A Cost-Effectiveness Analysis Comparing 3 Anterior Cruciate Ligament Graft Types Bone-Patellar Tendon-Bone Autograft, Hamstring Autograft, and Allograft

Background: Anterior cruciate ligament (ACL) reconstruction, despite being one of the most common surgical interventions, is also one of the least agreed upon surgeries when it comes to optimum graft choice. Three graft choices stand among the most widely used in this procedure: (1) bone-patellar tendon-bone autograft (BPTB), (2) quadruple hamstring tendon autograft (HS), and (3) allograft. Hypothesis: Bone-patellar tendon-bone ACL reconstruction is the most cost-effective method of ACL reconstruction. Study Design: Economic and decision analysis; Level of evidence, 2. Methods: A simplified decision tree model was created with theoretical patients assigned equally to 1 of 3 ACL reconstruction cohorts based on graft type. These treatment arms were further divided into outcome arms based on probabilities from the literature. The terminal outcomes were assigned a health state/utility score and a societal cost. Utilities were calculated from real clinic patients via the time trade-off questionnaire. Costs were literature based. An incremental cost-effectiveness ratio of $50 000/quality-adjusted life year (QALY) was used as the threshold for cost-effectiveness. Results: Hamstring tendon autograft was the least costly ($5375/surgery) and most effective (0.912) graft choice, dominating both BPTB and allograft reconstructions. Allograft was both the most costly and least effective strategy for the average patient undergoing ACL reconstruction. However, if baseline costs of BPTB could be reduced (by $500) or the effectiveness increased (anterior knee pain <15% or postoperative instability <7%), then BPTB became an incrementally cost-effective choice. In addition, if the effectiveness of HS could be reduced (instability >29% or revision rates >7%), then BPTB also became incrementally cost-effective. Conclusions: This model suggests that hamstring autograft ACL reconstruction is the most cost-effective method of surgery for the average patient with ACL deficiency. However, specific clinical scenarios that change postoperative probabilities of the different complications may sway surgeons to choose either allografts or BPTB. Cost-effectiveness analysis is not intended to replace individual clinician judgment but rather is intended to examine both the effectiveness and costs associated with theoretical groups undergoing specific multifactorial decisions.