JAAOS - 2026-08-15 - Journal Article; Systematic Review
Cost-Effectiveness of Rotator Cuff Repair With Concomitant Subacromial Decompression at Mid-Term Follow-Up: A Systematic Review and Economic Analysis.
Saad Berreta R, Badin D, Fox H, Koyejo LD, Mian M, Sundaresh S, Siragusa J, Ashkar A, Harris E, Chan D, Jain A, Srikumaran U
Topics
Key Takeaway
RCR with concomitant SAD dominates isolated RCR over 5 years, costing $1,145 less ($33,448 vs $34,593) while yielding 0.011 more QALYs and remaining cost-effective in 99.28% of Monte Carlo simulations.
Summary Depth
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Summary
This study asked whether adding SAD to RCR is cost-effective compared with isolated RCR for full-thickness rotator cuff tears at mid-term follow-up. A PRISMA-compliant systematic review identified Level I-II studies with ≥5-year follow-up, and a decision tree model using EQ-5D-derived utilities, revision rates, and published costs was analyzed with Monte Carlo (n=1,000 simulations) and one-way sensitivity analyses. RCR+SAD was the dominant strategy with a positive incremental NMB of $1,695, lower total cost, and higher QALYs, remaining cost-effective with burr costs up to $1,721 and additional OR time up to 43.6 minutes.
Key Limitation
The model assumes revision rate reduction with SAD is causally attributable to the decompression rather than confounded by differences in tear characteristics or surgeon selection across source studies.
Original Abstract
BACKGROUND
There is limited evidence evaluating the cost-effectiveness of adding subacromial decompression (SAD) to rotator cuff repair (RCR) in the treatment of full-thickness rotator cuff tears.
PURPOSE
The purpose of this study was to perform (1) a systematic review and (2) cost-utility analysis comparing isolated RCR versus RCR with SAD in patients with full-thickness rotator cuff tears.
STUDY DESIGN
This was an economic and decision-analysis study; Level II.
METHODS
A systematic review was conducted per Preferred Reporting Items for Systemactic reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify Level I-II studies comparing RCR and RCR with SAD at ≥5-year follow-up. A decision tree model evaluated cost-effectiveness over a 5-year time horizon. Costs, revision rates, and utility values (EQ-5D-based) were derived from the literature. Health utility was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was assessed using incremental cost-effectiveness ratios and net monetary benefit (NMB), with a $50,000/QALY willingness-to-pay threshold. Monte Carlo and one-way sensitivity analyses were done to account for parameter uncertainty.
RESULTS
Over 5 years, RCR with SAD had a lower mean cost ($33,448) compared with isolated RCR ($34,593) and yielded slightly higher QALYs (1.465 vs 1.454). RCR + SAD demonstrated a positive incremental NMB ($1,695) and a negative incremental cost-effectiveness ratio, emerging as the dominant strategy. Probabilistic sensitivity analysis favored RCR + SAD in 99.28% of 1,000 simulations. On one-way analysis, RCR + SAD remained cost-effective with burr costs up to $1,721, additional surgical time up to 43.6 minutes, and revision probabilities up to 10%.
CONCLUSION
Despite higher upfront costs, SAD during RCR remains cost-effective at mid-term follow-up. By reducing revision rates, SAD provides greater QALYs at a lower overall cost compared with isolated RCR.