The cost-effectiveness of the arthroscopic Bankart versus open Latarjet in the treatment of primary shoulder instability

Arthroscopic Bankart repair versus nonoperative management for first-time anterior shoulder instability: A cost-effectiveness analysis

Purpose

Arthroscopic Bankart repair (ABR) may be more effective than nonoperative management for patients with anterior shoulder instability following first-time dislocation. The purpose of the study was to determine the most cost-effective treatment strategy by evaluating the incremental cost-effectiveness ratio (ICER) for ABR versus nonoperative treatment.

Methods

This cost-effectiveness study utilized a Markov decision chain and Monte Carlo simulation. Probabilities, health utility values, and outcome data regarding ABR and nonoperative management of first-time shoulder instability derived from level I/II evidence. Costs were tabulated from Centers for Medicaid & Medicare Services. Probabilistic sensitivity analysis was performed using >100,000 repetitions of the Monte Carlo simulation. A willingness-to-pay (WTP) threshold was set at $50,000.

Results

The expected cost for operative management higher than nonoperative management ($32,765 vs $29,343). However, ABR (5.48 quality-adjusted life years (QALYs)) was the more effective treatment strategy compared to nonoperative management (4.61 QALYs). The ICER for ABR was $3943. Probabilistic sensitivity analysis showed that ABR was the most cost-effective strategy in 100% of simulations.

Discussion

ABR is more cost-effective than nonoperative management for first-time anterior shoulder dislocation. The threshold analysis demonstrated that when accounting for WTP, ABR was found to be the more cost-effective strategy.

Outcomes of the Latarjet procedure in female patients: A case series and matched-pair analysis

Background

The objective of this study was to retrospectively report on the outcomes of female patients undergoing the Latarjet procedure.

Methods

Female patients undergoing the Latarjet procedure with minimum 1 year follow-up were identified and contacted to obtain Numeric Pain Rating Scale (NPRS), Subjective Shoulder Value (SSV), and return to sport (RTS) data. Eligible females were then matched 1:1 with a male counterpart based on laterality and age (± 3 years), and outcomes compared.

Results

A total of 20 female patients with a mean follow-up of 73.8 months reported postoperative NPRS and SSV scores of 2.2  ±  2.3 and 69.3  ±  22.0, respectively. Of the nine athletes, 3 (33%) reported a successful RTS at a mean of 9 months. Four patients (20.0%) required reoperation at a mean of 27.1 months. The matched analysis demonstrated similar NPRS scores between male and female patients and a trend towards lower SSV scores and rates of RTS.

Conclusion

At mid-term follow-up female patients reported pain levels similar to female-specific literature reports, but overall low subjective shoulder function and RTS. Compared to propensity-matched males, females reported similar levels of pain, lower shoulder function, and lower rates of RTS, however, differences did not reach statistical significance.

Level of Evidence

IV, retrospective case series.

What keeps a shoulder stable - Is there an ideal method for anterior stabilisation?

The gleno-humeral joint is by far the most mobile in the human body but also afflicted by dislocations, predominantly anterior. Surgical stabilisation is often successful but failures not uncommon. The following review describes potential causes of failure and highlights the need of adapting surgical methods to pathomorphology.

Current Evidence Regarding Shoulder Instability in the Paediatric and Adolescent Population

Paediatric and adolescent shoulder instability is caused by a unique combination of traumatic factors, ligamentous laxity, and pattern of muscle contractility. The multifactorial nature of its aetiology makes interpretation of the literature difficult as nomenclature is also highly variable. The purpose of this review is to summarize the existing literature and shed light on the nuances of paediatric and adolescent shoulder instability. The epidemiology, clinical features, imaging, and management of all forms of paediatric shoulder instability are presented. The main findings of this review are that structural abnormalities following a dislocation are uncommon in pre-pubertal paediatric patients. Young post-pubertal adolescents are at the highest risk of failure of non-operative management in the setting of traumatic instability with structural abnormality, and early stabilisation should be considered for these patients. Remplissage and the Latarjet procedure are safe treatment options for adolescents at high risk of recurrence, but the side-effect profile should be carefully considered. Patients who suffer from instability due to generalized ligamentous laxity benefit from a structured, long-term physiotherapy regimen, with surgery in the form of arthroscopic plication as a viable last resort. Those who suffer from a predominantly muscle patterning pathology do not benefit from surgery and require focus on regaining neuromuscular control.

Epidemiology of shoulder instability procedures: A comprehensive analysis of complications and costs

Background

Recurrent shoulder instability is a debilitating condition that can lead to chronic pain, decreased function, and inability to return to activities or sport. This retrospective epidemiology study was performed to report 90-day postoperative complications and costs of Latarjet, anterior bone block reconstruction, arthroscopic, and open Bankart repair for shoulder instability.

Methods

Patients 18 years and older who underwent four primary shoulder surgeries from 2010 to 2019 were identified using national claims data. Patient demographics, comorbidities, and 90-day postoperative complications were analyzed using univariate analysis and multivariable logistic regression. Total and itemized 90-day reimbursements were determined for each procedure.

Results

The 90-day medical and surgery-specific complication rates were highest for anterior bone block reconstruction, followed by Latarjet. Arthroscopic Bankart repair had the highest 90-day costs and primary procedure costs compared to other procedures.

Conclusion

Anterior bone block reconstruction and Latarjet procedures were associated with the highest rates of 90-day medical and surgery-specific complications, while arthroscopic Bankart repair was associated with the highest costs.

Cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet reconstruction in anterior shoulder instability

PURPOSE

The ideal surgical treatment for anterior shoulder instability is still under debate. In the healthcare setting, both clinical and economic factors must be considered for optimal resource allocation. From the clinical perspective, the Instability Severity Index Score (ISIS) is a helpful and validated tool for surgeons, although a gray area between 4 and 6 exists. In fact, patients with an ISIS < 4 and > 6 can be treated effectively with arthroscopic Bankart repair and open Latarjet, respectively. The purpose of this study was to conduct a cost-effectiveness analysis of arthroscopic Bankart repair versus open Latarjet in patients with an ISIS between 4 and 6.

METHODS

A decision-tree model was constructed to simulate the clinical scenario of an anterior shoulder dislocation patient with an ISIS between 4 and 6. Based on previously published literature, outcome probabilities and utility values in the form of Western Ontario Instability Score (WOSI) were assigned to each branch of the tree, alongside institutional cost. The primary outcome assessed was an Incremental cost-effectiveness ratio (ICER) of the two procedures. Eden-Hybbinette was also considered in the model as a salvage procedure for failed Latarjet. A two-way sensitivity analysis was performed to identify the most impactful parameters on the ICER upon their variation within a pre-determined interval.

RESULTS

Base case cost was 1245.57 € (1220.48-1270.65 €) for arthroscopic Bankart repair, 1623.10 € (1580.82-1665.39 €) for open Latarjet and 2.373.95 € (1940.81-2807.10 €) for Eden-Hybbinette. Base-case ICER was 9570.23 €/WOSI. Sensitivity analysis showed that the most impactful parameters were the utility of arthroscopic Bankart repair, the probability of success of open Latarjet, the probability of undergoing surgery after post-operative recurrence of instability and the utility of Latarjet. Of these, utility of arthroscopic Bankart repair and Latarjet had the most significant impact on the ICER.

CONCLUSION

From a hospital perspective, open Latarjet was more cost-effective than arthroscopic Bankart repair in preventing further shoulder instability in patients with an ISIS between 4 and 6. Despite its several limitations, this is the first study to analyze this subgroup of patients from a European hospital setting from both an economic and clinical perspective. This study can help surgeons and administrations in the decision-making process. Further clinical studies are needed to prospectively analyze both aspects to further delineate the best strategy.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Cervical Versus Shoulder Surgery

STUDY DESIGN

Retrospective analysis of outcomes in cervical spine and shoulder arthroscopy patients.

OBJECTIVE

The objective of this study is to assess differential improvements in health-related quality of life for cervical spine surgery compared with shoulder surgery.

SUMMARY OF BACKGROUND DATA

An understanding of outcome differences between different types of orthopedic surgeries is helpful in counseling patients about expected postoperative recovery. This study compares outcomes in patients undergoing cervical spine surgery with arthroscopic shoulder surgery using computer-adaptive Patient-reported Outcome Information System scores.

MATERIALS AND METHODS

Patients undergoing cervical spine surgery (1-level or 2-level anterior cervical discectomy and fusion, cervical disc replacement) or arthroscopic shoulder surgery (rotator cuff repair±biceps tenodesis) were grouped. Patient-reported Outcome Information System scores of physical function, pain interference, and pain intensity at baseline and at 3, 6, and 12 months were compared using paired t tests.

RESULTS

Cervical spine (n=127) and shoulder (n=91) groups were similar in sex (25.8% vs. 41.8% female, P =0.731) but differed in age (51.6±11.6 vs. 58.60±11.2, P <0.05), operative time (148.3±68.6 vs. 75.9±26.9 min, P <0.05), American Society of Anesthesiologists (ASAs) (2.3±0.6 vs. 2.0±0.5, P =0.001), smoking status (15.7% vs. 4.4%, P =0.008), and length of stay (1.1±1.0 vs. 0.3±0.1, P =0.000). Spine patients had worse physical function (36.9 ±12.6 vs. 49.4±8.6, P <0.05) and greater pain interference (67.0±13.6 vs. 61.7±4.8, P =0.001) at baseline. Significant improvements were seen in all domains by 3 months for both groups, except for physical function after shoulder surgery. Spine patients had greater physical function improvements at all timepoints (3.33 vs. -0.43, P =0.003; 4.81 vs. 0.08, P =0.001; 6.5 vs. -5.24, P =<0.05). Conversely, shoulder surgery patients showed better 6-month improvement in pain intensity over spine patients (-8.86 vs. -4.46, P =0.001), but this difference resolved by 12 months.

CONCLUSIONS

Cervical spine patients had greater relative early improvement in physical function compared with shoulder patients, whereas pain interference and intensity did not significantly differ between the 2 groups after surgery. This will help in counseling patients about relative difference in recovery and improvement between the 2 surgery types.

LEVEL OF EVIDENCE

III.

Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate

PURPOSE

To compare the clinical outcomes of arthroscopic dynamic anterior stabilization (DAS) between transferring the long head of the biceps (DAS-LHB) and the conjoined tendon (DAS-CT) for anterior shoulder instability with <15% glenoid bone loss.

METHODS

From January 2016 to May 2019, a total of 63 patients who underwent DAS for recurrent anterior shoulder dislocation with <15% glenoid bone loss were included, comprising 33 patients in DAS-LHB group and 30 patients in DAS-CT group. Clinical outcomes were assessed preoperatively and at a minimum 3-year follow-up, including patient-reported outcomes, range of motion, and return to sports (RTS). Postoperative recurrent instability (including dislocation, subluxation, and subjective instability with a positive apprehension test), revisions and complications also were recorded.

RESULTS

No significant demographic characteristics difference was detected between the DAS-LHB (26.3 ± 7.9 years) and DAS-CT groups (26.0 ± 6.7 years). At the latest follow-up, there were no significant differences between the 2 groups in functional scores: Oxford Shoulder Instability Score (14.8 ± 2.8 vs 15.2 ± 3.6), Rowe score (95.9 ± 6.5 vs 93.2 ± 10.2), visual analog scale for pain (0.8 ± 1.2 vs 0.7 ± 1.7), and American Shoulder and Elbow Surgeons (95 ± 8.8 vs 95.2 ± 9.1) (all P > .218). No significant difference was detected between groups in the rates of RTS (90.1% vs 86.7%, P = .700) and RTS at previous level (78.7% vs 73.3%, P = .258), respectively. No recurrent dislocation occurred in either group. One patient felt occasional subluxation in the DAS-LHB group, and one was positive for the apprehension test in each group. One patient presented with postoperative shoulder stiffness and underwent a secondary arthroscopic debridement in the DAS-CT group.

CONCLUSIONS

Comparable rates of recurrence, complication, return to sports, and subjective shoulder function were observed between DAS-LHB and DAS-CT groups.

LEVEL OF EVIDENCE

Ⅲ; retrospective comparative therapeutic trial.

Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members

INTRODUCTION

The arthroscopic Bankart repair in the setting of glenoid bone loss has high rates of failure. In patients with anterior glenoid bone loss, the Latarjet provides glenohumeral stability through restoration of the glenoid bone, the conjoint tendon acting as a sling on the subscapularis, and anterior capsulolabral repair. Active-duty military personnel are at high risk for glenohumeral instability and have been equated to the contact athlete; most are young, male, and engage in contact sports. The purpose of this study is to assess the return to full-duty rates in active-duty military personnel following the Latarjet for anterior glenohumeral instability with glenoid bone loss.

METHODS

A retrospective review of all glenohumeral instability procedures were reviewed at a tertiary training hospital from June 2014 to June 2019. The patient population consisted of active-duty military personnel with glenoid bone loss and anterior glenohumeral instability, who were treated with a Latarjet. The primary outcome was return to full-duty status.

RESULTS

There were 50 patients identified for the study. Four patients were lost to follow-up, leaving 46 of 50 patients (92.0%) eligible for this study. The average age at the time of the index procedure was 23.1 years. The average percentage bone loss was 18.4%. Forty-one patients (89.1%) were able to return to full-duty status. Four patients (8.7%) sustained a recurrent dislocation following the Latarjet; all 4 dislocations occurred during a combat deployment. Four patients (8.7%) reported episodes of subluxation without dislocation. Forty-one patients (89.1%) reported that their shoulders felt stable, and we found an average return to full duty at 5.3 months CONCLUSION: In our active-duty military cohort, we found an 8.7% rate of recurrent instability after a Latarjet procedure, and 41 patients (89.1%) were able to return to full-duty status. In conclusion, the Latarjet procedure in the active-duty military population with anterior glenoid bone loss resulted in a high rate of return to duty, excellent functional outcomes, low rate of recurrent instability, and a low overall complication rate.

Shoulder conditions and health related quality of life and utility: a current concepts review

Study of the outcome of treatment of shoulder conditions has emphasized subjective evaluation of outcomes including a variety of disease, region, and joint-specific tools. In response to the rapidly rising cost of health care, further interest has been directed to cost-effectiveness and value. Comparison of the outcomes of different shoulder conditions with each other, other musculoskeletal, and nonorthopedic conditions requires more generalized outcome tools, especially when considering cost-effectiveness and utility analysis. The concept of quality of life (QoL) was developed to satisfy this goal, and there are a variety of general health and QoL assessments tools available. The purpose of this study is to review the concept of health-related QoL and discuss health-related QoL measures as they relate to shoulder conditions.

Primary Bankart Repair Versus Arthroscopic Anatomic Glenoid Reconstruction in Patients with Subcritical Bone Loss: A Cost-Utility Analysis

Anterior shoulder instability and its treatment is a quickly evolving field of interest in orthopaedics, both for patients and for health-care systems. In this study, we aimed to evaluate the cost-effectiveness of arthroscopic anatomic glenoid reconstruction (AAGR) compared with Bankart repair in the treatment of anterior shoulder instability in patients with subcritical glenoid bone loss.

Operative Versus Nonoperative Treatment Following First-Time Anterior Shoulder Dislocation

BACKGROUND

There is an ongoing debate about whether to perform operative or nonoperative treatment following a first-time anterior dislocation or wait for recurrence before operating. The aim of this systematic review is to compare recurrence rates following operative treatment following first-time anterior dislocation (OTFD) with recurrence rates following (1) nonoperative treatment (NTFD) or (2) operative treatment after recurrent anterior dislocation (OTRD).

METHODS

A literature search was conducted by searching PubMed (Legacy), Embase/Ovid, Cochrane Database of Systematic Reviews/Wiley, Cochrane Central Register of Controlled Trials/Wiley, and Web of Science/Clarivate Analytics from 1990 to April 15, 2020, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The revised tool to assess risk of bias in randomized trials (RoB 2) developed by Cochrane was used to determine bias in randomized controlled trials, and the methodological index for non-randomized studies (MINORS) was used to determine the methodological quality of non-randomized studies. The certainty of evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach using GRADEpro software.

RESULTS

Of the 4,096 studies for which the titles were screened, 9 comparing OTFD and NTFD in a total of 533 patients and 6 comparing OTFD and OTRD in a total of 961 patients were included. There is high-quality evidence that OTFD is associated with a lower rate of recurrence (10%) at >10 years of follow-up compared with NTFD (55%) (p < 0.0001). There is very low-quality evidence that patients receiving OTFD had a lower recurrence rate (11%) compared with those receiving OTRD (17%) (p < 0.0001).

CONCLUSIONS

There is high-quality evidence showing a lower recurrence rate at >10 years following OTFD compared with NTFD (or sham surgery) in young patients. There is evidence that OTFD is more effective than OTRD, but that evidence is of very low quality.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative study of arthroscopic Bankart repair versus open Latarjet procedure for recurrent shoulder dislocation

OBJECTIVES

The primary aim of this study was to compare the clinical outcomes of patients undergoing arthroscopic Bankart repair and the open Latarjet procedure for recurrent dislocation of the shoulder. The secondary aims were to assess and compare the surgical cost, patient satisfaction, and complications, including recurrence and infection.

METHODS

We retrospectively compared the clinical outcomes of all consecutive patients undergoing either arthroscopic Bankart repair or the open Latarjet procedure from May 2015 to May 2018 with a minimum 2-year follow-up. Forty-one patients (32 men, 9 women) in the Bankart group and 40 patients (34 men, 6 women) in the Latarjet group were available for the final follow-up.

RESULTS

There were no statistically significant differences in the demographic parameters or clinical outcomes between the two groups. Functional satisfaction was higher with the Latarjet procedure. Bankart repair had a significantly higher operating cost than the Latarjet procedure. Three patients in the Bankart group and no patients in the Latarjet group developed recurrence.

CONCLUSION

Both procedures provided satisfactory clinical outcomes. However, the Latarjet group had a higher rate of functional satisfaction and lower operating cost, and there was a trend toward higher recurrence in the arthroscopic Bankart group.

The Arthroscopic Bankart Repair: State of the Art in 2020: Decision-making and Operative Technique

Traumatic anterior shoulder instability is prevalent among young athletes, and recurrent dislocations can result in compromised upper extremity function, increasing glenohumeral bone loss, and ultimately, posttraumatic arthritis. Although management algorithms have evolved in response to contemporary data and technical innovation, the arthroscopic Bankart repair continues to be a mainstay for the primary surgical management of first-time or recurrent anterior shoulder instability with marginal attritional glenoid bone loss (ie, <10% to 15%) and/or "on track" Hill-Sachs defects. The advantages of arthroscopic stabilization include its minimally invasive technique, high cost effectiveness, and relatively low recurrence rates and propensity for perioperative complications. The current article reviews contemporary indications/contraindications, management of the first-time dislocator, critical glenoid bone loss, surgical technique, and reported clinical outcomes of the arthroscopic Bankart repair.

Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic

Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.

The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

Introduction

Shoulder dislocation is a costly problem and can have a high risk for recurrent instability after initial dislocation based on well-defined patient characteristics. Patients with recurrent instability can be treated with shoulder stabilizing procedures. Although more costly, surgery may decrease the overall health care burden of managing a patient with multiple shoulder dislocations nonoperatively.

Methods

We performed a retrospective chart review of all patients who presented to the emergency department (ED) with a diagnosis of a shoulder dislocation at a level 1 academic trauma center during the year 2016. Patient information regarding the current dislocation episode, previous dislocations, shoulder surgeries, and postreduction follow-up was gathered. These data were then used to determine the average cost of an ED presentation for a shoulder dislocation episode as obtained from the hospital finance department. The average cost of shoulder stabilization surgery was used to conduct a cost-benefit analysis of operative vs. nonoperative management.

Results

Data were collected on 104 individuals who presented to the ED with shoulder dislocations. Of these, 65 were primary dislocations and 39 were recurrent dislocations. Twelve patients underwent shoulder stabilization surgery after their ED presentation. The average cost to the institution for an ED visit requiring the closed reduction of a shoulder dislocation was $2207 ($973.21 without sedation and $3744 with conscious sedation). The average cost of a shoulder stabilization procedure performed at this same institution was $7807.

Discussion and conclusion

Although shoulder stabilization has a higher cost on the front end, this intervention results in cost savings if it prevents 2-3 future shoulder dislocations resulting in ED visits. These findings suggest that, for patients with a high risk for recurrent instability, not only would stabilization surgery help prevent subsequent dislocation events but would also minimize health care costs.

Outcomes following arthroscopic Bankart repair in female patients

PURPOSE

The purpose of this study is to evaluate clinical outcomes and recurrence among women who have undergone an arthroscopic Bankart repair for recurrent anterior shoulder instability.

METHODS

A retrospective review of patients with anterior shoulder instability that have undergone an arthroscopic Bankart repair between 2012-2017 was performed. Patients were followed up to assess their visual analog scale (VAS) score, Rowe score, Shoulder Instability-Return to Sport after Injury (SIRSI), and the Subjective Shoulder Value (SSV) and their satisfaction level. Whether they were able to return to sport, the timing of return, and the level to which they returned were reported.

RESULTS

Our study included 31 female patients (34 shoulders), with a mean follow-up of 51.9 months. Overall, 82.4% (28/34 shoulders) were satisfied/very satisfied with their surgery. The mean scores were as follows: Rowe, 79.2; SIRSI, 53.9; SSV, 81.9; and VAS, 1.9. Of the 29 patients (32 shoulders) who played sport prior to surgery, 24 returned to play and 17 returned to the same or higher level. One patient suffered a recurrent dislocation and 2 patients suffered recurrent subluxation. No patients underwent a revision procedure.

CONCLUSION

Female patients with anterior shoulder instability treated with arthroscopic Bankart repair have low recurrence rates, with good patient-reported outcomes and high satisfaction rates. Of those participating in sport prior to surgery, there was a high rate of return to play. The overall rate of complications was low, with a low rate of revision surgery.

Arthroscopic Latarjet for Shoulder Instability

Arthroscopic Latarjet is a relatively new, but viable option for the treatment of anterior shoulder instability. Arthroscopic Latarjet has the advantage of faster recovery, reduced stiffness, identification of additional shoulder pathology, and improved cosmesis when compared with open Latarjet. By the majority of clinical and radiographic parameters, arthroscopic Latarjet produces equivalent outcomes compared with open Latarjet. A relatively substantial learning curve for arthroscopic Latarjet exists at about 25 cases; however, multiple studies have demonstrated comparable outcomes and surgical time after the learning curve.

Cost Drivers Associated With Anterior Shoulder Stabilization Surgery

Background:

Arthroscopic Bankart repair, open Bankart repair, and the Latarjet procedure are common treatments for anterior shoulder instability; however, little is known of costs by patient- and surgeon-specific factors. This study aimed to identify areas where cost reduction may be achieved.

Hypothesis:

Increased total charges will be associated with low-volume surgeons and surgical facilities, hospital-owned facilities, open surgical techniques, and patients with at least 1 comorbidity.

Study Design:

Economic and decision analysis; Level of evidence, 3.

Methods:

The 2014 State Ambulatory Surgery and Services Databases from 6 states were utilized. There were 3 Current Procedural Terminology codes (23455, 23462, 29806) used to identify open Bankart repair, the Latarjet procedure, and arthroscopic Bankart repair, respectively. Patient demographic and surgical variables were evaluated on a univariate basis, and all significant factors were then included in the multiple linear regression to determine which factors had the largest effect on cost. Total charges billed for the encounter were used as a proxy for cost of surgery.

Results:

For open Bankart repair, arthroscopic Bankart repair, and the Latarjet procedure, longer operative times increased costs, and high-volume surgical facilities had decreased charges. For the arthroscopic Bankart group, additional factors that increased charges included postoperative hospital admission (US$11,516; P < .001), patient residence in a ZIP code with a below-median income (US$2909; P < .001), presence of a comorbidity (US$1982; P < .001), male sex (US$1545; P = .003), Hispanic race (US$2493; P = .005), and use of regional anesthesia (US$1898; P = .025). Additional cost drivers for the Latarjet procedure included postoperative hospital admission (US$7028; P = .022) and older age (US$187/y; P = .039).

Conclusion:

Postoperative admission to the hospital was the largest cost driver for arthroscopic Bankart repair and the Latarjet procedure. Low-volume facilities were the largest cost driver for open Bankart repair. High-volume surgery centers had lower costs when compared with low-volume surgery centers. Regional anesthesia increased costs in the arthroscopic Bankart group. These findings may help to show where cost savings can be achieved, particularly considering increasing trends toward bundled health care payments.

A single-institution analysis of factors affecting costs in the arthroscopic treatment of glenohumeral instability

Background

Although surgical shoulder stabilization is a substantial cost nationally within the United States, little information exists to analyze this cost. The purpose of this study was to identify factors associated with variation in direct costs with the arthroscopic treatment of glenohumeral instability.

Methods

This was a retrospective study of all patients who underwent arthroscopic treatment of glenohumeral instability between January 12, 2012 and July 11, 2017. Patient and procedure factors were collected. Direct perioperative costs were collected using a validated internal tool. Patient and procedure characteristics significantly associated with costs were identified using multivariate generalized linear models.

Results

The study included 302 patients, of whom 12% were undergoing revision and 32% were contact or collision athletes. Anterior instability was present in 73%, whereas 14% had posterior and 10% had multidirectional instability. Of the patients, 67% were recurrent dislocators and 33% were first-time dislocators or subluxators. Remplissage was performed in 13%; biceps tenodesis, 5%; and rotator cuff repair, 3%. An average of 4.0 ± 1.4 anchors were used. Of costs, 39% were operative facility utilization costs and 41% were implant costs. Factors associated with cost increase included an increased number of anchors (P < .0001), posterior vs. anterior instability (P = .001), recurrent instability vs. first-time dislocation (P = .025), remplissage (P = .006), rotator interval closure (P = .021), bicep tenodesis (P = .020), rotator cuff repair (P < .0001), an inpatient stay (P = .003), and repair of humeral avulsion of the glenohumeral ligaments (P = .012).

Conclusion

Most perioperative costs associated with the arthroscopic treatment of glenohumeral instability are facility utilization and implant costs. Nonmodifiable factors associated with increased cost included posterior direction of instability and recurrent instability. Modifiable factors included additional procedures and inpatient stay.

Cost Analysis in Shoulder Surgery: A Systematic Review

BACKGROUND

Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently.

PURPOSE

To analyze the current state of cost-effectiveness analyses in shoulder surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument).

RESULTS

A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7).

CONCLUSION

Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.

A Cost-Minimization Analysis of Intraoperative Costs in Arthroscopic Bankart Repair, Open Latarjet, and Distal Tibial Allograft

Background:

The optimal surgical treatment of anterior shoulder instability remains controversial.

Hypothesis:

(1) Implants and facility-related costs are the primary drivers of variation in direct costs between arthroscopic Bankart and Latarjet procedures, and (2) distal tibial allograft (DTA) is more costly than Latarjet as a function of the graft expense.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Intraoperative cost data were derived for all arthroscopic anterior stabilizations and Latarjet and DTA procedures performed at a single academic institution from January 2012 to September 2017. Cost comparisons were made between those undergoing arthroscopic stabilization and Latarjet and between Latarjet and DTA. Multivariate regressions were performed to determine the difference in direct costs accounting for various patient- and surgery-related factors.

Results:

A total of 87 arthroscopic stabilizations, 44 Latarjet procedures, and 5 DTA procedures were performed during the study period. Arthroscopic Bankart repair was found to be 17% more costly than Latarjet, with suture anchor implant cost being the primary driver of cost. DTA was 2.9-fold more costly than Latarjet, with greater costs across all domains. Multivariate analysis also found the number of prior arthroscopic procedures performed (P = .007) and whether the procedure was performed in an ambulatory or inpatient setting (P < .0001) to be significantly associated with higher direct costs.

Conclusion:

Latarjet is less costly than arthroscopic Bankart repair, largely because of implant cost. Value-driven strategies to narrow the cost differential could focus on performing these procedures in an outpatient setting in addition to reducing overall implant cost for arthroscopic procedures. Perceived potential benefits of DTA over Latarjet may be outweighed by higher costs.

Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the evidence in the literature to ascertain the functional outcomes and recurrences rates, as well as subsequent revision rates, following arthroscopic Bankart repair at a minimum of 10 years' follow-up.

METHODS

Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library databases. Studies were included if they were clinical studies on arthroscopic Bankart repair with a minimum of 10 years' follow-up. Statistical analysis was performed using SPSS software.

RESULTS

Our review found 9 studies including 822 shoulders meeting our inclusion criteria. The majority of patients were male patients (75.5%), the average age was 28.0 years (range, 15-73 years), and the mean follow-up period was 149.4 months. The most commonly used functional outcome score was the Rowe score, with a weighted mean of 87.0. Overall, 77.6% of athletes were able to return to sports postoperatively. The overall rate of recurrent instability was 31.2%, with 16.0% of patients having recurrent dislocations, and the overall revision rate was 17.0%. Evidence of instability arthropathy was found in 59.4% of patients, with 10.5% of patients having moderate to severe arthropathy.

DISCUSSION AND CONCLUSION

Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent long-term functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery. In addition, the high rate of instability arthropathy is a concern following arthroscopic Bankart repair in the long term.

Practicing Cost-Conscious Shoulder Surgery

Second only to the knee, the shoulder is the most commonly reported area of chronic joint pain. By practicing evidence-based methods for improved outcomes at lower costs, providers can increase both efficiency and margin, while patients experience better care and higher satisfaction. Current cost studies on shoulder care provide a base for improving evidence-based care and improving value.