Scientific Articles   |    
Societal and Economic Impact of Anterior Cruciate Ligament Tears
Richard C. Mather, III, MD1; Lane Koenig, PhD2; Mininder S. Kocher, MD, MPH3; Timothy M. Dall, MS4; Paul Gallo, BS4; Daniel J. Scott, MA5; Bernard R. Bach, Jr., MD6; Kurt P. Spindler, MD8; the MOON Knee Group
1 Duke Orthopaedic Surgery, 4709 Creekstone Drive, Suite 200, Durham, NC 27710
2 KNG Health Consulting, 15245 Shady Grove Road, Suite 305, Rockville, MD 20850. E-mail address: lane.koenig@knghealth.com
3 Division of Sports Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115
4 IHS Global Insight, 1150 Connecticut Avenue N.W., Washington, DC 20036-4104
5 Duke University School of Medicine, Erwin Road, Durham, NC 27710
6 Division of Sports Medicine, Rush University Medical Center, 1611 West Harrison Street, Chicago, IL 60612
8 Vanderbilt Sports Medicine, 4200 Medical Center East, South Tower, 1215 21st Avenue South, Nashville, TN 37232-8774
View Disclosures and Other Information
  • Disclosure statement for author(s): PDF

Investigation performed at KNG Health Consulting, Rockville, Maryland

Warren R. Dunn, MD, MPH, Annunziato Amendola, MD, Jack T. Andrish, MD, Christopher C. Kaeding, MD, Robert G. Marx, MD, MSc, Eric C. McCarty, MD, Richard D. Parker, MD, and Rick W. Wright, MD, are MOON Group members.

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 02;95(19):1751-1759. doi: 10.2106/JBJS.L.01705
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case



An anterior cruciate ligament (ACL) tear is a common knee injury, particularly among young and active individuals. Little is known, however, about the societal impacts of ACL tears, which could be large given the typical patient age and increased lifetime risk of knee osteoarthritis. This study evaluates the cost-effectiveness of ACL reconstruction compared with structured rehabilitation only.


A cost-utility analysis of ACL reconstruction compared with structured rehabilitation only was conducted with use of a Markov decision model over two time horizons: the short to intermediate term (six years), on the basis of Level-I evidence derived from the KANON Study and the Multicenter Orthopaedic Outcomes Network (MOON) database; and the lifetime, on the basis of a comprehensive literature review. Utilities were assessed with use of the SF-6D. Costs (in 2012 U.S. dollars) were estimated from the societal perspective and included the effects of the ACL tear on work status, earnings, and disability. Effectiveness was expressed as quality-adjusted life years (QALYs) gained.


In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a QALY gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation.


ACL reconstruction is the preferred cost-effective treatment strategy for ACL tears and yields reduced societal costs relative to rehabilitation once indirect cost factors, such as work status and earnings, are considered. The cost of an ACL tear over the lifetime of a patient is substantial, and resources should be directed to developing innovations for injury prevention and for altering the natural history of an ACL injury.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org


    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe

    RB Frobell(1), LS Lohmander (1,2,3)
    Posted on January 27, 2014
    Comment on ”Societal and economic impact of anterior cruciate ligament tears”
    (shown at end of comment)

    We have read this article with interest and thank our colleagues for this important study on the societal and economic impact of treatment alternatives after anterior cruciate ligament (ACL) tears. The results of health economy analyses rely heavily on the values and outcomes used for input in the models, and we note that results from the 2-year outcome of our randomized controlled trial KANON (Current Controlled Trials ISRCTN84752559) were used in this specific exercise [1]. However, data from the 5-year follow up, which might have been more appropriate to use, have been available since January 2013 [2]. We further note that some of the outcomes of the KANON study used in the modeling appear to be misinterpreted, potentially leading to incorrect results and conclusions.

    Meniscus surgeries have a large impact on the results of this economic modeling because they contribute not only as isolated events, but also form a base in the economic modeling to determine the later osteoarthritis development that contributes markedly in driving costs of the long-term model. It is therefore critical to use correct numbers when citing the high-level evidence of our study. In our 5-year follow up report, we described and analyzed in detail the frequency of meniscus surgery for the entire period, and found no statistically significant difference in frequency of meniscus surgery between the treatment groups [2]. Likewise, in our 2-year trial report, we found no statistically significant difference in meniscus surgery between the treatment groups when including all meniscus surgeries from baseline to end of follow-up [1]. We are thus unclear why Dr. Mather and colleagues chose to include only the frequency of delayed meniscus surgeries and thereby disregarded the menisci that underwent surgery at the time of ACL reconstruction. We are not aware of any publication indicating that meniscus surgery performed at the time of ACL reconstruction is less harmful than other types of meniscus surgery in relation to the risk of later osteoarthritis development. We also note that the significantly higher frequency of other types of surgeries and the significantly higher frequency of rehabilitation visits among those who underwent early ACL reconstruction did not find its way into the model.

    We further wish to point out that no high-level studies have shown an advantage of ACL reconstruction over non-surgical management with regard to the risk osteoarthritis development. On the contrary, observational studies have failed to find a difference [3], as did we after 5 years in the KANON-trial [2].

    Lastly, but also markedly influencing the societal and economic impact reported in this study, the authors assume that the 37% who underwent a delayed ACL reconstruction in our trial at the time of 2-year follow up (51% at 5 years) were considered to suffer from symptomatic instability and “have functional limitations similar to the pre-surgery limitations of patients with an ACL tear as reported in the MOON database”. This erroneous assumption was made in the presence of high-level published evidence at 2- and 5-year follow-up of no statistically significant differences in validated patient-reported outcomes or activity level between those who underwent early ACL reconstruction plus rehabilitation, rehabilitation alone with the option of delayed ACL reconstruction, or rehabilitation alone [1,2].

    We agree with Drs. Mather and colleagues that analyses of the economical and societal impact of ACL injury are important. However, we believe that to provide the most useful information, such analyses should be based on equipoise with regard to the different treatment alternatives, use the most recent and updated evidence from publications of high-level studies, and build models based on correct information from these studies.

    Author affiliations:
    (1) Orthopedics, Clinical Sciences Lund, Lund University, Sweden
    (2) Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
    (3) Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark


    1. Frobell, R.B. et al., A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med, 2010. 363(4): p. 331-42.
    2. Frobell, R.B. et al., Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ, 2013. 346: p. f232.
    3. Meuffels, D.E. et al., Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes. Br J Sports Med, 2009. 43(5): p. 347-51.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    Georgia - Choice Care Occupational Medicine & Orthopaedics
    Massachusetts - The University of Massachusetts Medical School
    Pennsylvania - Penn State Milton S. Hershey Medical Center