Friday, October 26, 2012

The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy. JSES

JSES publishes: The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy.

There has been a dramatic increase in the rate with which reverse total shoulder arthroplasty is being performed. Here's a graph from the recent article by Kim et al.

Against this background the authors of the recent JSES article sought to use a Markov decision model to determine the cost-effectivenss of  reverse total shoulder versus CTA arthroplasty in the treatment of cuff tear arthropathy. They used the SF36 to determine the utility of each procedure. 

They found that the cost-effectiveness was extremely sensitive to the rate of complications, such as those listed here. They also found that the implant price was a major determinant of the cost-effectivenss of the reverse, with a $13,000 price being the tipping point. They estimated that the hemiarthroplasty cost was $11, 500 while the cost of the reverse was approximately twice as great, $22,000. As a specialty we should strive to lower both the complication rate and the cost of both of these procedures as well as refining the indications for each.

In our practice the indications for these two procedures are not the same.  We favor a CTA arthroplasty for individuals who are active and for those who are at risk for falls when the shoulder does not have pseudoparalysis or anterosuperior escape. A nice example is a lady for whom we did a CTA arthroplasty this week. Her preoperative x-rays show femoralization of her humeral head and acetabularization of her shoulder socket. She had not had prior surgery (no acromioplasty!) and had active, but painful elevation to 90 degrees.

 Her immediate post operative films show that the curvature of her socket has been nicely matched by the humeral head prosthesis, that her humeral shaft has been moved distally so that deltoid tension is restored, and the her humeral component has been fixed by impaction grafting to minimize the risk of loosening and periprosthetic fracture.

While we do not yet know her post operative functional result, she is moving her arm actively and comfortably two days after surgery with no need to protect the arm.  An example of the kind of result that can be achieved with this prosthesis is shown in this two year followup clip.

By contrast we use the reverse total shoulder for individuals not at risk for falls and who have pseudoparalysis and anterosuperior escape as shown here. 

Appropriate application of these two procedures, striving to minimize the complications, and pressuring vendors to lower the costs should enable us to provide the greatest value in our treatment of individuals with cuff tear arthropathy.


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