Several studies have shown excellent results for acute arthroscopic stabilization of first-time, traumatic, anterior shoulder dislocations in young patients (15 to 35 years old). But the current emphasis on cost-effectiveness has raised questions about using surgery as first-line management of these injuries.

Research presented at the 2013 annual meeting of the American Orthopaedic Society for Sports Medicine should help answer those questions. According to Ryan P. Donegan, MD, MS, and colleagues, arthroscopic Bankart repair surgery is a cost-effective approach for patients who sustain a first-time, traumatic, anterior shoulder dislocation.

Using a Markov model
The researchers used a Markov model, which takes into account how surgery affects the patient’s recovery in relation to the actual costs of medical treatment. “A threshold incremental cost-effectiveness ratio (ICER) of less than $100,000 per quality adjusted life year (QALY) gained was set to define a cost-effective treatment modality,” explained Dr. Donegan.

Researchers drew data from literature and adjusted Medicare reimbursement rates to determine the probabilities of the various treatment outcomes and the costs associated with treatment. The literature search focused on studies reporting on first-time shoulder-repair arthroscopies in patients aged 15 to 35 years. A prospective survey of 50 patient volunteers, using a time trade-off method, was used to assess health state utilities for treatment outcomes of a recurrently dislocating shoulder and a stable shoulder.

Under this model, for arthro-scopic Bankart repair surgery to be cost-effective compared to nonsurgical treatment (physical therapy), researchers determined that surgery would have to meet the following criteria:

• Expenses must be less than $24,457 (Fig. 1).
• The probability of a second dislocation must be less than 7 percent.
• The quality-of-life rating must not fall below 0.86.

“Our research showed surgical costs of $11,267, probability of a second dislocation at only 4 percent, and a quality-of-life rating of 0.93—numbers suggesting surgery is a good investment for these patients,” commented Dr. Donegan. The ICER for arthroscopic Bankart repair versus nonsurgical treatment was $43,500—substantially less than the threshold set by the researchers.

“Shoulder dislocations are one of the most common orthopaedic issues today,” said Dr. Donegan. “Our research shows that, after weighing all the options, surgery can be both helpful to the recovery process and cost-effective.” He also noted, however, that nonsurgical treatment based on rest and physical therapy should still be considered an effective treatment option for patients.

The researchers called for additional studies focused on identifying patient populations that fall within the threshold values identified in their analysis.

Dr. Donegan’s coauthors for “The Cost-Effectiveness of Arthroscopic Bankart Repair Versus Non-Operative Treatment for First-time, Traumatic, Anterior Shoulder Dislocations” include Garrett Davis, MD; James Genuario, MD; and John-Eric Bell, MD.

Disclosure information: Drs. Donegan, Davis, and Bell—no conflicts. Dr. Genuario—Stryker.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Bottom Line

• This cost-effectiveness study compared the use of arthro-scopic Bankart repair and physical therapy to treat first-time, traumatic, anterior shoulder dislocations.
• Researchers found that arthro-scopic Bankart repair delivered an incremental cost-effectiveness ratio of $43,500/QALY compared to nonsurgical treatment, well under the $100,000/QALY threshold.
• Arthroscopic Bankart repair represents a cost-effective treatment option for patients ages 15 to 35 years who sustain a first-time, traumatic, anterior shoulder dislocation.