Cost-Effectiveness of Reverse Total Shoulder Arthroplasty Versus Arthroscopic Rotator Cuff Repair for Symptomatic Large and Massive Rotator Cuff Tears


      To compare the cost-effectiveness within the United States health care system of arthroscopic rotator cuff repair versus reverse total shoulder arthroplasty in patients with symptomatic large and massive rotator cuff tears without cuff-tear arthropathy.


      An expected-value decision analysis was constructed comparing the costs and outcomes of patients undergoing arthroscopic rotator cuff repair and reverse total shoulder arthroplasty for large and massive rotator cuff tears (and excluding cases of cuff-tear arthropathy). Comprehensive literature search provided input data to extrapolate costs and health utility states for these outcomes. The primary outcome assessed was that of incremental cost-effectiveness ratio (ICER) of reverse total shoulder arthroplasty versus rotator cuff repair.


      For the base case, both arthroscopic rotator cuff repair and reverse total shoulder were superior to nonoperative care, with an ICER of $15,500/quality-adjusted life year (QALY) and $37,400/QALY, respectively. Arthroscopic rotator cuff repair was dominant over primary reverse total shoulder arthroplasty, with lower costs and slightly improved clinical outcomes. Arthroscopic rotator cuff repair was the preferred strategy as long as the lifetime progression rate from retear to end-stage cuff-tear arthropathy was less than 89%. However, when the model was modified to account for worse outcomes when reverse shoulder arthroplasty was performed after a failed attempted rotator cuff repair, primary reverse total shoulder had superior outcomes with an ICER of $90,000/QALY.


      Arthroscopic rotator cuff repair—despite high rates of tendon retearing—for patients with large and massive rotator cuff tears may be a more cost-effective initial treatment strategy when compared with primary reverse total shoulder arthroplasty and when assuming no detrimental impact of previous surgery on outcomes after arthroplasty. Clinical judgment should still be prioritized when formulating treatment plans for these patients.

      Level of Evidence

      Level II, economic decision analysis.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Coe M.P.
        • Greiwe R.M.
        • Joshi R.
        • et al.
        The cost-effectiveness of reverse total shoulder arthroplasty compared with hemiarthroplasty for rotator cuff tear arthropathy.
        J Shoulder Elbow Surg. 2012; 21: 1278-1288
        • Denard P.J.
        • Ladermann A.
        • Jiwani A.Z.
        • Burkhart S.S.
        Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis.
        Arthroscopy. 2012; 28: 1214-1219
        • Boileau P.
        • Brassart N.
        • Watkinson D.J.
        • Carles M.
        • Hatzidakis A.M.
        • Krishnan S.G.
        Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal?.
        J Bone Joint Surg Am. 2005; 87: 1229-1240
        • Cole B.J.
        • McCarty III, L.P.
        • Kang R.W.
        • Alford W.
        • Lewis P.B.
        • Hayden J.K.
        Arthroscopic rotator cuff repair: Prospective functional outcome and repair integrity at minimum 2-year follow-up.
        J Shoulder Elbow Surg. 2007; 16: 579-585
        • Kim H.M.
        • Caldwell J.M.
        • Buza J.A.
        • et al.
        Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear.
        J Bone Joint Surg Am. 2014; 96: 106-112
        • Papadopoulos P.
        • Karataglis D.
        • Boutsiadis A.
        • Fotiadou A.
        • Christoforidis J.
        • Christodoulou A.
        Functional outcome and structural integrity following mini-open repair of large and massive rotator cuff tears: A 3-5 year follow-up study.
        J Shoulder Elbow Surg. 2011; 20: 131-137
        • Rhee Y.G.
        • Cho N.S.
        • Yoo J.H.
        Clinical outcome and repair integrity after rotator cuff repair in patients older than 70 years versus patients younger than 70 years.
        Arthroscopy. 2014; 30: 546-554
        • Yoo J.C.
        • Ahn J.H.
        • Koh K.H.
        • Lim K.S.
        Rotator cuff integrity after arthroscopic repair for large tears with less-than-optimal footprint coverage.
        Arthroscopy. 2009; 25: 1093-1100
        • Wiater J.M.
        • Moravek Jr., J.E.
        • Budge M.D.
        • Koueiter D.M.
        • Marcantonio D.
        • Wiater B.P.
        Clinical and radiographic results of cementless reverse total shoulder arthroplasty: A comparative study with 2 to 5 years of follow-up.
        J Shoulder Elbow Surg. 2014; 23: 1208-1214
        • Jost B.
        • Pfirrmann C.W.
        • Gerber C.
        • Switzerland Z.
        Clinical outcome after structural failure of rotator cuff repairs.
        J Bone Joint Surg Am. 2000; 82: 304-314
        • Klepps S.
        • Bishop J.
        • Lin J.
        • et al.
        Prospective evaluation of the effect of rotator cuff integrity on the outcome of open rotator cuff repairs.
        Am J Sports Med. 2004; 32: 1716-1722
        • Liu S.H.
        • Baker C.L.
        Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff.
        Arthroscopy. 1994; 10: 54-60
        • Boileau P.
        • Gonzalez J.F.
        • Chuinard C.
        • Bicknell R.
        • Walch G.
        Reverse total shoulder arthroplasty after failed rotator cuff surgery.
        J Shoulder Elbow Surg. 2009; 18: 600-606
        • Mather III, R.C.
        • Koenig L.
        • Acevedo D.
        • et al.
        The societal and economic value of rotator cuff repair.
        J Bone Joint Surg Am. 2013; 95: 1993-2000
        • Renfree K.J.
        • Hattrup S.J.
        • Chang Y.H.
        Cost utility analysis of reverse total shoulder arthroplasty.
        J Shoulder Elbow Surg. 2013; 22: 1656-1661
        • Gold M.R.
        Cost-effectiveness in health and medicine.
        Oxford University Press, New York1996
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; 371: 796-797
        • Braithwaite R.S.
        • Meltzer D.O.
        • King Jr., J.T.
        • Leslie D.
        • Roberts M.S.
        What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?.
        Med Care. 2008; 46: 349-356
        • Galatz L.M.
        • Ball C.M.
        • Teefey S.A.
        • Middleton W.D.
        • Yamaguchi K.
        The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.
        J Bone Joint Surg Am. 2004; 86: 219-224
        • Bisson L.
        • Zivaljevic N.
        • Sanders S.
        • Pula D.
        A cost analysis of single-row versus double-row and suture bridge rotator cuff repair methods.
        Knee Surg Sports Traumatol Arthrosc. 2015; 23: 487-493
        • Churchill R.S.
        • Ghorai J.K.
        Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: Mini-open versus all-arthroscopic.
        J Shoulder Elbow Surg. 2010; 19: 716-721
        • Genuario J.W.
        • Donegan R.P.
        • Hamman D.
        • et al.
        The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair.
        J Bone Joint Surg Am. 2012; 94: 1369-1377
        • Ponce B.A.
        • Oladeji L.O.
        • Rogers M.E.
        • Menendez M.E.
        Comparative analysis of anatomic and reverse total shoulder arthroplasty: In-hospital outcomes and costs.
        J Shoulder Elbow Surg. 2015; 24: 460-467
        • Virani N.A.
        • Williams C.D.
        • Clark R.
        • Polikandriotis J.
        • Downes K.L.
        • Frankle M.A.
        Preparing for the bundled-payment initiative: The cost and clinical outcomes of reverse shoulder arthroplasty for the surgical treatment of advanced rotator cuff deficiency at an average 4-year follow-up.
        J Shoulder Elbow Surg. 2013; 22: 1612-1622
        • Vitale M.A.
        • Vitale M.G.
        • Zivin J.G.
        • Braman J.P.
        • Bigliani L.U.
        • Flatow E.L.
        Rotator cuff repair: An analysis of utility scores and cost-effectiveness.
        J Shoulder Elbow Surg. 2007; 16: 181-187
      1. Health NC. Rotator cuff surgery cost and procedure information. Accessed January 20, 2015.

      2. US Department of Labor. Consumer Price Index. Accessed January 21, 2016.

        • Schmidt S.
        • Ferrer M.
        • Gonzalez M.
        • et al.
        Evaluation of shoulder-specific patient-reported outcome measures: A systematic and standardized comparison of available evidence.
        J Shoulder Elbow Surg. 2014; 23: 434-444
        • Provencher M.T.
        • Frank R.M.
        • Scuderi M.G.
        • et al.
        General and disease-specific use of outcomes scores for the shoulder: A survey of AOSSM, AANA, and ISAKOS members.
        Phys Sportsmed. 2014; 42: 120-130
        • Crall T.S.
        • Bishop J.A.
        • Guttman D.
        • Kocher M.
        • Bozic K.
        • Lubowitz J.H.
        Cost-effectiveness analysis of primary arthroscopic stabilization versus nonoperative treatment for first-time anterior glenohumeral dislocations.
        Arthroscopy. 2012; 28: 1755-1765
        • Mather III, R.C.
        • Orlando L.A.
        • Henderson R.A.
        • Lawrence J.T.
        • Taylor D.C.
        A predictive model of shoulder instability after a first-time anterior shoulder dislocation.
        J Shoulder Elbow Surg. 2011; 20: 259-266
        • Oh J.H.
        • Kim S.H.
        • Shin S.H.
        • et al.
        Outcome of rotator cuff repair in large-to-massive tear with pseudoparalysis: A comparative study with propensity score matching.
        Am J Sports Med. 2011; 39: 1413-1420
        • Park J.Y.
        • Lhee S.H.
        • Oh K.S.
        • Moon S.G.
        • Hwang J.T.
        Clinical and ultrasonographic outcomes of arthroscopic suture bridge repair for massive rotator cuff tear.
        Arthroscopy. 2013; 29: 280-289
        • Mulieri P.
        • Dunning P.
        • Klein S.
        • Pupello D.
        • Frankle M.
        Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis.
        J Bone Joint Surg Am. 2010; 92: 2544-2556
        • Arias E.
        United States life tables, 2002.
        Natl Vital Stat Rep. 2004; 53: 1-38
        • Berth A.
        • Neumann W.
        • Awiszus F.
        • Pap G.
        Massive rotator cuff tears: Functional outcome after debridement or arthroscopic partial repair.
        J Orthop Traumatol. 2010; 11: 13-20
        • Walch G.
        • Edwards T.B.
        • Boulahia A.
        • Nove-Josserand L.
        • Neyton L.
        • Szabo I.
        Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: Clinical and radiographic results of 307 cases.
        J Shoulder Elbow Surg. 2005; 14: 238-246
        • Paxton E.S.
        • Teefey S.A.
        • Dahiya N.
        • Keener J.D.
        • Yamaguchi K.
        • Galatz L.M.
        Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: Minimum ten-year follow-up.
        J Bone Joint Surg Am. 2013; 95: 627-632
        • Iagulli N.D.
        • Field L.D.
        • Hobgood E.R.
        • Ramsey J.R.
        • Savoie III, F.H.
        Comparison of partial versus complete arthroscopic repair of massive rotator cuff tears.
        Am J Sports Med. 2012; 40: 1022-1026
        • Ek E.T.
        • Neukom L.
        • Catanzaro S.
        • Gerber C.
        Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: Results after five to fifteen years.
        J Shoulder Elbow Surg. 2013; 22: 1199-1208
        • Castricini R.
        • Gasparini G.
        • Di Luggo F.
        • De Benedetto M.
        • De Gori M.
        • Galasso O.
        Health-related quality of life and functionality after reverse shoulder arthroplasty.
        J Shoulder Elbow Surg. 2013; 22: 1639-1649