Bone–Patellar Tendon–Bone and Quadriceps Tendon Autografts Are More Cost‐Effective Than Hamstring Autograft and Allograft for Anterior Cruciate Ligament Reconstruction

PURPOSE: To compare the cost-effectiveness of bone-patellar tendon-bone (BPTB) autograft, hamstring (HS) autograft, quadriceps tendon (QT) autograft, and allograft anterior cruciate ligament reconstruction using contemporary clinical data and time-driven activity-based costing. METHODS: A decision-analytic Markov model was constructed to compare 5-year costs and quality-adjusted life years (QALYs) for BPTB, HS, QT, and allograft anterior cruciate ligament reconstruction. Probabilities of graft failure, donor-site morbidity, infection, and revision outcomes were derived from contemporary literature. Direct medical costs were obtained from multicenter time-driven activity-based costing data. Model outcomes included costs, QALYs, and the incremental cost-effectiveness ratio. Deterministic and probabilistic sensitivity analyses assessed model robustness across clinically plausible parameter ranges. RESULTS: QT and BPTB autografts were the highest-value strategies in the model. At a willingness-to-pay threshold of $50,000 per QALY, QT was cost-effective relative to BPTB (incremental cost-effectiveness ratio: $42,905) and showed slightly greater modeled effectiveness; however, BPTB was least costly ($3917 vs $4901) and nearly as effective (4.589 vs 4.612 QALYs). HS autograft and allograft were more costly and less effective in the base-case model. Threshold analyses showed that small changes in operative cost (BPTB decrease of 4.5% or QT increase of 3.7%) or donor-site morbidity (BPTB decrease from 43.0% to 39.9% or QT increase from 2.9% to 7.8%) shifted the preferred strategy from QT to BPTB. In probabilistic sensitivity analyses, QT was preferred in 55.7% of simulations and BPTB was favored in the remaining 44.3%, with QT dominant in 22.4% of simulations. CONCLUSIONS: QT and BPTB autografts offered the highest value for anterior cruciate ligament reconstruction, with QT slightly more effective and BPTB least costly. HS autograft and allograft were more costly and less effective. Given the sensitivity of these results to surgeon-specific factors, operative costs, and donor-site morbidity, graft selection should remain individualized based on patient goals, clinical considerations, and surgeon expertise rather than cost alone. LEVEL OF EVIDENCE: Level III, economic and decision analysis.