Monday, August 1, 2016

Large/massive cuff tears: Reverse total shoulder or arthroscopic repair?

Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears.

The authors compared the cost-effectiveness of attempted arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy.

The input variables to their model are shown in the figure below. Note the retear rate after attempted arthroscopic repair is estimated at 68.5%

It is very interesting to look at the clinical states modeled, for example, the ASES scores assigned to cuff repair with and without retear are essentially the same.

They concluded that both attempted arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an incremental cost-effectiveness ratio (ICER) of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Attempted arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes even though over two thirds of these repair attempts would fail to re-establish the rotator cuff attachment to bone.

In their analysis arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY.

The authors concluded that attempted arthroscopic rotator cuff repair may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty despite high rates of tendon retearing for patients with large and massive rotator cuff tears.

Comment: As the readers of this blog know, we have found a secure place in our practice for the 'smooth and move' procedure for large and massive cuff tears - avoiding the cost and the rehabilitation of a cuff repair. See this link. This approach seems particularly attractive in light of the observation that less than 1/3 of attempted repairs of these tears are successful, so the effort to 'repair' the tear may not be worth it.

Readers will be interested in a prior relevant post (see this link).