Allografts

Allografts are increasing rapidly in popularity. A survey of the largest U.S. tissue banks discloses a price range for various ACL allografts of $1400 to more than $3000, with a mean of about $2000 per case. A recently published study³ using patient data from 1996 to 1998 showed allografts at that time to substantially reduce costs by decreasing the likelihood of admission and decreasing surgical time. However, today virtually all ACLR procedures may be performed as outpatient with the use of femoral blocks (see later), so there is little further potential cost savings in this regard from the use of allografts. Even without the use of femoral blocks, ACLR can usually be performed easily on an outpatient basis.

Allograft use will produce slightly decreased costs from reduced operating time due to the absence of a surgical harvest. Experienced surgeons will generally accomplish the harvest in about 10 minutes, but the time may be substantially higher for surgeons who perform the procedure only occasionally. In either case the reduced time will not significantly offset the high cost of the allograft; in addition, there is some diversion of assistant or surgeon time involved in opening, thawing, and washing the allograft. The other potential benefit of allograft use is avoidance of harvest morbidity. This may be significant regarding kneeling pain after bone–patellar tendon–bone (BPTB) harvest. The morbidity for hamstring harvest has been shown to be negligible. Disadvantages with allograft versus autograft use may include lower stability rates⁴ (see Chapter 69) as well as the small but definite risk of disease transmission.

The cost implications of widespread allograft use are staggering. Macroeconomically, $2000 per allograft multiplied by an estimated 110,000 predicted ACLRs yields a cost differential of more than $200 million between no use of allografts and complete use of allografts nationwide. Microeconomically, if allografts are not separately reimbursed above the basic cost of the procedure, their use will virtually always cause the procedure to be performed at a net loss to the institution. Because most contracts do reimburse for allografts, this is often not an issue, but it is important to be aware of contract provisions at the given institution for the specific payer involved.

Fixation Implants

We have surveyed the costs of the fixation implants produced by the major manufacturers of such devices. The cost range of these devices is summarized in Table 9-1. However, discounting of up to 25% below the listed range is common. Interference screws, which are still the most widely used devices, generally cost between $200 and $300 each. The cost differential between metal and bioabsorbable screws has largely disappeared, and most sales today are of the bioabsorbable devices. The former practice of using metal devices as a cost-saving measure is thus generally no longer productive. The tibial post screw stands alone as the least expensive tibial or femoral device, with a cost of less than $100. Some devices are priced as high as $500. In general there is little relationship between the sophistication of the device and its cost, and pricing by the companies would appear to be driven primarily by what the market will bear. Overall, combined tibial and femoral fixation device cost per case will generally be in the range of $400 to $500.

Table 9-1 Economics of Anterior Cruciate Ligament Reconstruction

Anterior Cruciate Ligament Instrumentation Tray Rental

ACL tray rentals vary widely but will often cost the institution about $500.

Disposables

Disposable pins and the like typically cost about $300 or less per case.

Total Cost

As is seen from the previous remarks and Table 9-1, disposables, tray rental, and fixation devices will produce an aggregate cost of $1200 per case; the cost is lower for the institution that owns its own ACL guide system. The addition of an allograft will increase the average cost to roughly $3200 per case. Thus, it can be seen that ACLR without allograft falls below total payer payments in virtually all cases, allowing the institution to retain some payment to cover its fixed costs. The addition of an allograft will not be problematic, provided it is separately reimbursed. Thus, from a microeconomic perspective, payer reimbursement of allografts becomes the key factor in preserving solvency.

Femoral Blocks

In the Chicago area, femoral blocks are reimbursed at roughly $60 to $80 per block. They are reimbursed either using a specific Current Procedural Terminology (CPT) code or, more often, as an additional 15 minutes or so of anesthesia time. They have been shown to be highly cost effective by permitting reliable, same-day discharge.^4–7 Although same-day discharge is routinely accomplished by most orthopaedic surgeons without the block, the block increases the percentage to nearly 100%, with greatly increased patient comfort. Pain is eliminated as a discharge obstacle, and nausea is also reduced as a discharge obstacle because there is no postoperative narcotic nausea exacerbation. Furthermore, femoral blocks clearly reduce short-term narcotic use after discharge, thus decreasing the incidence of nausea, constipation, and other opioid side effects at home, which can be significant in some patients. The small cost of the block is greatly outweighed by the overall reduced facility costs in allowing patients to leave the hospital expeditiously. The morbidity of these blocks has been negligible.

Cold Machines

Motorized ice-flow machines cost about $300. They are beloved by patients for their pain-relieving properties. The literature, including a meta-analysis, shows their efficacy after ACLR^8–10 and total knee arthroplasty.¹¹ However, despite this favorable literature, third-party payers have increasingly refused to pay for motorized ice-flow machines in recent years. In the absence of insurance reimbursement, most patients are not willing to pay out of pocket for them.

Continuous Passive Motion

Continuous passive motion (CPM) is somewhat less commonly used and more difficult to obtain reimbursement for than in prior years. Although early range of motion (ROM) may be improved, studies have failed to show significant benefit regarding ultimate ROM or postsurgical pain in ACLR.^12–14 This parallels studies showing little or no long-term benefit after total knee arthroplasty.^15–17 This literature has somewhat dampened third-party payer enthusiasm for these devices. The daily cost ranges upward from the Medicare rate of $23.

Postoperative Knee Braces

Postoperative knee braces have a definite use in some rehabilitation protocols in regaining knee extension. They also provide protection in the postoperative period. Some surgeons do not use them. They are universally paid by payers as a separate cost item.

Functional Knee Braces

So-called derotation braces were formerly routinely used when patients returned to pivoting activities. However, today they are used by far fewer surgeons than in past years. In the presence of a stable knee, there is no evidence that they are of significant benefit. In addition, the costs can be substantial, especially for custom braces. Many payers will reimburse the approximate $800 cost of “off the shelf” braces but not the higher $1500 price tag of custom braces.

Physical Therapy

Adequate physical therapy is necessary to restore motion, strength, and function. Although the costs vary by orders of magnitude among various regimens, there is little evidence regarding relative efficacies. Primarily home-based regimens are clearly more economical, but it is not clear that they are equally effective with clinic-based regimens. Also, the quantity of therapy needed varies somewhat by the demands of the patient, with high-performance competitive athletes generally needing more than others. Individual visit charges are also quite variable. The approximate cost range can vary from about $1000 to $3000 and much more in some cases. Most plans include physical therapy benefits, but some do not. The number of available visits should be known in advance so that the surgeon does not use them all before the rehabilitation is completed. Many, but not all, plans will allow expanded benefits in cases of special need after appropriate appeal.

Navigation

Computerized navigation systems have been introduced^18,19 but are not currently in widespread use. Their advantage is said to be greater tunnel placement accuracy. It is not clear whether their use will ever be widespread, but if so, they will add both direct cost and increased operative time cost to ACLR. The current cost of bringing in a system for a case is about $450. There is insufficient literature to evaluate relative outcomes with and without navigation. Some believe that the less-expensive option of simple intraoperative radiographs without computerized navigation can also be efficacious.

Double-Bundle Anterior Cruciate Ligament Reconstruction

Double-bundle ACLR is more time consuming than single-bundle cases and thus increases surgical times. It also generally doubles implant costs because two femoral and two tibial implants are needed in most cases—an approximate average increase of $450 per case for fixation implants alone. Early clinical results have been good,^20,21 but it is too soon to know whether the benefits are sufficient to justify the increased time, difficulty, and cost. Because many plans do not reimburse invoices at such a low level, the extra implant costs may ultimately be subtracted from the often-thin profit margin of these cases.

Tissue Engineering

The use of growth factors and delivery vehicles for them is imminent.^22,23 This will inevitably add significant cost to ACLR.