Adding a Lateral Extra‐articular Tenodesis Is Cost‐Effective in Primary Anterior Cruciate Ligament Reconstruction: A Markov Analysis

PURPOSE: To evaluate the cost-effectiveness of anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) augmentation in athletes with primary anterior cruciate ligament ruptures compared with ACLR alone. METHODS: A Markov chain Monte Carlo model evaluated the outcomes and costs of 1, 000 athletes undergoing ACLR with LET (ACLR-LET, iliotibial band) compared with ACLR alone. Costs, utility values, graft failure rates, and transition probabilities were derived from existing literature. Targeted meta-analysis of failure rates and patient-reported outcomes from randomized controlled trials comparing ACLR versus ACLR-LET was performed. Model outcomes included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio. Given varying definitions of "high risk, " sensitivity analyses assessed the cost-effectiveness of ACLR-LET across a range of theoretical failure rates. RESULTS: Meta-analysis of 1, 072 patients (530 ACLR-LET and 542 ACLR patients) showed a graft failure rate of 5. 1% (95% confidence interval CI, 2. 9%-8. 8%) for ACLR-LET compared with 11. 2% (95% CI, 7. 0%-17. 6%) for ACLR alone (relative risk, 0. 39; 95% CI, 0. 27-0. 57; P <. 001). Across a 5-year horizon, the mean total cost of ACLR alone was 68, 605 ± 9, 472 compared with 56, 217 ± 7, 349 for ACLR-LET. ACLR-LET yielded 1. 88 ± 0. 30 QALYs compared with 1. 54 ± 0. 30 QALYs for ACLR alone, and ACLR-LET was the preferred treatment in 98. 1% of patients in the microsimulation model. In sensitivity analyses, ACLR-LET remained more cost-effective assuming an ACLR-LET failure rate up to 11. 3% or an ACLR-alone failure rate down to 4. 8%. CONCLUSIONS: LET augmentation is cost-effective in athletes undergoing primary ACLR. The results of this Monte Carlo microsimulation suggest that ACLR-LET yields both superior outcomes and lower overall costs compared with ACLR alone. By use of sensitivity analysis, we found that only small improvements in graft failure rates were required for LET augmentation to be the favored treatment, suggesting that LET may be a cost-effective treatment option even when used beyond the athletes at highest-risk of graft rupture. LEVEL OF EVIDENCE: Level II, economic and decision analysis.