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Cost-effectiveness of Adding Remplissage to Bankart Repair for On-track Hill-Sachs Lesions: A Markov Decision
Matthew Frederickson1, Megan Kou1,2, Dylan Cullinane3
1Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California, USA.
Background:
Remplissage decreases recurrence after arthroscopic Bankart repair for anterior shoulder instability but has historically been reserved for off-track Hill-Sachs lesions. The addition of remplissage for patients with on-track lesions remains controversial because of concerns about added operative costs and potential loss of range of motion. The cost-effectiveness of remplissage in patients with on-track Hill-Sachs lesions has not been established.
Purpose:
To evaluate the cost-effectiveness of arthroscopic Bankart repair with remplissage versus isolated Bankart repair in patients with on-track Hill-Sachs lesions.
Study Design:
Economic decision analysis; Level of evidence, 3.
Methods:
A Markov decision model simulated a 10-year period from a societal perspective. There were 2 treatment strategies compared: isolated arthroscopic Bankart repair (IBR) and arthroscopic Bankart repair with remplissage (BR+R). Health states included stable shoulder, recurrent instability, stable shoulder after revision, and persistent instability. Transition probabilities were derived from random-effects meta-analysis of recurrence rates at a median 34.7-month follow-up. Costs (in 2025 United States dollars) included direct medical costs and indirect costs related to productivity loss. Costs and quality-adjusted life-years (QALYs) were discounted at 3% annually. Outcomes included total costs, QALYs, net monetary benefit (NMB), and incremental cost-effectiveness ratios (ICERs). Probabilistic sensitivity analysis (PSA) with Monte Carlo microsimulation was conducted with 1000 simulated patients and 10,000 PSA iterations. One-way sensitivity analysis evaluated the influence of individual parameters. Cost-effectiveness acceptability curves were generated at willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY.
Results:
Over a 10-year time horizon, BR+R yielded 8.59 QALYs at a cost of $24,980, whereas IBR yielded 8.18 QALYs at a cost of $23,333. BR+R was cost-effective in 99.89% and 99.99% of simulations at WTP thresholds of $50,000/QALY and $100,000/QALY, respectively. One-way sensitivity analysis showed that the model was most sensitive to recurrence probabilities.
Conclusion:
For patients with on-track Hill-Sachs lesions and subcritical glenoid bone loss, Bankart repair with remplissage was cost-effective compared with isolated Bankart repair, driven by reductions in recurrence and revision surgery. These findings support the consideration of remplissage in patients with on-track lesions, particularly those at a higher risk for recurrence.