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.