Two papers in this issue have both separately focused on the results of ALL reconstruction (Sonnery-Cottet) and LET (Lording). Both procedures show potential benefit in reducing rotational laxity; however, adequately controlled, appropriately powered prospective randomized clinical trial data are still lacking. The ongoing study by Getgood et al45 (STAbiLiTY Study: ClinicalTrials.gov #NCT02018354) will aim to provide important information as to the efficacy of adjuvant LET procedures to contemporary ACLR, as well as to provide important information as to who may benefit most from these procedures, both from a clinical and cost point of view.
Procedures which address reconstruction of the ALC of the knee fall largely into 2 camps: LET and reconstruction of the anterolateral ligament reconstruction (ALLR).
Multiple techniques exist for performing the LET, all of which share some commonality in redirecting a strip of the iliotibial band (ITB) underneath the fibular collateral ligament (FCL) more proximally. In 1975, Lemaire19 published the first description of his own extra-articular technique. A 15 cm by 12 mm strip of the posterior ITB was harvested, and left attached distally to Gerdy’s tubercle. An osseous tunnel was drilled distal and deep to the FCL attachment, exiting on the posterior femoral condyle. The ITB was passed through this tunnel, and then back under the proximal FCL and sutured onto itself. The graft was then secured with the knee held in full external rotation.
Modern techniques are modifications of the Lemaire and MacIntosh procedures which use a shorter strip of ITB which is left attached distally and passed under the FCL more proximally. This can then be secured to the femur either with an interference screw within a bone tunnel or simply with a bone staple (authors’ preferred technique). ALL reconstruction techniques must be differentiated from the above procedures. They attempt to recreate the anatomy of the ALL, rather than using the ITB which has a more medial attachment point on the proximal tibia. ALLR therefore involves the use of graft material—allograft or often ipsilateral or contralateral hamstring tendons, to recreate a ligament from femoral to tibial bony attachment points. Chahla et al48 describe their technique of an ipsilateral hamstring tendon graft passed under the ITB and secured to a femoral attachment point 4.7 mm proximal and posterior to the femoral origin of the FCL. The tibial anchor point is midway between Gerdy’s tubercle and the fibular head. In this and many described technique, the graft ends are secured by means of interference screws within bony tunnels.
The clinical results of these techniques are discussed in additional articles in this edition by Lording and Sonnery-Cottet.49 Above and beyond these, a significant cost-difference exists with a modified-Lemaire type LET only requiring the addition of a bony staple compared with the use of ≥2 additional interference screws with most described anatomic ALLR. The anatomic technique described by Sonnery-Cottet et al50 utilizes a double-bundle technique to recreate the triangular nature of the ALL but this requires 3 interference screws.
ACL tears are among the most common musculoskeletal injury and therefore represent a significant economic burden to the health care system.2 Given the high volume of ACLR procedures performed each year, it is crucial to not only optimize efficiency at the time of surgery, but also improve long-term outcomes by minimizing the risk of failure and further costly reoperations, and delaying the progression of knee osteoarthritis. Therefore, investigation of interventions that may improve outcomes following ACLR are warranted, particularly given constrained health care budgets and thus an increased focus on value-based care.
Although advanced surgical techniques have the potential to improve patient outcomes, they typically also come with increased costs. Importantly, in addition to evaluating clinical outcomes with adjunctive surgical procedures, the associated health care resources consumed also need to be evaluated to determine whether the increased cost is justified relative to the improvement in clinical outcome.
To ensure efficient allocation of scarce health care dollars, policy makers rely on high-quality data from economic evaluations. An economic evaluation is a systematic method to determine the value for money of health care interventions by simultaneously evaluating costs and clinical effectiveness. By determining the incremental cost of the new intervention compared with current standard of care to achieve an additional unit of effectiveness, an economic evaluation can assist decision makers, clinicians, and patients in deciding the treatment alternative that offers the best value relative to health care resources spent.
Similar to DB-ACLR, reconstruction with an adjuvant ALC technique results in an increase in cost from slightly longer operating room time and also increases the cost of the procedure through the use of additional fixation materials such as sutures, staples or anchors, and, depending on the technique, supplemental grafts. Nunez et al51 compared DB-ACLR to SB-ACLR and showed that while both techniques led to similar clinical outcomes 2 years after ACLR, the single-bundle technique had significantly lower total cost. However, they did not calculate the incremental cost of DB-ACLR compared with SB-ACLR, therefore conclusions about the cost-effectiveness cannot be made.
Brophy and colleagues investigated the economic impact if all SB-ACLRs were instead performed as DB-ACLR. The authors reported additional total costs of up to $3962 per surgery with the double-bundle technique,52 estimating that a reduction in revision rate from 4.0% to 1.5% after a DB-ACLR would be required to offset this additional cost. LET and ALL procedures may result in a reduced degree of rotational laxity and a reduced risk of failure53 which could contribute to lower overall costs in the longer-term. An LET such as the modified-Lemaire procedure performed by our group13 involves no additional grafts, a single bone staple, and 2 additional sutures. This further reduction in procedural costs might therefore require a lesser reduction in revision rate to offset these modest costs. Further, the potential improvement in patient outcomes and reduced risk of failure may also allow earlier return to work and a reduction in lost productivity which will also lower indirect costs, and thus offset the higher upfront procedural-related resource use.
Therefore, there is potential for these procedures that confer additional rotational stability to improve value from both the health care payer and societal perspectives. In addition to future evidence regarding the clinical efficacy of ALL and LET, high-quality evidence with longer-term follow-up that simultaneously evaluates both the clinical outcomes as well as both direct and indirect health care resource use is required to determine whether these procedures represent good value.
Persistent anterolateral rotatory laxity following contemporary ACLR procedures remains an unwelcome complication that can lead to poor outcomes. A greater understanding of the ALC of the knee has led to a renewed interest in adjunctive extra-articular procedures and ALL reconstruction in a bid to control rotational laxity and minimize graft failure. History has shown that modification of techniques in ACLR can lead to more favorable kinematics, but this has not always translated into an improvement in clinical outcomes. Similarly, adjunctive techniques are associated with increased procedural costs and operating time, which need to be balanced against potentially modest clinical gains. The clinical case for selective use of additional procedures in ACLR is building. In addition to randomized trials involving both LET and ALL reconstruction, economic analyses with accurate costs and longer-term outcome data will help to determine whether there is a place for these procedures in health care systems looking to provide value-based care.
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