For athletes facing a primary anterior cruciate ligament reconstruction (ACLR), the decision of how to reconstruct the anterior cruciate ligament (ACL) is a big one. Traditionally, ACLR alone has been the preferred method. But what if adding something could not only improve outcomes but also save money in the long run? I recently participated in a study (with Nathan H. Varady, MD, MBA, Jacob F. Oeding, PhD, Paul M. Inclan, MD, Anil S. Ranawat, MD, Andrew D. Pearle, MD, Scott A. Rodeo, MD, and Riley J. Williams, III, MD) that suggests a lateral extra-articular tenodesis (LET) augmentation is cost-effective in primary ACLR.
What Is ACLR + LET Augmentation?
LET augmentation is an additional procedure done alongside the ACLR. “Extra-articular” means it’s performed outside the knee joint capsule, unlike the ACLR, which is “intra-articular” (inside the joint). The main goal of LET is to provide additional rotational stability to the knee. It aims to prevent excessive internal rotation of the tibia (shin bone) relative to the femur (thigh bone), which can put stress on the newly reconstructed ACL graft and contribute to re-rupture.
How LET Augmentation Is Typically Done
- A small strip of tissue, most commonly from the iliotibial band (ITB) on the outside of the thigh, is harvested.
- This strip remains attached at one end (distally, near the shin bone).
- The free end is then passed under another ligament on the outside of the knee (the lateral collateral ligament, LCL) and secured to the femur (thigh bone) wit a suture anchor.
This creates a “tenodesis,” which means the tendon is anchored to a bone, which is thought to help prevent the ACL graft from stretching or re-tearing, especially in athletes who put a lot of rotational stress on their knees.
Why is it done?
LET augmentation is often considered for patients who are at higher risk of ACL re-rupture or who have significant rotational instability. This can include:
- Revision ACL surgeries: Where a previous ACL reconstruction has failed.
- Young, active athletes: Especially those involved in pivoting and contact sports.
- Patients with a “high-grade pivot shift”: This is a clinical test that indicates significant rotational instability in the knee.
- Patients with generalized joint laxity (hypermobility).
The Study
For this study, we used a Markov chain Monte Carlo model (a class of algorithms used to draw samples from a probability distribution) that evaluated the outcomes and costs of 1,000 athletes who underwent ACLR + LET augmentation compared to ACL alone. We pulled costs, utility values, graft failure rates, and transition probabilities from existing literature. We performed targeted meta-analysis of failure rates and patient reported outcomes from randomized control trials that compared the two procedures.
The Results
The findings were fairly compelling:
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- Fewer Re-Tears: The meta-analysis showed that the graft failure rate for ACLR+LET was significantly lower at 5.1% compared to 11.2% for ACLR alone. That difference means more athletes stayed healthy and active without needing another surgery.
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- Lower Costs: Across a five-year horizon, the average total cost for ACLR+LET was $56,217±$7,349, while ACLR alone came in at $68,605±$9,472. This suggests that ACLR+LET is more cost-effective.
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- Better Outcomes: Patients who underwent ACLR+LET also reported higher quality-adjusted life-years (QALYs) at 1.88±0.30 compared to 1.54±0.30 QALYs for ACLR alone.
In the microsimulation model, ACLR+LET was the preferred treatment in over 98% of cases. When we adjusted our assumptions in sensitivity analyses, ACLR+LET remained more cost-effective, assuming an ACLR+LET failure rate up to 11.3% or an ACLR alone failure rate down to 4.8%.
The Takeaway
Our conclusion from this study is that LET augmentation is cost-effective in athletes undergoing a primary ACLR. It suggests superior outcomes (fewer re-tears and better quality of life) but also results in lower overall costs over time.
This study suggests that LET could be a valuable option for many athletes, even those who might not be considered “highest risk,” due to its ability to prevent painful and costly re-injuries. If you’re an athlete considering ACL surgery, consider discussing the potential benefits of LET augmentation with your orthopedic surgeon.
Read the study abstract in The Journal of Arthroscopic and Related Surgery: Adding a Lateral Extra-Articular Tenodesis is Cost-Effective in Primary Anterior Cruciate Ligament Reconstruction: A Markov Analysis
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