We will be performing site maintenance on AAOS.org on February 8th from 7:00 PM – 9:00 PM CST which may cause sitewide downtime. We apologize for the inconvenience.

Universal neuromuscular training, such as this hop-and-hold exercise, can help prevent ACL injuries. Reproduced from Hewett TE, Myer GD, Ford KR, Slauterbeck JR: Dynamic neuromuscular analysis training for preventing anterior cruciate ligament injury in female athletes. Instr Course Lect 2007;56:397-406.

AAOS Now

Published 4/1/2014
|
Jennie McKee

Are Prevention Programs for ACL Injuries Cost Effective?

Anterior cruciate ligament (ACL) injuries in young athletes are associated with significant healthcare costs. According to research presented at the AAOS Annual Meeting, training programs aimed at improving neuromuscular control to reduce the incidence of ACL injuries are effective and low cost.

“As youth participation in sports has increased in the last decade, serious sports-related injuries have become a more common problem,” said lead author Eric F. Swart, MD. “Physicians’ appreciation of the significance of these injuries, as well as our understanding of risk factors, has grown, and we have begun to look into mechanisms to reduce and prevent injuries.

“In the case of ACL tears,” he continued, “several studies have suggested that training programs may reduce the risk of injury, while other research has sought to determine whether screening tools can measure a player’s risk of injury more accurately.”

As much as screening tools and preventive measures sound appealing, noted Dr. Swart, they can be challenging to implement on a widespread level due to financial and administrative factors.

“We conducted this study to gain a better understanding of the health impact and financial ramifications of implementing these practices,” said Dr. Swart.

Conducting the study
In accordance with guidelines created by the Panel on Cost-Effectiveness in Health and Medicine (a nonfederal panel with expertise in cost-effectiveness analysis, clinical medicine, ethics, and health outcomes measurement convened by the U.S. Public Health Service), the researchers created a decision-analytic model to assess the following three strategies for a population of young athletes participating in organized sports:

  • no training or screening
  • universal neuromuscular training
  • universal screening, with neuromuscular training for identified high-risk athletes only

“Because this was an economic analysis study—structured like a meta-analysis but also including financial factors and modeling—we did not have any actual participants,” explained Dr. Swart. “Instead, we analyzed data from published studies to understand the financial implications.”

The cohort included male and female high school and college students between the ages of 14 years and 22 years who participate in “cutting sports” such as soccer, handball, volleyball, and basketball.

The researchers estimated the athletes’ risk of injury, risk reduction from training and sensitivity, and specificity of screening based on data from the existing literature. They then performed sensitivity analyses on key model parameters to evaluate their effect on base case conclusions.

Dr. Swart and his colleagues calculated costs using a 20-year time horizon, based on the longest follow-up data they could obtain related to patients with ACL injuries. Costs for ACL reconstruction were estimated at between $5,000 and $17,000.

“Outcomes were expressed in quality-adjusted life years (QALY), which takes into account decreases in quality of life due to disease/injury as well as the time over which those changes occurred,” explained Dr. Swart.

Evaluating the results
Of the three strategies studied, universal neuromuscular training was the most cost-effective, noted Dr. Swart. On average, the data indicated that a universal training program would reduce the incidence of ACL injury by 63 percent (from 3 percent per player, per season, to 1.1 percent per player, per season), and would save $275 per player, per season. The analysis also showed that screening “was not cost-effective within the range of reported sensitivity and specificity values.”

“We were somewhat surprised that universal neuromuscular training seems to be more cost effective than universal screening with selective prevention and training,” noted Dr. Swart. “In retrospect, however, this makes sense, given that implementing universal training is relatively low cost, because it may mean simply altering a team’s warm-up routine. Screening all players, on the other hand, requires expensive items such as video cameras, computers, and other specialized equipment.

“While we were not surprised that training was more cost effective than no intervention,” continued Dr. Swart, “we were impressed at the magnitude of the benefit. Our results suggest that widely implementing a universal training strategy could actually pay for itself in terms of injuries prevented and surgeries avoided, which makes a very appealing case for primary prevention.”

Dr. Swart’s co-authors for “Prevention Programs for Anterior Cruciate Ligament Injuries: A Cost-Effectiveness Analysis,” include Lauren H. Redler, MD; Peter D. Fabricant, MD, MPH; Bert Mandelbaum, MD; Christopher S. Ahmad, MD; and Claire Wang, MD, PhD.

Disclosure information: Drs. Swart, Redler, Fabricant, and Wang—no conflicts. Dr. Mandelbaum—Arthrex, Inc.; Exactech, Inc.; Johnson & Johnson; Genzyme; Zimmer; Smith and Nephew; Alter G; Game Ready. Dr. Ahmad—Acumed, LLC; Arthrex, Inc.; and Stryker.

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

  • The goal of this economic analysis was to gain a better understanding of the health impact and financial ramifications of implementing screening tools and preventive measures for ACL injuries in young athletes.
  • Researchers created a decision-analytic model to assess the following three strategies for a population of young athletes participating in organized sports: no training or screening; universal neuromuscular training; and universal screening, with neuromuscular training for identified high-risk athletes only.
  • Training programs aimed at improving neuromuscular control to reduce the incidence of ACL injuries are effective and low cost, according to the study’s findings. On average, the data indicated that a universal training program would reduce the incidence of ACL injury by 63 percent (from 3 percent per player, per season, to 1.1 percent per player, per season), and would save $275 per player, per season

Additional Information
Presentation Abstract