title: Reconstruction versus conservative treatment after rupture of the anterior cruciate ligament: cost effectiveness analysis.
abstract: BACKGROUND
  The decision whether to treat conservatively or reconstruct surgically a torn anterior cruciate ligament (ACL) is an ongoing subject of debate. The high prevalence and associated public health burden of torn ACL has led to continuous efforts to determine the best therapeutic approach. A critical evaluation of benefits and expenditures of both treatment options as in a cost effectiveness analysis seems well-suited to provide valuable information for treating physicians and healthcare policymakers.
  
  
  METHODS
  A literature review identified four of 7410 searched articles providing sufficient outcome probabilities for the two treatment options for modeling. A transformation key based on the expert opinions of 25 orthopedic surgeons was used to derive utilities from available evidence. The cost data for both treatment strategies were based on average figures compiled by Orthopaedic University Hospital Balgrist and reinforced by Swiss national statistics. A decision tree was constructed to derive the cost-effectiveness of each strategy, which was then tested for robustness using Monte Carlo simulation.
  
  
  RESULTS
  Decision tree analysis revealed a cost effectiveness of 16,038 USD/0.78 QALY for ACL reconstruction and 15,466 USD/0.66 QALY for conservative treatment, implying an incremental cost effectiveness of 4,890 USD/QALY for ACL reconstruction. Sensitivity analysis of utilities did not change the trend.
  
  
  CONCLUSIONS
  ACL reconstruction for reestablishment of knee stability seems cost effective in the Swiss setting based on currently available evidence. This, however, should be reinforced with randomized controlled trials comparing the two treatment strategies.
authors.affiliation: Department of Orthopedic Surgery, University of Zürich, Balgrist University Hospital, Zürich, Switzerland. mazda.farshad@balgrist.ch
authors.forename: Mazda
authors.initials: M
authors.lastname: Farshad
authors.forename: Christian
authors.initials: C
authors.lastname: Gerber
authors.forename: Dominik C
authors.initials: DC
authors.lastname: Meyer
authors.forename: Alexander
authors.initials: A
authors.lastname: Schwab
authors.forename: Patricia R
authors.initials: PR
authors.lastname: Blank
authors.forename: Thomas
authors.initials: T
authors.lastname: Szucs
mesh_terms: D000328:Adult; D016118:Anterior Cruciate Ligament / Q000601:surgery*; D000070598:Anterior Cruciate Ligament Injuries; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D006302:Health Services Research; D006801:Humans; D019057:Quality-Adjusted Life Years; D012421:Rupture / Q000601:surgery / Q000628:therapy; D013557:Switzerland; D016896:Treatment Outcome
references.citation: Am J Sports Med. 1994 Mar-Apr;22(2):211-7; discussion 217-8
references.pmid: 8198189
references.citation: Med Sci Sports Exerc. 2008 Feb;40(2):215-22
references.pmid: 18202582
references.citation: Knee Surg Sports Traumatol Arthrosc. 1998;6(4):224-30
references.pmid: 9826804
references.citation: Am J Sports Med. 1995 Mar-Apr;23(2):160-5
references.pmid: 7778699
references.citation: Health Econ. 2004 May;13(5):437-52
references.pmid: 15127424
references.citation: Scand J Med Sci Sports. 1999 Apr;9(2):114-9
references.pmid: 10220847
references.citation: Sports Med. 1990 Apr;9(4):244-60
references.pmid: 2183332
references.citation: J Bone Joint Surg Am. 1983 Feb;65(2):154-62
references.pmid: 6687391
references.citation: Z Orthop Ihre Grenzgeb. 1991 Sep-Oct;129(5):438-46
references.pmid: 1836700
references.citation: Knee. 2002 Sep;9(3):197-200
references.pmid: 12126677
references.citation: Am J Sports Med. 2009 Jan;37(1):65-71
references.pmid: 19029313
references.citation: Orthop Clin North Am. 1985 Jan;16(1):47-67
references.pmid: 3881716
references.citation: Int Orthop. 2011 Jul;35(7):1093-7
references.pmid: 21287172
references.citation: Am J Sports Med. 2008 Sep;36(9):1717-25
references.pmid: 18483197
references.citation: J Bone Joint Surg Br. 1999 Sep;81(5):775-9
references.pmid: 10530835
references.citation: Contemp Clin Trials. 2007 May;28(3):295-302
references.pmid: 17137844
references.citation: Unfallchirurg. 2003 May;106(5):374-9
references.pmid: 12750810
references.citation: Am J Sports Med. 1994 Sep-Oct;22(5):632-44
references.pmid: 7810787
references.citation: Bull Hosp Jt Dis. 2001-2002;60(3-4):173-8
references.pmid: 12102406
references.citation: Int Orthop. 2006 Oct;30(5):431; author reply 432
references.pmid: 16718494
references.citation: Ann Rheum Dis. 2004 Mar;63(3):269-73
references.pmid: 14962961
references.citation: Int J Sports Med. 2001 May;22(4):304-9
references.pmid: 11414676
references.citation: Clin Orthop Relat Res. 1990 Oct;(259):192-9
references.pmid: 2208856
references.citation: N Engl J Med. 2010 Jul 22;363(4):331-42
references.pmid: 20660401
references.citation: Am J Sports Med. 1998 May-Jun;26(3):350-9
references.pmid: 9617395
references.citation: Am J Orthop (Belle Mead NJ). 2000 Jun;29(6):472-6
references.pmid: 10890463
references.citation: Clin Orthop Relat Res. 1983 Jan-Feb;(172):158-63
references.pmid: 6821986
references.citation: Arthroscopy. 2002 Sep;18(7):715-24
references.pmid: 12209428
references.citation: Arch Orthop Trauma Surg. 2010 Aug;130(8):1001-6
references.pmid: 20336305
references.citation: J Sci Med Sport. 2009 Nov;12(6):622-7
references.pmid: 18835221
references.citation: Int Orthop. 1998;22(3):145-8
references.pmid: 9728304
references.citation: Knee Surg Sports Traumatol Arthrosc. 1999;7(1):25-8
references.pmid: 10024959
references.citation: Am J Sports Med. 2007 Jul;35(7):1135-43
references.pmid: 17351121
references.citation: Clin Orthop Relat Res. 1985 Sep;(198):87-93
references.pmid: 3896609
references.citation: Am J Sports Med. 1994 Nov-Dec;22(6):758-67
references.pmid: 7856799
references.citation: J Orthop Trauma. 1990;4(4):406-10
references.pmid: 2266446
references.citation: Clin Orthop Relat Res. 1991 Mar;(264):255-63
references.pmid: 1997243
references.citation: Clin Orthop Relat Res. 1999 Oct;(367):272-82
references.pmid: 10546625
references.citation: Arthroscopy. 2007 Dec;23(12):1320-1325.e6
references.pmid: 18063176
references.citation: Knee Surg Sports Traumatol Arthrosc. 2008 May;16(5):442-8
references.pmid: 18292988
references.citation: Unfallchirurg. 1999 Mar;102(3):173-81
references.pmid: 10232033
references.citation: Am J Sports Med. 1982 May-Jun;10(3):150-4
references.pmid: 6896798
references.citation: Arch Orthop Trauma Surg. 1996;115(6):332-6
references.pmid: 8905107
references.citation: Unfallchirurg. 1998 Jan;101(1):26-31
references.pmid: 9522668
references.citation: BMC Health Serv Res. 2011 Aug 04;11:182
references.pmid: 21813026
references.citation: Arthroscopy. 2008 Mar;24(3):292-8
references.pmid: 18308180
references.citation: Chirurg. 1995 Nov;66(11):1050-60
references.pmid: 8542766
references.citation: Arch Orthop Trauma Surg. 2000;120(1-2):59-64
references.pmid: 10653106
references.citation: Sportverletz Sportschaden. 2005 Mar;19(1):15-21
references.pmid: 15776324
references.citation: Unfallchirurg. 1994 Jul;97(7):357-61
references.pmid: 7939737
references.citation: Knee Surg Sports Traumatol Arthrosc. 1994;2(2):80-4
references.pmid: 7584189
references.citation: Clin Orthop Relat Res. 1984 Mar;(183):122-40
references.pmid: 6365386
references.citation: Aktuelle Traumatol. 1993 Dec;23(8):371-5
references.pmid: 8147257
references.citation: Knee Surg Sports Traumatol Arthrosc. 2007 Aug;15(8):965-72
references.pmid: 17503019
references.citation: Am J Sports Med. 1986 May-Jun;14(3):205-10
references.pmid: 3752360
references.citation: Knee Surg Sports Traumatol Arthrosc. 1997;5(3):150-6
references.pmid: 9335026
references.citation: Sports Med. 2007;37(8):703-16
references.pmid: 17645372
references.citation: Arthroscopy. 2008 Aug;24(8):899-908
references.pmid: 18657738
references.citation: J Bone Joint Surg Am. 1997 Oct;79(10):1556-76
references.pmid: 9378743
references.citation: Knee Surg Sports Traumatol Arthrosc. 2005 May;13(4):248-55
references.pmid: 15690197
references.citation: Knee. 2001 Mar;8(1):51-7
references.pmid: 11248569
references.citation: Osteoarthritis Cartilage. 2004 Dec;12(12):986-96
references.pmid: 15564066
references.citation: Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):818-22
references.pmid: 19421736
references.citation: Unfallchirurg. 2001 Apr;104(4):317-24
references.pmid: 11357698
references.citation: J Bone Joint Surg Am. 2009 Feb;91 Suppl 1:108-14
references.pmid: 19182035
references.citation: Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001356
references.pmid: 15846618
references.citation: Clin Orthop Relat Res. 1996 Mar;(324):134-44
references.pmid: 8595749
references.citation: Am J Sports Med. 2007 May;35(5):740-8
references.pmid: 17293471
references.citation: Clin Orthop Relat Res. 1994 Jun;(303):67-78
references.pmid: 8194256
references.citation: Clin Orthop Relat Res. 1985 Sep;(198):43-9
references.pmid: 4028566
references.citation: J Trauma. 2007 May;62(5):1159-62
references.pmid: 17495718
references.citation: Br J Sports Med. 2009 May;43(5):347-51
references.pmid: 18603576
references.citation: J Bone Joint Surg Br. 1986 May;68(3):458-61
references.pmid: 3755441
references.citation: Scand J Med Sci Sports. 2007 Jun;17(3):230-7
references.pmid: 17501866
references.citation: J Bone Joint Surg Am. 1988 Dec;70(10):1483-8
references.pmid: 3198673
references.citation: Int Orthop. 1993;17(4):219-23
references.pmid: 8407036
references.citation: Aktuelle Traumatol. 1993 Jun;23(4):200-6
references.pmid: 8101686
references.citation: Am J Sports Med. 1990 Nov-Dec;18(6):618-23
references.pmid: 2285092
references.citation: Arch Orthop Trauma Surg. 2005 May;125(4):217-21
references.pmid: 15875231
references.citation: Arthroscopy. 2002 May-Jun;18(5):515-8
references.pmid: 11987063
references.citation: Chirurg. 1994 Nov;65(11):992-8
references.pmid: 7821082