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The Cost-Effectiveness of Meniscal Repair Versus Partial Meniscectomy in the Setting of Anterior Cruciate Ligament Reconstruction

      Purpose

      To compare the cost-effectiveness of anterior cruciate ligament (ACL) reconstruction with meniscal repair to ACL reconstruction with partial meniscectomy.

      Methods

      A decision-analytic Markov disease progression model with a 40-year horizon was created simulating outcomes after both meniscal repair and partial meniscectomy at the time of ACL reconstruction. Event probabilities, costs, and utilities were used for the index procedures. The development of osteoarthritis and subsequent knee replacement were either calculated or selected from published literature. Difference in cost, difference in quality-adjusted life-years (QALYs), and incremental cost-effective ratio were calculated to determine which index procedure is most cost-effective.

      Results

      There is total direct cost from ACL reconstruction with meniscus repair of $17,898 compared with that with partial meniscectomy of $24,768 (cost savings of $6,870). There was an estimated gain of 18.00 QALYs after ACL reconstruction with meniscus repair compared with 17.16 QALYs with partial meniscectomy (increase of 0.84 QALYs). In this scenario, meniscus repair is the dominant index procedure at the time of ACL reconstruction.

      Conclusions

      Meniscal repair at the time of ACL reconstruction is more cost-effective than partial meniscectomy.

      Level of Evidence

      Level IV, economic and decision analysis.
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      References

        • Sanders T.L.
        • Kremers H.M.
        • Bryan A.J.
        • et al.
        Is anterior cruciate ligament reconstruction effective in preventing secondary meniscal tears and osteoarthritis?.
        Am J Sports Med. 2016; 44: 1699-1707
        • Andriacchi T.P.
        • Mündermann A.
        • Smith R.L.
        • Alexander E.J.
        • Dyrby C.O.
        • Koo S.
        A framework for the in vivo pathomechanics of osteoarthritis at the knee.
        Ann Biomed Eng. 2004; 32: 447-457
        • Hart A.J.
        • Buscombe J.
        • Malone A.
        • Dowd G.S.
        Assessment of osteoarthritis after reconstruction of the anterior cruciate ligament: A study using single-photon emission computed tomography at ten years.
        J Bone Joint Surg Br. 2005; 87: 1483-1487
        • Keays S.L.
        • Newcombe P.A.
        • Bullock-Saxton J.E.
        • Bullock M.I.
        • Keays A.C.
        Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery.
        Am J Sports Med. 2010; 38: 455-463
        • Li R.T.
        • Lorenz S.
        • Xu Y.
        • Harner C.D.
        • Fu F.H.
        • Irrgang J.J.
        Predictors of radiographic knee osteoarthritis after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2011; 39: 2595-2603
        • Lohmander L.S.
        • Ostenberg A.
        • Englund M.
        • Roos H.
        High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury.
        Arthritis Rheum. 2004; 50: 3145-3152
        • Oiestad B.E.
        • Engebretsen L.
        • Storheim K.
        • Risberg M.A.
        Knee osteoarthritis after anterior cruciate ligament injury: A systematic review.
        Am J Sports Med. 2009; 37: 1434-1443
        • von Porat A.
        • Roos E.M.
        • Roos H.
        High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: A study of radiographic and patient relevant outcomes.
        Ann Rheum Dis. 2004; 63: 269-273
        • Bellabarba C.
        • Bush-Joseph C.A.
        • Bach B.R.
        Patterns of meniscal injury in the anterior cruciate-deficient knee: A review of the literature.
        Am J Orthop (Belle Mead NJ). 1997; 26: 18-23
        • Kilcoyne K.G.
        • Dickens J.F.
        • Haniuk E.
        • Cameron K.L.
        • Owens B.D.
        Epidemiology of meniscal injury associated with ACL tears in young athletes.
        Orthopedics. 2012; 35: 208-212
        • Shoemaker S.C.
        • Markolf K.L.
        The role of the meniscus in the anterior-posterior stability of the loaded anterior cruciate-deficient knee: Effects of partial versus total excision.
        J Bone Joint Surg Am. 1986; 68: 71-79
        • Warren R.F.
        • Levy I.M.
        Meniscal lesions associated with anterior cruciate ligament injury.
        Clin Orthop Relat Res. 1983; 172: 32-37
        • Han S.B.
        • Shetty G.M.
        • Lee D.H.
        • et al.
        Unfavorable results of partial meniscectomy for complete posterior medial meniscus root tear with early osteoarthritis: A 5- to 8-year follow-up study.
        Arthroscopy. 2010; 26: 1326-1332
        • Meunier A.
        • Odensten M.
        • Good L.
        Long-term results after primary repair or non-surgical treatment of anterior cruciate ligament rupture: A randomized study with a 15-year follow-up.
        Scand J Med Sci Sports. 2007; 17: 230-237
        • Nakata K.
        • Shino K.
        • Horibe S.
        • et al.
        Arthroscopic anterior cruciate ligament reconstruction using fresh-frozen bone plug-free allogeneic tendons: 10-year follow-up.
        Arthroscopy. 2008; 24: 285-291
        • Roos H.
        • Laurén M.
        • Adalberth T.
        • Roos E.M.
        • Jonsson K.
        • Lohmander L.S.
        Knee osteoarthritis after meniscectomy: Prevalence of radiographic changes after twenty-one years, compared with matched controls.
        Arthritis Rheum. 1998; 41: 687-693
        • Feeley B.T.
        • Liu S.
        • Garner A.M.
        • Zhang A.L.
        • Pietzsch J.B.
        The cost-effectiveness of meniscal repair versus partial meniscectomy: A model-based projection for the United States.
        Knee. 2016; 23: 674-680
        • Lubowitz J.H.
        • Appleby D.
        Cost-effectiveness analysis of the most common orthopaedic surgery procedures: Knee arthroscopy and knee anterior cruciate ligament reconstruction.
        Arthroscopy. 2011; 27: 1317-1322
        • Mather R.C.
        • Koenig L.
        • Kocher M.S.
        • et al.
        Societal and economic impact of anterior cruciate ligament tears.
        J Bone Joint Surg Am. 2013; 95: 1751-1759
        • Paxton E.S.
        • Stock M.V.
        • Brophy R.H.
        Meniscal repair versus partial meniscectomy: A systematic review comparing reoperation rates and clinical outcomes.
        Arthroscopy. 2011; 27: 1275-1288
        • Buseck M.S.
        • Noyes F.R.
        Arthroscopic evaluation of meniscal repairs after anterior cruciate ligament reconstruction and immediate motion.
        Am J Sports Med. 1991; 19: 489-494
        • Cannon W.D.
        • Vittori J.M.
        The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees.
        Am J Sports Med. 1987; 20: 176-181
        • Melton J.T.K.
        • Murray J.R.
        • Karim A.
        • Pandit H.
        • Wandless F.
        • Thomas N.P.
        Meniscal repair in anterior cruciate ligament reconstruction: A long-term outcome study.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1729-1734
        • Shelbourne K.D.
        • Carr D.R.
        Meniscal repair compared with meniscectomy for bucket-handle medial meniscal tears in anterior cruciate ligament-reconstructed knees.
        Am J Sports Med. 2003; 31: 718-723
        • Toman C.V.
        • Dunn W.R.
        • Spindler K.P.
        • et al.
        Success of meniscal repair at anterior cruciate ligament reconstruction.
        Am J Sports Med. 2009; 37: 1111-1115
        • Kaminski R.
        • Kulinski K.
        • Kozar-Kaminska K.
        • et al.
        A prospective, randomized, double-blind, parallel-group, placebo-controlled study evaluating meniscal healing, clinical outcomes, and safety in patients undergoing meniscal repair of unstable, complete vertical meniscal tears (bucket handle) augmented with platelet-rich plasma.
        BioMed Res Int. 2018; 2018: 9315815
        • Miao Y.
        • Yu J.K.
        • Ao Y.F.
        • Zheng Z.Z.
        • Gong X.
        • Leung K.K.
        Diagnostic values of 3 methods for evaluating meniscal healing status after meniscal repair: Comparison among second-look arthroscopy, clinical assessment, and magnetic resonance imaging.
        Am J Sports Med. 2011; 39: 735-742
        • Stein T.
        • Mehling A.P.
        • Welsch F.
        • von Eisenhart-Rothe R.
        • Jäger A.
        Long-term outcome after arthroscopic meniscal repair versus arthroscopic partial meniscectomy for traumatic meniscal tears.
        Am J Sports Med. 2010; 38: 1542-1548
        • Aglietti P.
        • Zaccherotti G.
        • De Biase P.
        • Taddei I.
        A comparison between medial meniscus repair, partial meniscectomy, and normal meniscus in anterior cruciate ligament reconstructed knees.
        Clin Orthop Relat Res. 1994; 307: 165-173
        • Brophy R.H.
        • Wright R.W.
        • David T.S.
        • et al.
        Association between previous meniscal surgery and the incidence of chondral lesions at revision anterior cruciate ligament reconstruction.
        Am J Sports Med. 2012; 40: 808-814
        • Muraki S.
        • Akune T.
        • Oka H.
        • et al.
        Incidence and risk factors for radiographic knee osteoarthritis and knee pain in Japanese men and women: A longitudinal population-based cohort study.
        Arthritis Rheum. 2012; 64: 1447-1456
        • Mather III, R.C.
        • Hettrich C.M.
        • Dunn W.R.
        • et al.
        Cost-effectiveness analysis of early reconstruction versus rehabilitation and delayed reconstruction for anterior cruciate ligament tears.
        Am J Sports Med. 2014; 42: 1583-1591
        • Ginsburg P.B.
        Wide variation in hospital and physician payment rates evidence of provider market power.
        Res Brief. 2010; 16: 1-11
        • Bozic K.J.
        • Stacey B.
        • Berger A.
        • Sadosky A.
        • Oster G.
        Resource utilization and costs before and after total joint arthroplasty.
        BMC Health Serv Res. 2012; 12: 73
        • Gupta S.
        • Hawker G.A.
        • Laporte A.
        • Croxford R.
        • Coyte P.C.
        The economic burden of disabling hip and knee osteoarthritis (OA) from the perspective of individuals living with this condition.
        Rheumatology. 2005; 44: 1531-1537
        • Losina E.
        • Walensky R.P.
        • Kessler C.L.
        • et al.
        Cost-effectiveness of total knee arthroplasty in the United States: Patient risk and hospital volume.
        Arch Intern Med. 2009; 169: 1113-1121
        • Ruiz D.
        • Koenig L.
        • Dall T.M.
        • et al.
        The direct and indirect costs to society of treatment for end-stage knee osteoarthritis.
        J Bone Joint Surg Am. 2013; 95: 1473
        • Center for the Evaluation of Value and Risk in Health
        CEA: Cost-Effectiveness Analysis Registry 2017.
        • Gottlob C.A.
        • Baker Jr., C.L.
        Anterior cruciate ligament reconstruction: Socioeconomic issues and cost effectiveness.
        Am J Orthop (Belle Mead NJ). 2000; 29: 472-476
        • Stewart B.A.
        • Momaya A.M.
        • Silverstein M.D.
        • Lintner D.
        The cost-effectiveness of anterior cruciate ligament reconstruction in competitive athletes.
        Am J Sports Med. 2017; 45: 23-33
        • Mather III, R.C.
        • Garrett W.E.
        • Cole B.J.
        • et al.
        Cost-effectiveness analysis of the diagnosis of meniscus tears.
        Am J Sports Med. 2015; 43: 128-137
        • Moulton S.G.
        • Bhatia S.
        • Civitarese D.M.
        • Frank R.M.
        • Dean C.S.
        • LaPrade R.F.
        Surgical techniques and outcomes of repairing meniscal radial tears: A systematic review.
        Arthroscopy. 2016; 32: 1919-1925
        • Kurzweil P.R.
        • Lynch N.M.
        • Coleman S.
        • Kearney B.
        Repair of horizontal meniscus tears: A systematic review.
        Arthroscopy. 2014; 30: 1513-1519
        • Papageorgiou C.D.
        • Gil J.E.
        • Kanamori A.
        • Fenwick J.A.
        • Woo S.L.
        • Fu F.H.
        The biomechanical interdependence between the anterior cruciate ligament replacement graft and the medial meniscus.
        Am J Sports Med. 2001; 29: 226-231
        • Smith III, J.P.
        • Barrett G.R.
        Medial and lateral meniscal tear patterns in anterior cruciate ligament-deficient knees. A prospective analysis of 575 tears.
        Am J Sports Med. 2001; 29: 415-419
        • Rochcongar G.
        • Cucurulo T.
        • Ameline T.
        • et al.
        Meniscal survival rate after anterior cruciate ligament reconstruction.
        Orthop Traumatol Surg Res. 2015; 101: S323-S326
        • Westermann R.W.
        • Wright R.W.
        • Spindler K.P.
        • Huston L.J.
        • Wolf B.R.
        Meniscal repair with concurrent anterior cruciate ligament reconstruction: Operative success and patient outcomes at 6-year follow-up.
        Am J Sports Med. 2014; 42: 2184-2192
        • Van Meer B.L.
        • Meuffels D.E.
        • Van Eijsden W.A.
        • Verhaar J.A.N.
        • Bierma-Zeinstra S.M.A.
        • Reijman M.
        Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review.
        Br J Sports Med. 2015; 49: 975-983