Cost-Effectiveness of Rotator Cuff Repair With Concomitant Subacromial Decompression at Mid-Term Follow-Up: A Systematic Review and Economic Analysis.

Abstract

There is limited evidence evaluating the cost-effectiveness of adding subacromial decompression (SAD) to rotator cuff repair (RCR) in the treatment of full-thickness rotator cuff tears. The purpose of this study was to perform (1) a systematic review and (2) cost-utility analysis comparing isolated RCR versus RCR with SAD in patients with full-thickness rotator cuff tears. This was an economic and decision-analysis study; Level II. A systematic review was conducted per Preferred Reporting Items for Systemactic reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify Level I-II studies comparing RCR and RCR with SAD at ≥5-year follow-up. A decision tree model evaluated cost-effectiveness over a 5-year time horizon. Costs, revision rates, and utility values (EQ-5D-based) were derived from the literature. Health utility was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was assessed using incremental cost-effectiveness ratios and net monetary benefit (NMB), with a $50,000/QALY willingness-to-pay threshold. Monte Carlo and one-way sensitivity analyses were done to account for parameter uncertainty. Over 5 years, RCR with SAD had a lower mean cost ($33,448) compared with isolated RCR ($34,593) and yielded slightly higher QALYs (1.465 vs 1.454). RCR + SAD demonstrated a positive incremental NMB ($1,695) and a negative incremental cost-effectiveness ratio, emerging as the dominant strategy. Probabilistic sensitivity analysis favored RCR + SAD in 99.28% of 1,000 simulations. On one-way analysis, RCR + SAD remained cost-effective with burr costs up to $1,721, additional surgical time up to 43.6 minutes, and revision probabilities up to 10%. Despite higher upfront costs, SAD during RCR remains cost-effective at mid-term follow-up. By reducing revision rates, SAD provides greater QALYs at a lower overall cost compared with isolated RCR.