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Q&A: Costs, non-clinical considersations factor into pediatric ACL surgery decisions

ACL InjuryAn anterior cruciate ligament (ACL) tear often devastates active patients and their families. It’s a complicated injury with an extended rehabilitation period that can stretch to six months or longer. The medical community has not yet reached consensus on how to best treat ACL tears. The primary choices—surgical reconstruction or structured rehabilitation—present risks and benefits that vary depending on the severity of the injury and the patient’s age and activity level.

A recent study, published in The Journal of Bone and Joint Surgery, may help guide the decision-making process. The cost-effectiveness study showed surgery costs $4,500 less than rehabilitation by six years after the injury. The cost savings add up to more than $50,000 during the patient’s lifetime, reported the study’s authors, including Mininder S. Kocher, MD, MPH, orthopedic surgeon at Boston Children’s Hospital.

Pediatric Dose: What are the primary clinical risks and benefits for patients, their families and primary care physicians to consider as they weigh treatment options for a torn ACL?

Kocher: When patients delay or bypass surgery and opt for non-surgical treatment, they must cope with knee instability, which increases the risk for additional injuries and impacts quality of life. Surgery can return stability and function, allowing patients to return to normal activities. However, surgery carries risks, such as a small chance of complications and infection. The decision about how to manage a torn ACL is more complicated for pediatric patients because few sites offer the specialized ACL reconstruction surgery they need.

Pediatric Dose: What were the objectives and methods of recent cost-effectiveness study?

Kocher: We wanted to calculate and compare the direct costs of surgery and rehabilitation.  Rehabilitation consisted of physical therapy, bracing and return to some activities. We also included other factors in the model, including quality of life issues, such as mobility, ability to work and downstream costs, such as arthritis and knee replacement surgery. 

We reviewed data from 988 patients with primary ACL tears in the MOON (Multicenter Orthopaedic Outcomes Network) database and 121 patients in the KANON (Knee Anterior cruciate ligament, NON-surgical versus surgical treatment) study to estimate costs. The average age of patients was 26 years in the MOON database and 30 years in the KANON study.

The primary initial costs of non-surgical treatment include physical therapy and office visits. Initial cost for rehabilitation is approximately $6,630, while ACL reconstruction costs $19,342. However, by six years after the injury, some rehabilitation patients opt for surgery. Others incur additional injuries like meniscal tears, which require knee arthroscopy. Consequently, by six years after the injury, costs for patients who initially chose rehabilitation are $4,500 higher than costs for patients who underwent surgery.

We estimated this difference increases to $50,417 over the patients’ lifetimes, with both arthritis and the long-term disability resulting from knee instability factoring into the total costs of rehabilitation.

Pediatric Dose: How do these findings apply to pediatric patients?

Kocher: When we extrapolate these findings to younger patients, the results are even more impactful. Results are amplified, because teens and youth who tear an ACL have a longer time frame to experience the consequences of a treatment decision.

Surgical reconstruction can reduce a teen’s risk for arthritis or meniscal injury, but a teen who bypasses surgery for a torn ACL might be diagnosed with arthritis at age 35. This has a much larger impact in terms of quality of life, productivity and knee replacement surgery than an arthritis diagnosis at age 65 years. Arthritis can occur after ACL surgery, but ACL surgery results in stabilization of the knee, which reduces the subsequent risk of meniscus or articular cartilage injury.

Pediatric Dose: Are there other issues to consider with pediatric patients?

Kocher: Teens and youth who forego surgery can’t participate in sports or gym activities, because they risk further injury.

This is the time when youth are forming their identity and building a peer group. There could be major psycho-social implications, such as an increased risk for disruptive behavior and substance abuse, for children whose activities are limited. Lifelong habits of exercise and fitness are developed during the teen years as well, so kids with activity restrictions may not build these habits and face an increased risk of obesity.

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