JSES - 2026-09-01 - Journal Article
Is robotic-assisted reverse shoulder arthroplasty economically justified? A break-even analysis.
Menendez ME, Moverman MA, Schiffman CJ, Matsen FA
Topics
Key Takeaway
Robotic-assisted rTSA requires an absolute risk reduction in early revision of 6.55% (1 revision prevented per 15 cases) to break even, which exceeds the observed baseline early revision rate of 2.1%, making routine economic justification impossible under current conditions.
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Summary
This break-even analysis asked whether the incremental cost of robotic assistance ($1,500/case) could be offset by preventing early revisions (baseline rate 2.1%, cost $22,920 each) after rTSA. The required ARR of 6.55% exceeds the total observed revision rate, yielding a mathematically negative break-even revision rate (-4.45%), meaning break-even is unachievable under typical conditions. Sensitivity analyses showed the required ARR is insensitive to baseline revision rate variation but decreases meaningfully as revision cost increases, suggesting selective use in high-cost failure pathways or centers leveraging an existing robotic platform may improve viability.
Key Limitation
The model is restricted to early (within 1 year) revision as the sole outcome, excluding the potential long-term value of improved component positioning on implant survivorship, functional scores, and indirect costs such as lost productivity or downstream revision complexity.
Original Abstract
BACKGROUND
Robotic assistance in reverse total shoulder arthroplasty (rTSA) is likely to improve implant positioning and may reduce revision risk, but its cost-effectiveness is unknown. Break-even models can determine the economic viability of interventions in settings with low outcome event rates that would realistically preclude a randomized clinical trial. We applied this approach to determine the economic plausibility of robotic assistance for the prevention of revision after rTSA.
METHODS
Incremental robotic assistance costs ($1,500), baseline early revision rates after rTSA (2.1%; within 1 year of surgery), and revision surgery-related costs ($22,920) were derived from institutional estimates and the literature. A break-even equation incorporating these variables was developed to determine the absolute risk reduction (ARR) in revision rate required for robotic assistance to be economically justified. The number needed to treat was calculated from the ARR. To provide a widely applicable model, multiple simulations were performed by varying the incremental cost of robotic assistance, baseline revision rate, and revision surgery cost.
RESULTS
Robotic assistance would be economically justified only if it prevented 1 revision for every 15 procedures (ARR = 6.55%). Because this required ARR exceeds the observed early revision rate (2.1%), the calculated break-even revision rate is negative (-4.45%), indicating that break-even cannot be achieved under typical clinical conditions. The required ARR remained unchanged when baseline revision rates were varied, but decreased substantially as the modeled cost of revision surgery increased.
CONCLUSIONS
Robotic assistance in rTSA is unlikely to be economically justified for routine use when evaluated solely on prevention of early postoperative revision. Selective application to higher-risk anatomy, costly failure pathways, or high-volume centers able to amortize robotic costs may improve economic viability, particularly when shoulder adoption leverages an existing robotic platform with lower incremental per-case costs rather than new capital investment. Because the value of positioning accuracy may accrue over time through delayed time-to-revision and better patient-centered outcomes, studies linking robotic assistance to longer-term implant survivorship and functional outcomes are needed to more fully define the technology's value proposition.