Lateral Extra‐articular Tenodesis is Cost‐Effective at the Time of Primary Hamstring Autograft Anterior Cruciate Ligament Reconstruction in High‐Risk Patients

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Abstract
Purpose: To perform breakeven analysis to assess the cost‐effectiveness of performing lateral extra‐articular tenodesis (LET) at the time of hamstring autograft primary anterior cruciate ligament reconstruction (ACLR) in high‐risk patients. Methods: Baseline costs for ACLR, ACLR with LET (ACLR‐LET), revision ACLR, and initial failure rate were collected from the literature. Two initial failure rates following hamstring autograft ACLR without LET in high‐risk patients were used based on a previous study: the rate of revision surgery (11%) and the rate of clinical failure due to rotatory instability (40%). Breakeven economic analysis was used to assess the cost‐effectiveness of adding LET to primary ACLR. To account for the variability in cost, initial failure rates, and procedural differences across institutions, a wide range of values were used to calculate the absolute risk reduction (ARR) and number needed to treat (NNT) to achieve cost‐effectiveness. Results: Assuming primary ACLR cost of $20,840, ACLR‐LET cost of $27,405, and revision ACLR cost of $35,205, primary LET is cost‐effective at initial failure rates exceeding 18.7% (ARR = 0.187, NNT = 5). Assuming a 40% failure rate, LET is cost‐effective when revision surgery costs are greater than $16,412 (ARR = 0.400, NNT = 3) or when primary ACLR‐LET costs less than $39,422 (ARR = 0.400, NNT = 3). When assuming a failure rate of 11%, LET is cost‐effective when revision surgery costs exceed $59,700 (ARR = 0.110, NNT = −9) or when primary ACLR‐LET is no greater than $24,712 (ARR = 0.110, NNT = 10). Conclusions: Primary LET is a cost‐effective intervention for a wide range of primary and revision surgery costs according to this breakeven economic analysis. Using surgical cost estimates from literature, LET is cost‐effective when the initial failure exceeds 18.7%, or when revision surgery exceeds $16,412, which is greater than reported in current literature, thus indicating the clinical and economic benefits of primary LET in high‐risk patients undergoing hamstring autograft ACLR. Level of Evidence: Level IV, economic analysis.

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