after the procedure.

The costs were based on how the initial ACL tear affected patients' work status, disability and earnings.

Costs were compared over a six-year period that researchers categorized as a short to intermediate term. Costs were also compared over patients' lifetime.

The researchers measured the effectiveness of rehab compared to that of ACL reconstruction by tracking the number of quality adjusted life years (QALYs) that patients gained. QALY is a measurement of disease burden. For example, one additional QALY would translate to the gain of one additional year of life in good health.

Indirect costs were also measured based on lost wages, disability and productivity.

ACL reconstruction reduced costs in the short to intermediate term by about $4,500 on average compared to having rehabilitation only, the researchers found.

ACL reconstruction was also more effective than rehab in the short to intermediate term. Reconstruction patients had an average quality-adjusted life years gain of 0.18 more than rehab alone.

The average lifetime cost to society for a typical patient undergoing ACL reconstruction was $50,417 less than having rehab alone. Average lifetime costs for ACL reconstruction and rehab alone were $38,121 and $88,538, respectively.

Almost a third of the total cost for ACL reconstruction was accrued more than six years after the procedure. With rehab, 63 percent of the total cost was accrued after six years.

Quality-adjusted life years in the long-term also increased by 0.72 with ACL construction compared to rehab only.

According to the researchers, the effectiveness and functional gains in the ACL reconstruction group were fueled by the rehab group's increased chance of having unstable knees and poor related function, especially after patients initially started rehab.

Limited access to ACL reconstruction "...may be harmful to patients and costly to society," the researchers said.

"In conclusion, ACL reconstruction was shown to be cost-saving and more effective in both the short to intermediate term and the long term," the researchers wrote in their report. "Long-term outcomes, although less certain, appeared to only increase the cost savings of the ACL reconstruction strategy. Substantial downstream effects of ACL tears exist."

The researchers noted a few limitations with their study. For one, ACL tear reports were based only on patients' reported symptoms, which researchers said could have affected the long-term difference in how osteoarthritis developed in both groups of patients.

The evidence for short- to intermediate-term costs and effectiveness was also stronger than that for long-term costs and effectiveness. Based on this, the authors said they could not make strong recommendations for treatments that could improve long-term outcomes.

In addition, the authors said that they were not able to determine how having an unstable knee or osteoarthritis directly impacted employment and other economic outcomes.

The authors said that further research into patient-centered care is needed to find the optimal strategy for both patients and providers.

"The Mather study suggests that ACL reconstruction is both lower cost and higher quality than rehabilitation alone in the short-term and long-term. While surgeries are obviously expensive, having ACL surgery increases the likelihood that a person can continue working. When the cost of lost wages and other indirect expenditures are considered, ACL surgery is actually the less expensive option," Adam Powell, PhD, Partner and President of Payer+Provider, told dailyRx News.

The study, supported by the American Academy of Orthopaedic Surgeons, was published online October 2 in The Journal of Bone & Joint Surgery. Two authors received payments or services from a third party in support of this study.

Review Date: 
October 7, 2013
Last Updated:
October 8, 2013