Safer and Cheaper: An Enhanced Milestone-Based Return to Play Program After Anterior Cruciate Ligament Reconstruction in Young Athletes Is Cost-Effective Compared With Standard Time-Based Return to Play Criteria

Abstract

Background: Safe return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is critical to patient satisfaction. Enhanced rehabilitation after ACL reconstruction with appropriate objective criteria for RTP may reduce the risk of subsequent injury. The cost-effectiveness of an enhanced RTP (eRTP) strategy relative to standard post-ACL reconstruction rehabilitation has not been investigated. Purpose: To determine if an eRTP strategy after ACL reconstruction is cost-effective compared with standard rehabilitation. Study Design: Economic and decision analysis. Methods: A decision-analysis model was utilized to compare standard rehabilitation with an eRTP strategy, which includes additional neuromuscular retraining, advanced testing, and follow-up physician visits. Cost-effectiveness was evaluated from a payer perspective. Costs of surgical procedures and rehabilitation protocols, risks of graft rupture and contralateral ACL injury, risk reductions as a result of the eRTP strategy, and relevant health utilities were derived from the literature. An incremental cost-effectiveness ratio of <$100,000/quality-adjusted life-year was used to determine cost-effectiveness. Sensitivity analyses were performed on pertinent model parameters to assess their effect on base case conclusions. In the base case analysis, the eRTP strategy cost was conservatively estimated to be $969 more than the standard rehabilitation protocol. Completion of the eRTP strategy was considered to confer a 25% risk reduction for graft rupture in comparison with standard rehabilitation. Results: The eRTP strategy was more cost-effective than standard rehabilitation alone. Based on 1-way threshold analyses, the eRTP strategy was cost-effective as long as its additional cost over standard rehabilitation was <$2092 or the eRTP strategy decreased the incidence of contralateral ACL rupture by >13.8%. Conclusion: The eRTP strategy in this study adds additional neuromuscular retraining and additional physician follow-up—as well as advanced testing goals upon which RTP is contingent—to traditional physical therapy. Our data suggest that these additions are cost-effective, even assuming only modest associated decreases in ACL graft failure. This study also determined that the only variable that had the potential to change the cost-effectiveness conclusion based on predetermined ranges was the additional cost of rehabilitation based on 1-way sensitivity analysis. Clinical Relevance: This study provides evidence of cost-effectiveness for payers, supporting the use of enhanced RTP programs. The sensitivity analyses herein may be used to determine if any given RTP program going forward is cost-effective, regardless of the exact components of the program.

Return-to-Competition Criteria After Ulnar Collateral Ligament Reconstruction: A Systematic Review and Meta-analysis

“…This observed lack of formal postoperative functional testing during UCLR rehabilitation stands in stark contrast to the anterior cruciate ligament reconstruction (ACLR) literature, in which numerous functional assessment tools have been devised and studied, such as hop testing, the running t test, KT-1000 arthrometry, dynamometer strength testing, isokinetic testing, and postural control analysis. 9,25,39 While successful progression through a return-to-throwing program without pain can serve as a crude functional assessment, athletes may downplay discomfort or alter their throwing mechanics in an attempt to expedite RTC. As the utilization of UCLR continues to increase, there is a growing need for validated methods of assessing functional recovery of not only the upper extremity but also the entire kinetic chain, including the core and lower extremities.…”

Return to Sport After Bone–Patellar Tendon–Bone Autograft ACL Reconstruction in High School–Aged Athletes

“… 7 , 9 Historically, there was a movement toward accelerated rehabilitation and earlier return to play, but this was based largely on lower-level evidence. DeFrancesco et al 8 proposed that enhanced rehabilitation, which includes additional neuromuscular training, advanced testing, and follow-up physician visits as compared with standard rehabilitation, is cost-effective based on a reduction in subsequent ACL injuries. To date, the optimal method of determining an athlete’s readiness to RTS is unknown and should be based on a patient’s physical function and the biologic factors that affect graft healing.…”

An In-Depth Analysis of Graft Rupture and Contralateral Anterior Cruciate Ligament Rupture Rates After Pediatric Anterior Cruciate Ligament Reconstruction

“…The high rates of complication found here further support the use of prevention programs and formal return-to-play programs, as previous research has shown that their value increases with the likelihood of subsequent injury. 2,9 We recognize that techniques in pediatric ACLR continue to evolve-the senior author (T.J.G.) now almost exclusively uses quadriceps tendon autograft with cortical button fixation-which may limit the generalizability of our findings to current patients.…”