Cost-Utility Analysis of Arthroscopic Rotator Cuff Repair: A Prospective Health Economic Study Using Real-World Data.

PURPOSE: To assess the change in quality of life (QOL) and costs for patients with rotator cuff tears after arthroscopic rotator cuff repair (aRCR) compared with continued nonoperative management, using real-world evidence. METHODS: Patients indicated for aRCR were included in a prospective study and followed up to 2 years after surgery (postop) for all measurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, subjective shoulder value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs in Swiss francs (CHF; 1 CHF = 1.03 USD). Baseline data at recruitment and costs sustained over 1 year before surgery (preop) served as a proxy for nonoperative management. Total direct medical costs to gain 1 extra quality-adjusted life year (QALY) were calculated as the incremental cost-effectiveness ratio (ICER; mean of 2 years postop compared with 1 year preop) from a societal perspective. Subgroup analyses were separately performed for traumatic (trauma-OP) and degenerative (degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients included more intensive nonoperative treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis. RESULTS: For 153 aRCR patients (mean age 57 years; 63% male), the mean EQ-5D index improved from 0.71 (preop) to 0.94 (1 year postop) and 0.96 (2 years postop). Mean total costs increased from 5,499 CHF (preop) to 17,116 CHF (1 year postop), then decreased to 4,226 CHF (2 years postop). The ICER for all aRCR patients was 24,924 CHF/QALY (95% confidence interval [CI] 16,742 to 33,106) and 17,357 CHF/QALY (95% CI 10,951 to 23,763) and 36,474 CHF/QALY (95% CI 16,301 to 56,648) for the trauma-OP and degen-OP groups, respectively. QOL and shoulder function were significantly associated (P < .001). CONCLUSIONS: For RC patients treated at a specialized Swiss orthopaedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL up to 2 years after repair compared with prior nonoperative management. LEVEL OF EVIDENCE: Economic Analyses - Developing an Economic Model, Level II.

Latissimus dorsi muscle transfer reduces external rotation deficit at the cost of internal rotation in reverse shoulder arthroplasty patients: a cohort study.

HYPOTHESIS: We hypothesized that treatment of rotator cuff arthropathy (RCA) with reverse shoulder arthroplasty (RSA) and an additional latissimus dorsi transfer (LDT) in patients with an active external rotation deficit (ERD) would restore external rotation (ER) with concomitant deterioration in internal rotation. METHODS: In our cohort study, 26 RCA patients with an active ERD (ie, positive lag sign and maximum active ER of 0°) underwent RSA between September 2007 and February 2015; LDT was completed in 13 of these patients. In addition, 88 control patients without ERD who underwent only RSA were identified. Clinical outcomes of strength, range of motion, Constant-Murley score, and Shoulder Pain and Disability Index score, as well as complications, were documented 6, 12, 24, and 60 months postoperatively. We made comparative analyses using statistical mixed models. RESULTS: The LDT procedure extended the surgical time by 26 minutes (P = .003). LDT patients had up to 22° better postoperative active ER than control patients (P < .001), although this was accompanied by an internal rotation deficit (77% vs 46% of control patients could not reach the lumbosacral region, P = .010). We calculated a 23% risk of local procedure-related complications for RSA patients with an active ERD and LDT. CONCLUSION: Patients with RCA and an active ERD seem to benefit from an LDT, although this is accompanied by the potential loss of internal rotation. This additional procedure is associated with an extended surgical time as well as a possible increase in the risk of a complication occurring.

Comprehensive assessment of clinical outcome and quality of life after total elbow arthroplasty.

OBJECTIVE: To assess quantitatively the outcome and to explore the physiometric and psychometric properties of clinical, generic, and condition-specific instruments after total elbow arthroplasty. METHODS: Seventy-nine patients were assessed in a 6-19-year cross-sectional catamnesis by means of 6 widely used questionnaires, clinical examinations, and radiographic examinations. RESULTS: With regard to pain, general physical health, and all the mental health dimensions of the Short Form 36 (SF-36), the patients showed scores comparable to normative values. Elbow joint stability and satisfaction were both good. Significant functional limitation was evidenced by the low mean scores of the SF-36 physical functioning measure (48.7, normative 69.9) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) function measure (51.1, normative 89.3). The SF-36 physical component summary and the DASH correlated highly (r = 0.76) and, in factor analysis, loaded on the factor "physical unspecific." The patient and clinical modified American Shoulder and Elbow Surgeons questionnaire (mASES) correlated with the Patient Related Elbow Evaluation form (r = 0.92 with the patient mASES) and loaded on "physical specific." The SF-36 mental component summary loaded on "mental quality of life." CONCLUSION: The patients' self-rated health, quality of life, and clinical outcome were good and were not affected by impairment in some specific functional abilities. A questionnaire set comprising the SF-36 and the patient and clinical mASES is proposed for the comprehensive and specific assessment of outcome after elbow arthroplasty.