2015 ISAKOS Biennial Congress ePoster #1319

Routine Early Postoperative Radiography After Primary ACL Reconstruction is Not Cost Effective

Brian C. Werner, MD, Charlottesville, VA UNITED STATES
Michelle Kew, Charlottesville, VA UNITED STATES
Ian Dempsey, Charlottesville, VA UNITED STATES
Frank Winston Gwathmey, MD, Charlottesville, VA UNITED STATES
Mark D. Miller, MD, Charlottesville, VA UNITED STATES
David R. Diduch, MD, MS, Charlottesville, VA UNITED STATES

University of Virginia, Charlottesville, Virginia, USA

FDA Status Not Applicable

Summary: : Routine early postoperative radiography after primary ACL reconstruction is not cost effective, as the significant per-patient expense is not balanced by the low yield of clinically meaningful data.

Rate:

Abstract:

Objectives: Post-operative knee radiographs are frequently obtained in the first 6 to 12 weeks following uncomplicated primary anterior cruciate ligament (ACL) reconstruction. The objective of this study is to assess the utility and cost-effectiveness of routine postoperative radiography after uncomplicated primary ACL reconstruction.

Methods

After IRB approval was obtained, 1120 consecutive adult patients undergoing ACL reconstruction at a single institution were retrospectively reviewed. Exclusion criteria were revision ACL reconstruction (97 patients), multiligament reconstruction (83 patients) or concomitant high tibial osteotomy (7 patients), yielding a final cohort of 933 primary ACL reconstructions. Records were reviewed to determine whether a postoperative knee x-ray was obtained within the first 3 months after surgery. The radiologist read of the x-ray was reviewed, as were any subsequent knee x-rays or MRIs. An x-ray was considered to lead to a significant management change if any of 5 criteria were met: 1) demonstration of postoperative fracture, 2) demonstration of effusion that required aspiration not noted on physical exam, 3) demonstration of malpositioned hardware or anchor, 4) demonstration of aberrant tunnel placement or 5) if the initial postoperative x-ray was referred to in subsequent films which resulted in a change in intervention (ie, tunnel widening noted leading to revision surgery). X-ray charges, including imaging, technical and professional charges were calculated.

Results

599 of 933 primary ACL reconstruction patients (64.8%) had postoperative knee radiography at an average of 6.3 ± 3.5 weeks postoperatively. 97.7% of x-rays were read as normal by a musculoskeletal radiologist. 70.3% of x-ray results were documented in the clinical note. 14.1% of patients with a postoperative x-ray had subsequent imaging. 56% of patients with x-rays had radiopaque femoral fixation; 21.5% had radiopaque tibial fixation. There were no significant management changes based on the routine postoperative radiographs using the defined criteria. A total of $336,683 was billed to patients for postoperative x-rays, which equates to an average of $562 per patient.

Conclusions

Routine early postoperative radiography after primary ACL reconstruction is not cost effective. The significant per-patient expense is not balanced by the low yield of clinically meaningful data, as nearly all radiographs in the present series were normal, subsequent imaging was rarely obtained and none resulted in significant changes in postoperative clinical management.