Reconstruction versus conservative treatment after rupture of the anterior cruciate ligament: cost effectiveness analysis

BACKGROUND: The decision whether to treat conservatively or reconstruct surgically a torn anterior cruciate ligament (ACL) is an ongoing subject of debate. The high prevalence and associated public health burden of torn ACL has led to continuous efforts to determine the best therapeutic approach. A critical evaluation of benefits and expenditures of both treatment options as in a cost effectiveness analysis seems well-suited to provide valuable information for treating physicians and healthcare policymakers. METHODS: A literature review identified four of 7410 searched articles providing sufficient outcome probabilities for the two treatment options for modeling. A transformation key based on the expert opinions of 25 orthopedic surgeons was used to derive utilities from available evidence. The cost data for both treatment strategies were based on average figures compiled by Orthopaedic University Hospital Balgrist and reinforced by Swiss national statistics. A decision tree was constructed to derive the cost-effectiveness of each strategy, which was then tested for robustness using Monte Carlo simulation. RESULTS: Decision tree analysis revealed a cost effectiveness of 16,038 USD/0.78 QALY for ACL reconstruction and 15,466 USD/0.66 QALY for conservative treatment, implying an incremental cost effectiveness of 4,890 USD/QALY for ACL reconstruction. Sensitivity analysis of utilities did not change the trend. CONCLUSION: ACL reconstruction for reestablishment of knee stability seems cost effective in the Swiss setting based on currently available evidence. This, however, should be reinforced with randomized controlled trials comparing the two treatment strategies

Proprioceptive performance of bilateral upper and lower limb joints: side-general and site-specific effects

Superiority of the left upper limb in proprioception tasks performed by right-handed individuals has been attributed to better utilization of proprioceptive information by a non-preferred arm/hemisphere system. However, it is undetermined whether this holds for multiple upper and lower limb joints. Accordingly, the present study tested active movement proprioception at four pairs of upper and lower limb joints, after selecting twelve participants with both strong right arm and right leg preference. A battery of versions of the active movement extent discrimination apparatus were employed to generate the stimuli for movements of different extents at the ankle, knee, shoulder and fingers on the right and left sides of the body, and discrimination scores were derived from participants’ responses. Proprioceptive performance on the non-preferred left side was significantly better than the preferred right side at all four joints tested (overall F(1, 11) = 36.36, p < 0.001, partial η(2) = 0.77). In the 8 × 8 matrix formed by all joints, only correlations between the proprioceptive accuracy scores for the right and left sides at the same joint were significant (ankles 0.93, knees 0.89, shoulders 0.87, fingers 0.91, p ≤ 0.001; all others r ≤ 0.40, p ≥ 0.20). The results point to both a side-general effect and a site-specific effect in the integration of proprioceptive information during active movement tasks, whereby the non-preferred limb/hemisphere system is specialized in the utilization of the best proprioceptive sources available at each specific joint, but the combination of sources employed differs between body sites

A narrative review on haptic devices: relating the physiology and psychophysical properties of the hand to devices for rehabilitation in central nervous system disorders

Purpose. This paper provides rehabilitation professionals and engineers with a theoretical and pragmatic rationale for the inclusion of haptic feedback in the rehabilitation of central nervous system disorders affecting the hand.Method. A narrative review of haptic devices used in sensorimotor hand rehabilitation was undertaken. Presented papers were selected to outline and clarify the underlying somatosensory mechanisms underpinning these technologies and provide exemplars of the evidence to date.Results. Haptic devices provide kinaesthetic and/or tactile stimulation. Kinaesthetic haptics are beginning to be incorporated in central nervous system rehabilitation, however, there has been limited development of tactile haptics. Clinical research in haptic rehabilitation of the hand is embryonic but initial findings indicate potential clinical benefit. Conclusions. Haptic rehabilitation offers the potential to advance sensorimotor hand rehabilitation but both scientific and pragmatic developments are needed to ensure that its potential is realised.<br/