Early ACL reconstruction preferable, depending on cost to patient

Bernstein J. J Bone Joint Surg (Am). 2011; 93:e48(1-5).

A decision analysis model of an earlier randomized controlled trial found that early anterior cruciate ligament reconstruction may be preferable if the cost of preventing a meniscal tear outweighs the cost of reconstruction.

The results of an earlier randomized, controlled trial showed the risks and values involved with either early or delayed anterior cruciate ligament (ACL) reconstruction were equal. However, researcher Joseph Bernstein, MD, noted in his study, the original investigators omitted an important factor: They did not analyze the utility of one method versus the other in preventing meniscal tears. Fewer meniscal tears were found in the group that underwent early ACL reconstruction.

Using the options and probabilities from the trial, Bernstein constructed a decision tree to analyze the costs of a meniscal tear and ACL reconstruction. It revealed that 23% of 62 patients in the early surgery group had resected menisci (29 resections) and 35% of 59 patients in the rehabilitation group that avoided surgery initially had resected menisci (41 resections).

Furthermore, Bernstein found that “when the cost of a meniscal tear exceeds the cost of surgery by more than a factor of 5.25,” early surgery is the better option and vice versa.

Rehabilitation with potential delayed surgery may be the better treatment option for patients if the risks of the surgery would outweigh the risks of a meniscal tear. In the study, Bernstein suggested working with each individual patient to determine the risks and benefits of either strategy.