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Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures

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  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Current options for treating an Achilles tendon rupture (ATR) include conservative and surgical approaches. Endoscopic flexor hallucis longus (FHL) transfer has been recently proposed to treat acute ruptures, but its cost-effectiveness potential remains to be evaluated. Therefore, the objective of this study was to perform an early cost-effectiveness analysis of endoscopic FHL transfer for acute ATRs, comparing the costs and benefits of current treatments from a societal perspective.

Methods

A conceptual model was created, with a decision tree, to outline the main health events during the treatment of an acute ATR. The model was parameterized using secondary data. A systematic review of the literature was conducted to gather information on the outcomes of current treatments. Data related to outcomes of endoscopic FHL transfers in acute Achilles ruptures was obtained from a single prospective study. Analysis was limited to the two first years. The incremental cost-effectiveness ratio was the main outcome used to determine the preferred strategy. A willingness-to-pay threshold of $100,000 per quality-adjusted life-year was used. Sensitivity analyses were performed to determine whether changes in input parameters would cause significant deviation from the reference case results. Specifically, a probability sensitivity analysis was conducted using Monte Carlo simulations, and a one-way sensitivity analysis was conducted by sequentially varying each model parameter within a given range.

Results

For the reference case, incremental cost-effectiveness ratios exceeded the willingness-to-pay threshold for all the surgical approaches. Overall, primary treatment was the main cost driver. Conservative treatment showed the highest direct costs related to the treatment of complications. In the probabilistic sensitivity analysis, at a willingness-to-pay threshold of $100,000, open surgery was cost-effective in 50.9%, minimally invasive surgery in 55.8%, and endoscopic FHL transfer in 72% of the iterations. The model was most sensitive to parameters related to treatment utilities, followed by the costs of primary treatments.

Conclusion

Surgical treatments have a moderate likelihood of being cost-effective at a willingness-to-pay threshold of $100,000, with endoscopic FHL transfer showing the highest likelihood. Following injury, interventions to improve health-related quality of life may be better suited for improved cost-effectiveness.

Level of evidence

Level III.

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Abbreviations

AT:

Achilles tendon

ATR:

Achilles tendon rupture

ATRS:

Achilles Tendon Total Rupture Score

CEA:

Cost-effectiveness analysis

CI:

Confidence interval

DVT:

Deep venous thrombosis

FHL:

Flexor hallucis longus

HRQoL:

Health-related quality of life

ICER:

Incremental cost-effectiveness ratio

MIS:

Minimally invasive surgery

NMB:

Net monetary benefit

ORS:

Open revision surgery

PSA:

Probabilistic sensitivity analysis

QALYs:

Quality-adjusted life-years

RTW:

Return to work

WHPs:

Wound-healing problems

WTP:

Willingness to pay

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Acknowledgements

This work is financed by national funds from FCT – Fundação para a Ciência e a Tecnologia, I.P., in the scope of the Project UIDB/04565/2020 and UIDP/04565/2020 of the Research Unit Institute for Bioengineering and Biosciences – iBB and the project LA/P/0140/2020 of the Associate Laboratory Institute for Health and Bioeconomy – i4HB.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Hospital de Sant’Ana, Rua de Benguela, 501, 2775-028, Parede, Lisbon, Portugal

    Pedro Diniz & André Soares Ferreira

  2. Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal

    Pedro Diniz & Frederico Castelo Ferreira

  3. Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal

    Pedro Diniz & Frederico Castelo Ferreira

  4. Fisiogaspar, Lisbon, Portugal

    Pedro Diniz

  5. Clinical Department Club Atletico Boca Juniors, CAJB Centro Artroscopico, Buenos Aires, Argentina

    Lígia Figueiredo

  6. Head of Orthopedic Department, Dr Nasef OrthoClinic, Private Practice, Cairo, Egypt

    Jorge Pablo Batista

  7. Orthopaedic Department, Centro Hospitalar Póvoa de Varzim, Vila Do Conde, Portugal

    Nasef Abdelatif

  8. Ripoll y De Prado Sports Clinic: FIFA Medical Centre of Excellence, Murcia/Madrid, Spain

    Hélder Pereira

  9. PT Government Associate Laboratory, University of Minho ICVS/3B’s, Braga/Guimarães, Portugal

    Hélder Pereira

  10. Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Academic Center for Evidence Based Sports Medicine (ACES), Amsterdam University Medical Centers, Amsterdam Collaboration for Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands

    Hélder Pereira

  11. Institute for Data, Systems and Society, Massachusetts Institute of Technology, Cambridge, MA, USA

    Gino M. M. J. Kerkhoffs

  12. Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA, USA

    Stan N. Finkelstein

  13. Bioceramed - Cerâmicos para Aplicações Médicas S.A., Loures, Portugal

    Stan N. Finkelstein

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  1. Pedro Diniz
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Contributions

PD, GK, SF, and FCF designed the study. PD and ASF screened and selected clinical studies and extracted clinical study data. PD, JB, NA, HP, and GK created the decision tree, defined model assumptions, and cost items and quantities. PD developed the computational model with support from LF. PD and FCF, analyzed the data. PD drafted the manuscript with input from LF and FCF. JB, NA, HP, GK, and SF revised the final manuscript. All authors read and approved the final manuscript.

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Correspondence to Pedro Diniz.

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Diniz, P., Ferreira, A.S., Figueiredo, L. et al. Early analysis shows that endoscopic flexor hallucis longus transfer has a promising cost-effectiveness profile in the treatment of acute Achilles tendon ruptures. Knee Surg Sports Traumatol Arthrosc 31, 2001–2014 (2023). https://doi.org/10.1007/s00167-022-07146-5

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