Focus on economics indicates surgery may be “a good deal”

Mary Ann Porucznik and the Washington Health Policy Fellows

In the second of a series of studies examining the economic impact of orthopaedic procedures, researchers found that outcomes for patients who had appropriately selected anterior cruciate ligament (ACL) reconstruction were both more effective (short- to intermediate-term) and less costly than rehabilitation alone. In addition, long-term costs to society were approximately $50,000 less per patient undergoing ACL reconstruction compared to rehabilitation.

“In younger patients, surgery for an ACL tear is usually the best option for getting them back on their feet and reducing the likelihood of arthritis down the road,” said Mininder S. Kocher, MD, MPH,associate director, division of sports medicine at Boston Children’s Hospital and one of the study’s authors. “Patients and their families are often worried about their ability to return to sports, their mobility in the future, and the cost of the surgery. This study sheds light on all three of these important factors.”

How to treat a torn ACL is a matter of considerable controversy. Nonsurgical treatment—such as bracing, physical therapy, and activity modification—can be a successful option for some patients, especially those who have partial tears or are less active. But more than 200,000 ACL injuries occur annually, many in people who participate in sports that require cutting and pivoting, such as basketball, football, skiing, and soccer.

About 1 of every 100 female high-school athletes in these sports—as well as handball and tennis—will injure an ACL before she graduates, according to Letha Y. Griffin, MD, a sports medicine specialist at Peachtree Orthopaedic Clinic in Atlanta. In college-level players, notes Dr. Griffin, the risk rises to 1 in 10—and is much higher than the rate among male athletes. Also, studies have shown that if an athlete tears the ACL in one knee, the likelihood of sustaining an injury in the opposite knee increases.

In addition, about half of all ACL injuries also involve damage to the meniscus, articular cartilage, and other ligaments, or bone bruises beneath the cartilage surface. This can lead to early-onset osteoarthritis of the knee. Studies indicate that the risk of knee osteoarthritis developing within 10 years after injury in patients who have a torn ACL but no meniscal tear is relatively low (less than 15 percent). However, that risk doubles—or even triples—if the patient has both a torn ACL and a torn meniscus.