A Cost-Effectiveness Analysis of the Addition of Autograft Lateral Extra-Articular Procedures to Primary Anterior Cruciate Ligament Reconstruction

Abstract

Background:

Multiple clinical studies have highlighted the improved outcomes of ACLR in associated with LEAPs. However, such procedures are associated with increased costs and operating room time, thus questioning their cost-effectiveness.

Purpose:

To evaluate the cost-effectiveness of augmenting an anterior cruciate ligament reconstruction (ACLR) with autograft lateral extra-articular procedures (LEAP), either a modified Lemaire or anterolateral ligament reconstruction.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

A cost-effectiveness analysis was developed using failure rates for ACLR with and without concomitant autograft LEAPs from existing level 1 and 2 studies. Institutional data were used to estimate costs, including hospital and surgeon fees for ACLR and additional implant costs for LEAP. Utility measures were derived by linear approximation of the European Quality of Life 5 Dimension from the Knee injury and Osteoarthritis Outcome Score to evaluate improvements in quality-adjusted life years (QALY), a standardized metric that combines quantity and quality of life into a single value, over 1 year. Cost-effectiveness was determined based on previous literature, with an intervention considered cost-effective if the incremental cost-effectiveness ratio (ICER) was <$50,000/QALY. Three 1-way sensitivity analyses were conducted to assess the effect of implant cost, LEAP failure rates, and surgical time on cost-effectiveness.

Results:

The total cost of an isolated ACLR was estimated at $14,000, increasing to $14,990 with LEAP augmentation. Cost-effectiveness analysis showed an ICER of $25,313/QALY with LEAP augmentation, remaining below the $50,000/QALY cost-effectiveness threshold. Implant costs could rise to $1265 while maintaining cost-effectiveness, given an LEAP operation time (OR) of 15 minutes. Additionally, the failure rate of LEAP-augmented ACLR could increase from 2.9% to 7.7% while still meeting cost-effectiveness criteria. Finally, time sensitivity analysis indicated that for the procedure to remain cost-effective, the maximum allowable additional operative time is 36 minutes, given an OR cost of $46/minute.

Conclusion:

Although LEAP increases the time and cost of ACLR, it remains a cost-effective strategy for patients who are suitable candidates for augmentation.

Keywords

anterior cruciate ligament cost-effectiveness incremental cost-effectiveness ratio lateral extra-articular tenodesis

Primary anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed procedures in orthopaedic surgery, accounting for an estimated annual cost of $7 billion.²² It is a reliable intervention that typically yields excellent outcomes after anterior cruciate ligament (ACL) tears.^2,3,17 However, despite its high success rates, failure can still occur in up to 18% of primary ACLRs and as high as 20% in revision procedures.^7,17 Several factors have been associated with an increased risk of failure after ACLR, including increased tibial slope, generalized hyperlaxity or knee recurvatum, participation in pivoting sports, increased pivot-shift, revision surgery, and younger age.^5,15,16,17 In these high-risk cases, it is hypothesized that standard ACLR alone may not sufficiently restore rotational stability, thus increasing the likelihood of graft failure.^{7,10,13,17,20}

To address this issue, there has been increased interest in lateral extra-articular procedures (LEAP), which have been shown to reduce failure rates in high-risk scenarios.^10,20 The 2 most commonly performed techniques are the modified Lemaire procedure and anterolateral ligament reconstruction (ALLR).⁷ Both procedures enhance rotational stability when performed alongside ACLR, improving functional outcomes and reducing graft failure risk.^7,10,20 Although these techniques are not particularly technically demanding, they do increase the overall cost of surgery due to the need for additional fixation devices and extra intraoperative time.

Given the interplay between the observed decrease in failure rate and the increase in cost, the present study aimed to perform a cost-effectiveness analysis using institutional pricing data and clinical outcomes for ACLR with or without concomitant autograft LEAPs. The authors hypothesized that, in high-risk patients, adding a LEAP would be significantly more cost-effective than performing an isolated ACLR, given its ability to lower the risk of graft failure.

Methods

Model Design

A decision tree analytical model was used to evaluate the cost-effectiveness of autograft LEAP augmentation in ACLR (Figure 1). This decision tree was developed using TreeAge Pro (TreeAge Software) to simulate a cohort of patients undergoing ACLR, with or without modified Lemaire or autograft ALLR augmentation. Only autograft ALLR was considered for the present study, given the lack of level 1 and 2 data on outcomes after allograft ALLR. After surgical simulation, patients could experience 1 of 2 terminal outcomes: clinical success or graft failure/retear. As is standard in cost-effectiveness analyses, several key assumptions were made to simplify the clinical scenarios and allow for accurate economic analyses. These assumptions included (1) all patients with ACL tears underwent ACLR; (2) patients who achieved clinical success required no further treatment; and (3) patients who experienced graft failure or retear were assumed to return to the same quality-adjusted life year (QALY) value as patients with an untreated ACL tear.

Figure 1.

Decision tree model for cost-effectiveness evaluation of ACLR augmented with a LEAP. Terminal outcome represented by a red triangle. ACL, anterior cruciate ligament; ACLR, anterior cruciate ligament reconstruction; LET, lateral extra-articular tenodesis; ALLR, anterolateral ligament reconstruction.

Model Parameters

Cost of Care

Both terminal outcomes, clinical success and graft failure/retear, were associated with a total cost of care and a corresponding improvement in QALY over a defined 1-year postoperative period. Procedure costs, limited to facility/anesthesia/surgeon fees, were estimated using a combination of institutional pricing data and expert opinion (Table 1). The expert consulted was a board-certified, triple-sports medicine fellowship-trained orthopaedic surgeon (J.C.) who performed >900 surgical cases annually, including a high volume of ACLRs and LEAPs. This level of clinical volume and specialization was considered sufficient to define expert status for cost estimation. Given the heterogeneity in modified Lemaire and autograft ALLR techniques, the additional cost of implants for the procedures was based on an average between a commercially available interference screw (for inlay fixation techniques) and an all-suture suture anchor (for onlay fixation), for 2 common methods of iliotibial band and gracilis autograft fixation, respectively.

Table 1

Utilized Sources for Transition Probabilities, Utilities, and Cost Inputs for Decision Tree Cost-Effectiveness Analysis ^a

Transition	Probabilities	Level of Evidence	Source/Reference (Year)
Isolated ACLR retear rate	10.1 ( 9.8-11.1)	1/2	D’Ambrosi et al⁶ (2025)/Park etal²¹ (2023)/Bosco etal⁴ (2024)/Onggo etal²⁰ (2021)
Isolated ACLR clinical success rate	89.9	1/2	-
LEAP augmented ACLR retear rate	2.9 (2.8-3.3)	1/2	Ambrosi etal⁶ (2025) / Park etal²¹ (2023)/Bosco etal⁴ (2024)/ Onggo etal²⁰ (2021)²
LEAP augmented clinical success rate	97.1	1/2	-
Utilities
ACL tear	0.37	1	Frobell etal⁸ (2010)
Isolated ACLR	0.87 (0.73-0.91)	1/2	Bosco etal⁴ (2024)
LEAP ACLR	0.88 (0.75-0.95)	1/2	Bosco etal (2024)
Costs
ACLR surgeon/hospital/anesthesia fees	$14,000	NA	Institutional data
LEAP implant	$300, fixation	NA	Institutional data/expert opinion
Additional OR time	$46/min.	4	Smith etal²³ (2022)

Data are presented as % (range), unless otherwise indicated. ACL, anterior cruciate ligament; ACLR, ACL reconstruction; LEAP, lateral extra-articular procedure; NA, not applicable; OR, operating room.

Utilities

Utilities are utilized in cost-effectiveness studies to measure the extent of an intervention on a scale from 0 to 1. In the present study, utilities were derived by linearly approximating the European Quality of Life 5 Dimensions (EQ-5D) from the Knee injury and Osteoarthritis Outcome Score (KOOS) to evaluate improvements in QALY over a 1-year postoperative period (Table 1). QALYs are a widely used metric in health economics that combines the length of life and its quality on a scale from 0 (equivalent to death) to 1 (perfect health).¹⁴ To streamline data entry into our model, KOOS scores from multiple level 1 and 2 studies^4,8 were weighted to generate a single value, eliminating the need to account for ranges. This weighted score was then converted into an improvement in QALY over a defined 1-year period.

Transition Probabilities

Two terminal outcomes were studied within each treatment arm (clinical success and/or retear/graft failure) for which transition probabilities were calculated from the available level 1 and 2 studies^4,6,20,21 (Table 1). As previously stated, only autograft ALLR was considered for the present study, given the lack of level 1 and 2 data on outcomes after allograft ALLR.

Analysis and Sensitivity Analysis

The ICER was calculated as the additional cost of LEAP augmentation relative to standard ACLR, divided by the corresponding increase in QALY between the 2 groups. The formula used for ICER calculation was as follows:

ICER = (Cos t^{ACLR + LEAP} - Cos t^{ACLR}) / (QAL Y^{ACLR + LEAP} - QAL Y^{ACLR}) .

A willingness-to-pay (WTP) threshold of $50,000 per QALY was applied, consistent with thresholds utilized in previously published cost-effectiveness analyses.¹⁹ The WTP reflects the maximum amount of money that society is considered to spend for 1 additional year of life, thus acting as a cutoff to decide the worthiness of the additional cost of an intervention.^18,19

Three 1-way sensitivity analyses were performed to assess the effect of implant cost, LEAP failure rates, and surgical time on cost-effectiveness. The first 1-way sensitivity analysis evaluated the maximum allowable cost of the LEAP augmentation to remain cost-effective under the $50,000/QALY threshold, assuming an additional operative room (OR) time of 15 minutes. For this analysis, the cost per minute in the OR was estimated at $46, as established in previous literature.²³ In the referred analysis, the cost of the LEAP was incrementally increased while holding all other variables constant. The following 1-way sensitivity analysis explored the interplay between the cost of LEAP augmentation and its effectiveness in reducing retear/graft failure rates. Specifically, it determined the degree to which the absolute retear/graft failure rate (pooled at 2.9% for ACLR+LEAP) would need to decrease compared with remaining cost-effective across varying LEAP costs. One last 1-way sensitivity analysis was conducted to determine the maximum increase in OR added time that LEAP could generate while remaining cost-effective. Consistent with previous calculations, the cost per OR minute was estimated at $46, based on established literature.²³

Results

Simulation results showed that LEAP augmentation increased QALY from 0.64 in the isolated ACLR cohort to 0.68 in the LEAP-augmented ACLR group.In terms of cost, augmented ACLR was associated with a higher expense of $14,990 compared with $14,000 for isolated ACLR. The calculated ICER for the LEAP-augmented group was $25,313 per QALY gained, remaining below the established $50,000/QALY threshold, thereby confirming the intervention’s cost-effectiveness.

The first sensitivity analysis examined the effect of LEAP implant cost on the procedure’s cost-effectiveness. Results showed that the implant price could increase to $1265 while remaining cost-effective, assuming a LEAP OR time of 15 minutes (Figure 2). Our second sensitivity analysis assessed the probability of clinical success for LEAP-augmented ACLR based on the calculated ICER. Simulation results indicated that the failure rate could rise from 2.9% to 7.7% while still meeting cost-effectiveness criteria (Figure 3). A final 1-way sensitivity analysis examined the effect of LEAP-added intraoperative time on the calculated ICER. Results indicated that to maintain cost-effectiveness, the maximum allowable additional operative time for the LEAP procedure was 36minutes, assuming an OR cost of $46 per minute (Figure 4).

Figure 2.

One-way sensitivity analysis comparing the LEAP additional cost with the calculated ICER. ALLR, anterolateral ligament reconstruction; ICER, incremental cost-effectiveness ratio; LEAP, lateral extra-articular procedure; LET, lateral extra-articular tenodesis; QALY, quality adjusted life years; WTP, willingness to pay.

Figure 3.

One-way sensitivity analysis comparing the LEAP probability of clinical success with the calculated ICER. ICER, incremental cost-effectiveness ratio; LEAP, lateral extra-articular procedure; QALY, quality adjusted life years.

Figure 4.

One-way sensitivity analysis comparing LEAP with added intraoperative time with the calculated ICER. ICER, incremental cost-effectiveness ratio; LEAP, lateral extra-articular procedure; QALY, quality adjusted life years; WTP, willingness to pay.

Discussion

The most important finding of the present study was that autograft LEAP augmentation improved QALY while maintaining cost-effectiveness, with an ICER of $25,313 per QALY gained, well below the $50,000/QALY threshold. Furthermore, although augmented ACLR yielded a slightly higher cost, sensitivity analyses confirmed its economic viability. The procedure remained cost-effective with an implant cost of up to $1265, a failure rate increase from 2.9% to 7.7%, and an operative time increase of 36 minutes at $46 per OR minute. These findings highlight the robustness of autograft LEAP augmentation’s cost-effectiveness under varying clinical and economic conditions.

Notably, the increase in QALY suggests long-term value beyond the initial procedure. The financial and clinical benefits of potentially avoiding an ACL graft revision reconstruction are substantial, reinforcing the cost-effectiveness of autograft LEAP augmentation at the index ACLR.^6,20 Moreover, several unaccounted downstream costs could be mitigated, including the risk of sustaining concomitant injuries at the time of ACL graft rupture that would require surgical intervention, the need for an additional graft harvesting procedure and any associated morbidity with this, additional health care utilization costs such as repeat magnetic resonance imaging, repeat physical therapy rehabilitation postoperatively, and the additional societal costs of time off of work. The strength of this cost-benefit is best exemplified by the model’s ability to tolerate more than a 2-fold increase in LEAP’s failure rate while remaining cost-effective.

Furthermore, the sustained cost-effectiveness of LEAP augmentation is further supported when accounting for variation in surgical technique. In a modified Lemaire, graft fixation may involve a suture anchor, staple, or interference screw.²⁴ Even with an implant price of $300 (the mean cost between an all-suture suture anchor and interference screw), the cost margin of $1265 enables the use of up to 4 implants before exceeding the cost-effectiveness thresholds. The margin becomes even more favorable if using less expensive implants. This favorable advantage extends even if autograft ALLR is used, which requires 2 fixation devices. However, it should also be noted that some surgeons use commercial augmentation kits for ALLR, which can increase cost and have therefore been listed as a limitation of the present investigation. In such cases, the margin for cost-effectiveness would be narrower.

Not only is there a financial buffer before LEAP augmentation becomes cost-ineffective, but there is also a substantial time margin. While the model assumed a mean LEAP augmentation time of 15 minutes, we recognize that variability exists based on surgeon experience, technique, and institutional workflows.⁹ Despite this, sensitivity analysis demonstrated that up to 36 additional minutes can be incurred before the procedure exceeds the cost-effectiveness threshold. Therefore, there is some flexibility for less-experienced surgeons to perform LEAP augmentation at the time of ACLR while remaining cost-effective. In summary, these findings demonstrate that autograft LEAP augmentation not only improves QALYs but also is cost-effective, with sustained value even when accounting for variability in failure rates, implant costs, and operative times. The present study underscores that modified Lemaire and autograft ALLR augmentation are both economically and clinically beneficial to ACLR in suitable candidates.

Limitations

This study is not without limitations. First, the data are based on prices at 1 institution and do not account for other surgeons at other institutions who may use differing techniques and at differing rates. However, as mentioned above, there is a considerable financial buffer. Secondarily, and perhaps more significantly, these data do not account for complications that may come exclusively from LEAP augmentation. This includes symptomatic hardware at the LEAP site that may warrant removal, wound complications at the additional surgical site, and complications arising from prolonged operative time.¹¹ although operative time as a result of LEAP augmentation is limited as above, there is still the possibility that more prolonged exposure to anesthesia may result in complications such as deep vein thrombosis, surgical site infections, and hospital readmissions that were not accounted in this model.¹ Cost-effectiveness stratified by ACLR graft (as graft rerupture rates vary between autografts and allografts) could not be performed due to the absence of level 1 and 2 outcome data necessary for inclusion in the current model. Nevertheless, emerging evidence indicates a declining preference for allograft options in lateral extra-articular augmentation, with reported¹² utilization rates <4%. In addition, our fixation cost estimates were based on common individual implant prices rather than complete commercial augmentation kits, which can sometimes be utilized (typically for ALLR). Although this study focused on autograft LEAPs and incorporated both the modified Lemaire and ALLR techniques, they were grouped for the model. This simplification does not account for biomechanical or outcome-based differences between techniques. Lastly, the use of 1-way sensitivity analyses limits the ability to account for simultaneous variability among multiple variables, potentially underestimating the model’s full uncertainty.

Conclusion

Although LEAPs increase the time and cost of ACLR, they remain a cost-effective strategy for patients who are suitable candidates for augmentation.

Footnotes

Final revision submitted October 10, 2025; accepted October 25, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: N.N.V. has received hospitality payments from Abbot Laboratories, Axonics Inc, Boston Scientific Corporation, Foundation Fusion Solutions, IBSA Pharma Inc, Nalu Medical Inc, Nevro Corp, Orthofix Medical, Pacira Pharmaceuticals Incorporated, Relievant Medsystems Inc, Salix Pharmaceuticals, Spinal Simplicity, Vericel Corporation, and Vertos Medial Inc; research support from Arthrex, Breg, Ossur, Smith & Nephew, and Stryker; consulting fees from Medacta USA and Stryker; and royalties from Arthrex, Graymont Professional Products, Smith & Nephew, and Stryker. J.C. has received consulting fees from Arthrex, CONMED Linvatec, DePuy Synthes Sales, Ossur, RTI Surgical, Smith & Nephew, and Vericel; hospitality payments from Breg, Joint Restoration Foundation, Medical Device Business Services, Pacira Pharmaceuticals, SI-Bone, and Stryker; speaking fees from Synthes GmbH; and support for education from Midwest Associates. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iDs

Rodrigo Saad-Berreta

Jorge Chahla

References

Agarwalla

Gowd

Liu

, et al. Effect of operative time on short-term adverse events after isolated anterior cruciate ligament reconstruction. Orthop J Sports Med. 2019;7(2):2325967118825453.

Ardern

Webster

Taylor

Feller

JA.

Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596-606.

Berreta

Villarreal-Espinosa

Pallone

, et al. Anterior cruciate ligament repair results in similar patient-reported outcome measures as anterior cruciate ligament reconstruction: a systematic review of prospective comparative studies. Arthroscopy. 2024;0(0).

Bosco

Giustra

Masoni

, et al. Combining an anterolateral complex procedure with anterior cruciate ligament reconstruction reduces the graft reinjury rate and improves clinical outcomes: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2024;52(8):2129-2147.

Costa

Perelli

Grassi

Russo

Zaffagnini

Monllau

JC.

Minimizing the risk of graft failure after anterior cruciate ligament reconstruction in athletes. A narrative review of the current evidence. J Exp Orthop. 2022;9(1):26.

D’Ambrosi

Corona

Cerciello

, et al. Combining an anterolateral complex procedure with anterior cruciate ligament reconstruction reduces graft reinjury without increasing the rate of complications: a systematic review and meta-analysis of randomized controlled trials. Am J Sports Med. 2025;53(10):2462-2470.

Delaloye

Hartog

Blatter

, et al. Anterolateral ligament reconstruction and modified Lemaire lateral extra-articular tenodesis similarly improve knee stability after anterior cruciate ligament reconstruction: a biomechanical study. Arthroscopy. 2020;36(7):1942-1950.

Frobell

Roos

Ranstam

Lohmander

LS.

A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010;363(4):331-342.

Giusto

Cohen

Dadoo

, et al. Lateral extra-articular tenodesis may be more cost-effective than independent anterolateral ligament reconstruction: a systematic review and economic analysis. J ISAKOS. 2024;9(4):689-698.

10.

Grassi

Olivieri Huerta

Lucidi

, et al. A Lateral extra-articular procedure reduces the failure rate of revision anterior cruciate ligament reconstruction surgery without increasing complications: a systematic review and meta-analysis. Am J Sports Med. 2024;52(4):1098-1108.

11.

Heard

Marmura

Bryant

, et al. No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction—results from the stability randomized trial. J ISAKOS. 2023;8(4):246-254.

12.

Hollyer

Sholtis

Loughran

, et al. Trends in lateral extra-articular augmentation use and surgical technique with anterior cruciate ligament reconstruction from 2016 to 2023, an ACL study group survey. J ISAKOS. 2024;9(6).

13.

Inderhaug

Stephen

Williams

Amis

AA.

Biomechanical comparison of anterolateral procedures combined with anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(2):347-354.

14.

Kiadaliri

Alava

Roos

Englund

Mapping EQ-5D-3L from the knee injury and osteoarthritis outcome score (KOOS). Qual Life Res. 2020;29(1):265-274.

15.

Liu

Jiang

, et al. An increased posterior tibial slope is associated with a higher risk of graft failure following ACL reconstruction: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2377-2387.

16.

Maletis

Inacio

MCS

Funahashi

TT.

Risk factors associated with revision and contralateral anterior cruciate ligament reconstructions in the Kaiser Permanente ACLR registry. Am J Sports Med. 2015;43(3):641-647.

17.

Monllau

Perelli

Costa

GG.

Anterior cruciate ligament failure and management. EFORT Open Rev. 2023;8(5):231.

18.

Neumann

Cohen

Weinstein

MC.

Updating Cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold. N Engl J Med. 2014;371(9):796-797.

19.

Neumann

Kim

DD.

Cost-effectiveness thresholds used by study authors, 1990-2021. JAMA. 2023;329(15):1312-1314.

20.

Onggo

Rasaratnam

Nambiar

, et al. Anterior cruciate ligament reconstruction alone versus with lateral extra-articular tenodesis with minimum 2-year follow-up: a meta-analysis and systematic review of randomized controlled trials. Am J Sports Med. 2022;50(4):1137-1145.

21.

Park

Lee

Cho

Pujol

Kim

SH.

Combined lateral extra-articular tenodesis or combined anterolateral ligament reconstruction and anterior cruciate ligament reconstruction improves outcomes compared to isolated reconstruction for anterior cruciate ligament tear: a network meta-analysis of randomized controlled trials. Arthroscopy. 2023;39(3):758-776.e10.

22.

Sherman

Calcei

Ray

, et al. ACL Study Group presents the global trends in ACL reconstruction: biennial survey of the ACL Study Group. J ISAKOS. 2021;6(6):322-328.

23.

Smith

Evans

Moriel

, et al. The cost of OR time is $46.04 per minute. J Orthop Bus. 2022;2(4):10-13.

24.

Tollefson

Shoemaker

Slette

, et al. Adequate failure loads for modified Lemaire lateral extra-articular tenodesis are achieved with an interference screw, staple, and suture anchor: a biomechanical study of structural properties. Am J Sports Med. Published online January 6, 2025:03635465241305739.