Orthogate Subspecialty Journal Scan: Shoulder and Elbow

Curated critical appraisals of recent high-impact trials and practice-changing studies across shoulder and elbow, structured using the SBAR framework for immediate surgical and clinical application.

Featured Shoulder and Elbow Studies This Edition (September 2026)
Shoulder and Elbow

1. Cost-Effectiveness of Rotator Cuff Repair With Concomitant Subacromial Decompression at Mid-Term Follow-Up: A Systematic Review and Economic Analysis.

Authors: Saad Berreta R, Badin D, Fox H, Koyejo L, Mian M et al. | Journal: The Journal of the American Academy of Orthopaedic Surgeons (Aug 2026) | View Source / DOI

Situation

The purpose of this study was to perform (1) a systematic review and (2) cost-utility analysis comparing isolated RCR versus RCR with SAD in patients with full-thickness rotator cuff tears.

Background

There is limited evidence evaluating the cost-effectiveness of adding subacromial decompression (SAD) to rotator cuff repair (RCR) in the treatment of full-thickness rotator cuff tears.

Assessment & Findings
  • Study Design & Methodology: A systematic review was conducted per Preferred Reporting Items for Systemactic reviews and Meta-Analyses (PRISMA) 2020 guidelines to identify Level I-II studies comparing RCR and RCR with SAD at ≥5-year follow-up. A decision tree model evaluated cost-effectiveness over a 5-year time horizon. Costs, revision rates, and utility values (EQ-5D-based) were derived from the literature. Health utility was expressed in quality-adjusted life years (QALYs). Cost-effectiveness was assessed using incremental cost-effectiveness ratios and net monetary benefit (NMB), with a $50,000/QALY willingness-to-pay threshold. Monte Carlo and one-way sensitivity analyses were done to account for parameter uncertainty.
  • Primary & Secondary Findings: Over 5 years, RCR with SAD had a lower mean cost ($33,448) compared with isolated RCR ($34,593) and yielded slightly higher QALYs (1.465 vs 1.454). RCR + SAD demonstrated a positive incremental NMB ($1,695) and a negative incremental cost-effectiveness ratio, emerging as the dominant strategy. Probabilistic sensitivity analysis favored RCR + SAD in 99.28% of 1,000 simulations. On one-way analysis, RCR + SAD remained cost-effective with burr costs up to $1,721, additional surgical time up to 43.6 minutes, and revision probabilities up to 10%.
Recommendation & Practice Takeaway

Clinical Pearl: Despite higher upfront costs, SAD during RCR remains cost-effective at mid-term follow-up. By reducing revision rates, SAD provides greater QALYs at a lower overall cost compared with isolated RCR.

Shoulder and Elbow

2. Cost-Effectiveness of Surgery Versus Functional Bracing for Humeral Shaft Fractures in Adults: A Prespecified Economic Evaluation of the Finnish Shaft of the Humerus (FISH) Trial.

Authors: Suter C, Ibounig T, Reito A, Mattila H, Sumrein B et al. | Journal: The Journal of bone and joint surgery. American volume (Jul 2026) | View Source / DOI

Situation

Investigating clinical outcomes, surgical technique efficacy, and patient recovery profiles in this targeted cohort.

Background

Humeral shaft fractures commonly affect working-age adults and can lead to prolonged work absence and substantial economic burden. Although surgical fixation and functional bracing offer comparable functional outcomes, their relative cost-effectiveness remains unclear.

Assessment & Findings
  • Study Design & Methodology: We conducted a prespecified economic evaluation alongside a multicenter, superiority, randomized clinical trial at 2 Finnish university hospitals between 2012 and 2018. Eighty-two adults (mean age, 48.9 years; 38 women) with displaced, closed humeral shaft fractures were randomly assigned to surgical fixation (n = 38) or functional bracing (n = 44) and followed for 2 years. The primary outcome was the incremental net monetary benefit (INMB) based on quality-adjusted life years (QALYs) measured with the 15-dimensional (15D) instrument, analyzed from both societal and health-care perspectives.
  • Primary & Secondary Findings: From a societal perspective, surgical treatment was both more effective and less costly than bracing. The mean total cost per patient was €23,680 for surgery and €30,389 for bracing, yielding an INMB of €9,423 (95% confidence interval [CI], €4,139 to €14,609). Cost-effectiveness acceptability curves showed that surgery was highly likely to be cost-effective across all willingness-to-pay thresholds up to €120,000 per QALY. The cumulative QALYs from 6 weeks to 2 years post-injury were 1.776 (95% CI, 1.725 to 1.827) for surgery and 1.705 (95% CI, 1.641 to 1.769) for bracing, corresponding to a QALY difference of 0.071 (95% CI, 0.012 to 0.130) in favor of surgery. From the health-care perspective, functional bracing was less costly (€4,904 versus €10,967) and therefore more cost-effective, with an INMB of -€4,087 (95% CI, -€5,215 to -€3,054). When considering only direct medical costs, surgery was unlikely to be cost-effective at thresholds below €80,000 per QALY, reaching a 75% probability of cost-effectiveness only at €120,000 per QALY.
Recommendation & Practice Takeaway

Clinical Pearl: Surgery is cost-effective when societal costs are considered. Functional bracing remains a reasonable option, particularly for patients less affected by time away from work. Shared decision-making should incorporate both economic and individual patient factors.

Shoulder and Elbow

3. Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humerus fractures in elderly patients: results from a prior randomized clinical trial.

Authors: Lopiz Y, Alcobía-Díaz B, Coderch J, Rodrigo-Muro S, García-Fernandez C et al. | Journal: Journal of shoulder and elbow surgery (Sep 2026) | View Source / DOI

Situation

Investigating clinical outcomes, surgical technique efficacy, and patient recovery profiles in this targeted cohort.

Background

Proximal humerus fractures (PHFs) are among the most common fractures in elderly patients, yet there is insufficient evidence from randomized controlled trials (RCTs) to determine the most appropriate interventions for their management. This study presents the long-term results of the first prospective RCT comparing surgical treatment with reverse shoulder arthroplasty (RSA) versus nonoperative treatment in displaced PHFs in elderly patients.

Assessment & Findings
  • Study Design & Methodology: Comparative cohort and clinical outcome analysis utilizing validated functional endpoints.
  • Primary & Secondary Findings: From the initial series, 12 patients treated conservatively and 17 with RSA were included, with mean ages of 88 and 92 years (P = .004) and mean follow-up of 7.4 and 7.6 years (P = .171), respectively. Functional outcomes for RSA versus conservative treatment were as follows: Constant 62/51 (P = .039), Disabilities of the Arm, Shoulder and Hand questionnaire 16/25 (P = .069), SF-12 Physical 42/43 (P = .808), SF-12 Mental 59/60 (P = .690), and visual analog scale 1.5/1.4 (P = .274). All nonoperatively treated fractures healed in malposition, but none required revision to RSA. Among patients treated with RSA, one required revision surgery due to prosthesis dislocation.
Recommendation & Practice Takeaway

Clinical Pearl: These results suggest that long term treatment with RSA for displaced 3- or 4- part PHF provides better functional outcomes compared to nonoperative treatment. This difference is attributed to the deterioration of functional outcomes of the nonoperative treatment over time.

Orthogate Weekly Journal Scan is curated and synthesized by ORION (Orthopaedic Research, Intelligence & Operations Navigator) for orthopaedic surgeons, fellows, and residents. Evidence synthesized under the clinical direction of Christian Veillette, MD, MSc, FRCSC.