Purpose
The purpose of this study is to evaluate the cost effectiveness of the use of extracellular
matrix (ECM) augment at the time of primary rotator cuff repair utilizing a decision
tree analysis.
Methods
A decision tree model was created utilizing the existing literature for retear rates
with and without dermal graft augmentation. Costs for rotator cuff repair (hospital
and surgeon fees) were based on published studies and the cost for graft augmentation
was based on institutional data. Utility measures were based upon EQ-5D (European
Quality of Life 5 Dimension) scores to assess for improvement in quality adjusted
life years (QALY) over a 10-year postoperative period with and without graft augmentation.
Cost effectiveness was assessed using the incremental cost effectiveness ratio (ICER),
or the incremental cost for per QALY with graft augmentation. Cost effectiveness is
based on previous literature whereby an intervention is considered cost effective
if the ICER is less than $50,000/QALY.
Results
On the basis of our decision tree analysis, total cost for rotator cuff tear without
augmentation was $12,763, while the cost increased to $16,039 with ECM augmentation.
With graft augmentation there was an improvement in 2.29 QALY, while there was an
improvement of 2.05 without graft augmentation. The ICER of graft augmentation is
$14,000/QALY, well below the cost effectiveness cut-off of $50,000/QALY. Sensitivity
analysis showed the maximum cost of the ECM augment to be cost effective is $11,921.
Conclusion
Graft augmentation does come with a significant upfront cost; however, on the basis
of our decision-tree analysis, it may represent a cost-effective procedure. There
is evidence to potentially consider more routine use in rotator cuff repairs, while
being cost effective.
Level of Evidence
Economic: Level IV: computer simulation model (Monte Carlo simulation, Markov model)
with inputs derived from Level IV studies.
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References
- Prevalence and incidence of adults consulting for shoulder conditions in UK primary care: Patterns of diagnosis and referral.Rheumatology (Oxford). 2006; 45: 215-221
- National trends in rotator cuff repair.J Bone Joint Surg Am. 2012; 94: 227-233
- Increasing incidence of rotator cuff repairs—A nationwide registry study in Finland.BMC Musculoskelet Disord. 2015; 16: 189
- Direct and indirect economic burden associated with rotator cuff tears and repairs in the US.Curr Med Res Opin. 2021; 37: 1199-1211
- Work-related musculoskeletal disorders of the neck, back, and upper extremity in Washington State, 1992–2000.(Technical Report Number 40-12-2015-a) Sharp Program, Olympia, WA2002
- The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.J Bone Joint Surg Am. 2004; 86: 219-224
- Rotator cuff repair: Published evidence on factors associated with repair integrity and clinical outcome.Am J Sports Med. 2015; 43: 491-500
- Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal?.J Bone Joint Surg Am. 2005; 87: 1229-1240
- Surgery for rotator cuff tears.Cochrane Database Syst Rev. 2019; 12: CD013502
- The effect of age on risk of retear after rotator cuff repair: A systematic review and meta-analysis.JSES Int. 2020; 4: 625-631
- Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair.Am J Sports Med. 2012; 40: 2242-2247
- Rotator cuff repair in patients over 75 years of age: Clinical outcome and repair integrity.Clin Orthop Surg. 2016; 8: 420-427
Wylie JD, Baran S, Granger EK, Tashjian RZ. A Comprehensive evaluation of factors affecting healing, range of motion, strength, and patient-reported outcomes after arthroscopic rotator cuff repair. Orthop J Sports Med 2018;6:2325967117750104.
- The clinical effect of a rotator cuff retear: A meta-analysis of arthroscopic single-row and double-row repairs.Am J Sports Med. 2017; 45: 733-741
- What influence does progression of a nonhealing rotator cuff tear have on shoulder pain and function?.Clin Orthop Relat Res. 2017; 475: 1596-1604
- Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair?.Arthroscopy. 2010; 26: 393-403
- Tendon augmentation grafts: Biomechanical failure loads and failure patterns.Arthroscopy. 2006; 22: 534-538
- Ultimate tensile failure loads of a human dermal allograft rotator cuff augmentation.Arthroscopy. 2008; 24: 20-24
- Biomechanical effect of rotator cuff augmentation with an acellular dermal matrix graft: a cadaver study.Clin Biomech (Bristol, Avon). 2012; 27: 789-792
- Biomechanical comparison of augmentation of engineered tendon-fibrocartilage-bone composite with acellular dermal graft using double rip-stop technique for canine rotator cuff repair.Orthop J Sports Med. 2020; 8:2325967120939001
- Rotator cuff repair using an acellular dermal matrix graft: an in vivo study in a canine model.Arthroscopy. 2006; 22: 700-709
- Reconstruction of large rotator-cuff tears with acellular dermal matrix grafts in rats.J Shoulder Elbow Surg. 2009; 18: 288-295
- Rotator cuff bridging repair using acellular dermal matrix in large to massive rotator cuff tears: Histologic and clinical analysis.J Shoulder Elbow Surg. 2017; 26: 1897-1907
- Outcome of large to massive rotator cuff tears repaired with and without extracellular matrix augmentation: A prospective comparative study.Arthroscopy. 2015; 31: 1459-1465
- Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes.J Shoulder Elbow Surg. 2019; 28: 1918-1927
- Rotator cuff matrix augmentation and interposition: A systematic review and meta-analysis.Am J Sports Med. 2019; 47: 1496-1506
- Health care CBA and CEA from 1991 to 1996: An updated bibliography.Med Care. 1998; 36: MS1-MS9:5 Suppl
- The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair.J Bone Joint Surg Am. 2012; 94: 1369-1377
- Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up.J Bone Joint Surg Am. 2014; 96: 1504-1514
- Rotator cuff repair: An analysis of utility scores and cost-effectiveness.J Shoulder Elbow Surg. 2007; 16: 181-187
- Cost-effectiveness and satisfaction following arthroscopic rotator cuff repair: does age matter?.Bone Joint J. 2019; 101-B: 860-866
- The societal and economic value of rotator cuff repair.J Bone Joint Surg Am. 2013; 95: 1993-2000
- The cost-effectiveness of using platelet-rich plasma during rotator cuff repair: A Markov model analysis.Arthroscopy. 2016; 32: 1237-1244
- Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes.J Shoulder Elbow Surg. 2019; 28: 1918-1927
- Long-term results after arthroscopic transosseous rotator cuff repair.J Shoulder Elbow Surg. 2019; 28: 706-714
- 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
- Revision rotator cuff repair: A systematic review.J Shoulder Elbow Surg. 2020; 29: 624-633
- Arthrography and roentgenography in ruptures of the tendon of the shoulder joint.Acta Radiol. 1939; 20: 548-562
- On pathogenesis of ruptures of the tendon aponeurosis of the shoulder joint.Acta Radiol. 1939; 20: 563-577
- In vivo visualization of vascular patterns of rotator cuff tears using contrast-enhanced ultrasound.Am J Sports Med. 2010; 38: 2464-2471
- Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: Age- and activity-related changes in the intact asymptomatic rotator cuff.J Shoulder Elbow Surg. 2008; 17: 96S-100S
- Pathologic evidence of degeneration as a primary cause of rotator cuff tear.Clin Orthop Relat Res. 2003; 415: 111-120
- Immunohistochemical distribution of type I, II and III collagens in the rabbit supraspinatus tendon insertion.J Anat. 1994; 185: 279-284
- Tendon degeneration and chronic shoulder pain: changes in the collagen composition of the human rotator cuff tendons in rotator cuff tendinitis.Ann Rheum Dis. 1994; 53: 359-366
- The collagen types in the attachment zone of rotator cuff tendons in the elderly: an immunohistochemical study.J Rheumatol. 1994; 21: 2096-2100
- Age-related prevalence of rotator cuff tears in asymptomatic shoulders.J Shoulder Elbow Surg. 1999; 8: 296-299
- Prevalence of asymptomatic rotator cuff tear and their related factors in the Korean population.J Shoulder Elbow Surg. 2017; 26: 30-35
- Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village.J Orthop. 2013; 10: 8-12
- Prevalence and risk factors of a rotator cuff tear in the general population.J Shoulder Elbow Surg. 2010; 19: 116-120
- Time to failure after rotator cuff repair: A prospective imaging study.J Bone Joint Surg Am. 2013; 95: 965-971
- Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears.J Shoulder Elbow Surg. 2014; 23: 182-188
- Does suture technique affect re-rupture in arthroscopic rotator cuff repair? A meta-analysis.Arthroscopy. 2015; 31: 1576-1582
- Evaluation of a cross-linked acellular porcine dermal patch for rotator cuff repair augmentation in an ovine model.J Shoulder Elbow Surg. 2007; 16: S184-S190:(5 Suppl)
- Human tendon cell response to 7 commercially available extracellular matrix materials: An in vitro study.Arthroscopy. 2010; 26: 1181-1188
- Repair of a rotator cuff tendon defect using an acellular human dermal graft in a large primate model (SS-44).Arthroscopy. 2008; 24: e24-e25
- The use of a patch to augment rotator cuff surgery—A survey of UK shoulder and elbow surgeons.PLoS One. 2020; 15e0230235
Article info
Publication history
Published online: January 20, 2022
Accepted:
January 8,
2022
Received:
May 21,
2021
Footnotes
See commentary on page 2175
The authors report the following potential conflicts of interest or sources of funding: N.V. reports receiving royalty or license from Smith & Nephew, Inc., consulting fees from Stryker Corporation, and personal fees from Relievant Medsystems, Inc., outside the submitted work. B.J.C. has received research support from Aesculap, Regentis, Arthrex, and the National Institutes of Health; has received royalties from Elsevier Publishing and Operative Techniques in Sports Medicine; and has received stocks or stock options from Ossio, Regentis, and Bandgrip, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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© 2022 by the Arthroscopy Association of North America
