Cost-Effectiveness of Medial Patellofemoral Ligament Reconstruction for First-Time Patellar Dislocations: A Markov Analysis

BACKGROUND: Nonoperative management versus medial patellofemoral ligament reconstruction (MPFLR) for first-time patellar dislocations remains controversial, and it is unclear whether the increased up-front costs from MPFLR are justified. PURPOSE: To compare the cost-effectiveness of an initial trial of physical therapy alone to that of early MPFLR to determine the preferred cost-effective treatment strategy for first-time patellar dislocations. STUDY DESIGN: Economic and decision analysis; Level of evidence, 3. METHODS: A Markov chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs (in US$) of 1000 simulated patients undergoing nonoperative management versus MPFLR for first-time patellar dislocations. Health utility values, transition probabilities, and costs were derived from published level 1/2 evidence in the literature. Outcome measures included costs, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio (ICER). The 10-year cost for each patient in the microsimulation model was averaged by the initial treatment strategy to capture the costs of any subsequent treatment methods that the patient underwent as a result of recurrent dislocations. Cycle length was defined as 1 year, with all costs and utilities discounted at 3% annually. RESULTS: Over the 10-year time horizon, mean total costs resulting from nonoperative management and MPFLR were $46,223 ± $9562 and $37,298 ± $14,130, respectively. On average, MPFLR was associated with 8.5 ± 0.6 QALYs, while nonoperative management was associated with 7.1 ± 0.5 QALYs. Overall, MPFLR was determined to be the preferred cost-effective strategy in 95.3% of patients included in the microsimulation, with nonoperative management predicted to be the preferred strategy in 4.7% of patients. CONCLUSION: MPFLR was shown to be the dominant cost-effective treatment strategy for first-time patellar dislocations based on the Monte Carlo microsimulation and probabilistic sensitivity analysis, and despite increased up-front costs, MPFLR was found to save costs in the long term. Patients who underwent an initial trial of nonoperative management experienced an increased risk of recurrent dislocations that ultimately resulted in an average cost for the nonoperative group that exceeded that of the MPFLR group because of the increased downstream costs incurred for recurrent dislocations. While this study supports the long-term cost-saving potential of MPFLR, these findings should be interpreted within the context of individual patient characteristics and clinical judgment.