The Cost-Effectiveness Of Arthroscopic Bankart Repair Versus Non-Operative Treatment For First-time, Traumatic, Anterior Shoulder Dislocations

OBJECTIVES: Prior studies have demonstrated excellent results after acute arthroscopic stabilization of first-time, traumatic, anterior shoulder dislocations in young patients. However, this treatment has not been widely accepted as first line management of this injury. Surgeons may point to the initial direct costs of surgical management as one rationale for conservative management of these injuries. The purpose of this study is to determine whether surgical stabilization of first time traumatic anterior shoulder dislocation represents a cost effective treatment alternative when compared to non-operative treatment with physical therapy. METHODS: A decision-analytic model was constructed to assess the cost-effectiveness of arthroscopic bankart repair compared with non-operative treatment with physical therapy based on the incremental cost-effectiveness ratio (ICER). A threshold ICER of less than $100,000/quality adjusted life year gained was set to define a cost-effective treatment modality. Health state utilities for treatment outcomes of a recurrently dislocating shoulder and a stable shoulder were collected prospectively by surveying fifty patient volunteers using a time trade-off METHOD: The probabilities of the various treatment outcomes and the costs associated with treatment were derived from the orthopaedic literature and adjusted Medicare reimbursement rates. RESULTS: The incremental cost-effectiveness ratio (ICER) for arthroscopic bankart versus non-operative treatment was $43,500. The estimated cost of surgical treatment must increase from approximately $11,000 to over $24,000 for surgery to no longer be cost-effective. The one-year probability of dislocation after bankart repair must increase from approximately 4% to 7%, or the probability of dislocation after non-operative treatment must decrease from 17% to approximately 11% for surgery to no longer be cost-effective CONCLUSION: Using currently available probabilities, estimated costs, and prospectively collected health state utilities, arthroscopic bankart repair represents a cost-effective treatment alternative for first-time, traumatic anterior shoulder dislocations in young patients. These results are robust when the costs, probabilities, and utilities are widely varied. Further studies should focus on identifying patient populations who fall within the threshold values identified in this analysis.