Cost-effectiveness of total shoulder arthroplasty: A systematic review of the evidence

BACKGROUND: Total shoulder arthroplasty (TSA) is increasingly used to treat a range of shoulder disorders. Although TSA improves pain and function, its cost-effectiveness remains uncertain. This systematic review evaluated the cost-effectiveness of TSA for glenohumeral arthritis, rotator cuff arthropathy, massive rotator cuff tears and proximal humerus fractures. METHODS: We systematically searched MEDLINE, Embase, and CINAHL from inception to July 2025 for full economic evaluations comparing TSA with surgical or non-operative alternatives. Eligible studies included primary anatomical total shoulder arthroplasty (ATSA) or reverse total shoulder arthroplasty (RTSA). Studies could be randomised, observational or model-based, and had to provide costs and outcomes to allow determination of an incremental cost-effectiveness ratio or equivalent expression. Study quality was assessed with the Drummond checklist. Given study heterogeneity, results were synthesised narratively. RESULTS: Of 308 potentially eligible studies, 26 were included, comprising 15,163 patients, all of which were conducted in high-income countries. Fifteen studies were modelled, relying on published literature for costs and outcomes. Most studies were rated as fair (58%) or good (38%) quality. In four studies regarding osteoarthritis, ATSA was consistently cost-effective or dominant (more effective and less costly) over hemiarthroplasty. In three studies regarding osteoarthritis with intact rotator cuff, ATSA and RTSA were similarly effective, and costs were similar or less for ATSA, depending on patient age. In four studies regarding proximal humerus fractures, RTSA was cost-effective or dominant over hemiarthroplasty. In three studies regarding massive rotator cuff tears, cuff repair was always substantially less costly and marginally more effective than RTSA. CONCLUSIONS: Despite the increasing use of TSA, evidence regarding its cost-effectiveness is limited to a small number of studies from high-income countries. Although TSA might be cost-effective for selected indications, high-quality, randomised, prospective economic evaluations from a diverse range of settings are needed to provide rigorous evidence to guide value-based care in shoulder arthroplasty.