Allograft Augmentation of Hamstring Autograft for Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction: Clinical and Cost-Effectiveness Analyses

Abstract

Background: Younger patients and those with smaller hamstring autograft diameters have been shown to be at significantly greater risk of graft failure after anterior cruciate ligament (ACL) reconstruction. To date, there is no information in the literature about the clinical success and/or cost-effectiveness of increasing graft diameter by augmenting with semitendinosus allograft tissue for younger patients. Hypothesis: Hybrid hamstring grafts are a cost-effective treatment option because of a reduced rate of graft failure. Study Design: Cohort study (economic and decision analysis); Level of evidence, 3. Methods: We retrospectively identified patients younger than 18 years who had undergone ACL reconstruction by a single surgeon between 2010 and 2015. During this period, the operating surgeon’s graft selection algorithm included the use of bone–patellar tendon–bone (BTB) autografts for the majority of patients younger than 18 years. However, hamstring autografts (hamstring) or hybrid hamstring autografts with allograft augment (hybrid) were used in skeletally immature patients and in those whom the surgeon felt might have greater difficulty with postoperative rehabilitation after BTB graft harvest. Patient demographics, graft type, graft diameter, the time the patient was cleared to return to activity, and the need for secondary surgical procedures were compared between the hamstring and hybrid groups. The clinical results were then used to assess the potential cost-effectiveness of hybrid grafts in this select group of young patients with an ACL injury or reconstruction. Results: This study comprised 88 patients (hamstring group, n = 46; hybrid group, n = 42). The 2 groups did not differ in terms of age, sex, timing of return to activity, or prevalence of skeletally immature patients. Graft diameters were significantly smaller in the hamstring group (7.8 vs 9.9 mm; P < .001), which corresponded with a significantly greater rate of graft failure (13 of 46 [28.3%] vs 5 of 42 [11.9%]; P = .049). As a result of the reduced revision rate, the hybrid graft demonstrated incremental cost savings of US$2765 compared with the hamstring graft, and the hybrid graft was the preferred strategy in 89% of cases. Conclusion: Driven by increased graft diameters and the reduced risk of revision, hybrid grafts appear to be a more cost-effective treatment option in a subset of younger patients with an ACL injury.