AJSM - 2026-06-01 - Journal Article
Cost-effectiveness of Adding Remplissage to Bankart Repair for On-Track Hill-Sachs Lesions: A Markov Decision Analysis.
Frederickson M, Kou M, Cullinane D, Menendez ME
Topics
Key Takeaway
Bankart repair with remplissage for on-track Hill-Sachs lesions yields 0.41 additional QALYs at $1,647 incremental cost over 10 years, achieving cost-effectiveness in 99.89% of simulations at a $50,000/QALY willingness-to-pay threshold.
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Summary
This Markov decision analysis compared isolated arthroscopic Bankart repair (IBR) versus Bankart repair with remplissage (BR+R) in patients with on-track Hill-Sachs lesions and subcritical glenoid bone loss over a 10-year societal-perspective horizon. BR+R generated 8.59 QALYs at $24,980 versus 8.18 QALYs at $23,333 for IBR, yielding an ICER well below standard WTP thresholds. BR+R was cost-effective in 99.89% and 99.99% of simulations at $50,000/QALY and $100,000/QALY thresholds, respectively, with model sensitivity driven primarily by recurrence probability inputs.
Key Limitation
The model's dominant driver is recurrence probability, yet the input data derive from studies with median follow-up under 3 years, meaning the cost-effectiveness conclusion rests on extrapolated rather than observed 10-year recurrence and revision rates.
Original Abstract
BACKGROUND
Remplissage decreases recurrence after arthroscopic Bankart repair for anterior shoulder instability but has historically been reserved for off-track Hill-Sachs lesions. The addition of remplissage for patients with on-track lesions remains controversial because of concerns about added operative costs and potential loss of range of motion. The cost-effectiveness of remplissage in patients with on-track Hill-Sachs lesions has not been established.
PURPOSE
To evaluate the cost-effectiveness of arthroscopic Bankart repair with remplissage versus isolated Bankart repair in patients with on-track Hill-Sachs lesions.
STUDY DESIGN
Economic decision analysis; Level of evidence, 3.
METHODS
A Markov decision model simulated a 10-year period from a societal perspective. There were 2 treatment strategies compared: isolated arthroscopic Bankart repair (IBR) and arthroscopic Bankart repair with remplissage (BR+R). Health states included stable shoulder, recurrent instability, stable shoulder after revision, and persistent instability. Transition probabilities were derived from random-effects meta-analysis of recurrence rates at a median 34.7-month follow-up. Costs (in 2025 United States dollars) included direct medical costs and indirect costs related to productivity loss. Costs and quality-adjusted life-years (QALYs) were discounted at 3% annually. Outcomes included total costs, QALYs, net monetary benefit (NMB), and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) with Monte Carlo microsimulation was conducted with 1000 simulated patients and 10,000 PSA iterations. One-way sensitivity analysis evaluated the influence of individual parameters. Cost-effectiveness acceptability curves were generated at willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY.
RESULTS
Over a 10-year time horizon, BR+R yielded 8.59 QALYs at a cost of $24,980, whereas IBR yielded 8.18 QALYs at a cost of $23,333. BR+R was cost-effective in 99.89% and 99.99% of simulations at WTP thresholds of $50,000/QALY and $100,000/QALY, respectively. One-way sensitivity analysis showed that the model was most sensitive to recurrence probabilities.
CONCLUSION
For patients with on-track Hill-Sachs lesions and subcritical glenoid bone loss, Bankart repair with remplissage was cost-effective compared with isolated Bankart repair, driven by reductions in recurrence and revision surgery. These findings support the consideration of remplissage in patients with on-track lesions, particularly those at a higher risk for recurrence.