Regarding “Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt. A Cost-Effectiveness Model”

We read with great interest the paper “Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt: A Cost-Effectiveness Model” by Makhni et al.1 The surgical treatment of anterior glenohumeral insta- bility is a common worldwide issue as well as the management of failed operations. For both primary and revision cases, bone-block procedures and soft tissue repairs have been proposed. The authors have perfectly shown the social costs of these 2 operations and their cost-effectiveness. In Europe, the cost of surgical pro- cedures is even more relevant in daily practice. In Italy, all patients have the right of being assisted by the public health system due to the fact of paying taxes. The health system reimburses the hospitals and the subsi- dized private hospitals for their activity according to the diagnosis-related group (DRG). This is based on patients’ pathologies and on the interventions the physicians perform and accounts for hospitalization, implantable materials, and physicians. The reimbursement for primary or revision open stabilization is 4,303V (code 8182, DRG224) (open), whereas the reimbursement for the same procedure under arthroscopy is 1,333V (code 8182þ8021, DRG232). The same reimbursement is given for revi- sion surgeries. However, the costs for these 2 operations are completely different. The DRG of an arthroscopic Bankart repair covers 2 nights of hospitalization (as decided by the health sys- tem) (600V), implanted materials (480V for burr and shaver, 290V for a radiofrequency system, 2,000V for 4 absorbable anchors, and 88V for 2 cannulas) (data from Mitek Italy), occupation of the operating room (300V for 60 minutes), and various other costs (100V, which includes drugs, irrigation bags, sutures, surgical drapes). In case of associated remplissage, 2 additional anchors (1,080V) and 1/2 hour of operating room (150V) must be considered. The total cost is 3,858V with additional 1,230V in case of remplissage, whereas the DRG covers only 1,333V. The DRG of an open Latarjet covers implanted materials (40V for 2 malleolar screws and washers) and occupation of the operating room (225V for 45 mi- nutes). Drugs and hospitalization are the same as Bankart repair (600V). The total cost is 965V, whereas the cost that the DRG covers is 4,303V. The cost for imaging analysis (150V for a computed tomography scan), physician consultation (300V for 3 consultations), and postoperative physical therapy (400V for 10 sessions) is not included in the DRG reimbursement but has been calculated (850V) as a comparison with the study by Makhni et al. The total cost for an arthroscopic soft tissue repair varies from 4,708V to 5,938V all included (in the study by Makhni et al., it is $13,672). The total cost for an open Latarjet is 1,815V (in the study by Makhni et al., it is $15,287). The functional outcomes of both bone-block procedures (either open or arthroscopic) and soft tissue repairs are extremely satisfying.2 However, they greatly differ in terms of costs for the public health system. Open Latarjet is much more convenient in terms of costs/DRG reimbursement (all costs account for one-fourth of the expected reim- bursement) than arthroscopic soft tissue repairs (all costs exceed almost 4 times the expected reimburse- ment). The problem of expected expenses of surgical procedures has great relevance in some European countries. In fact, a policy of cost reduction has been introduced and could therefore influence surgeons’ decision making, favoring open procedures over arthroscopy.