Table I.

Main findings and study designs of cost-effectiveness studies included in this review, organized by anatomic region.^*

ANATOMY	AUTHOR	YEAR	COUNTRY	STUDY DESIGN	ICER (2016 values)	WTP	MAIN FINDINGS

Shoulder	Butt³³	2015	UK	Prospective cohort	NA	NA	Arthroscopic decompression for subacromial impingement provides 0.23 QALYs gained for £5,683
	Jowett³⁴	2013	UK	RCT	Dominant	£20,000/QALY	Corticosteroid injection and exercise therapy may be cheaper and more effective (i.e. dominant) to exercise-alone in moderate to severe subacromial impingement syndrome
	Carr²⁴	2015	UK	RCT	£32,510/QALY	£20,000/QALY	Open rotator cuff repair was not a cost-effective alternative to arthroscopic rotator cuff repair in the base case, intention-to-treat analysis
	Crall²⁵	2012	USA	Microsimulation	Multiple; all <WTP or dominant	$25,000/QALY	Primary arthroscopic stabilization was a cost-effective alternative to nonoperative treatment for first-time anterior glenohumeral dislocation with ICERs <$25,000/QALY across majority of age groups
	Coe³⁵	2012	USA	Markov cohort	$103,668/QALY^**	$100,000/QALY	Reverse shoulder arthroplasty was a cost-effective alternative to humeral head replacement for rotator cuff tear arthropathy
	Genuario²⁶	2012	USA	Decision tree	Tears <3 cm: $638,601/QALY; Tears ≥3 cm: $514,233/QALY	$100,000/QALY	Double-row rotator cuff repair is not a cost-effective alternative for any size rotator cuff tears
	Mather³⁶	2013	USA	Markov cohort	Dominant	$50,000/QALY	Surgical rotator cuff repair is a cost-effective alternative for the U.S. populations compared to nonoperative treatment with lifetime savings of $13,771 and 0.62 QALY improvement
	Renfree³⁷	2013	USA	Prospective cohort	NA	NA	Reverse shoulder arthroplasty for rotator cuff arthropathy provides 2-year gain of 1.02 (SF-36) and 1.97 (EQ-5D) QALYs for a cost of $21,536
	Vavken³⁸	2015	USA	Decision tree	$132,009/QALY	$100,000/QALY	Platelet-rich plasma after arthroscopic rotator cuff repair is not a cost-effective alternative to repair without platelet-rich plasma, assuming a 5% revision rate
	Vitale³⁹	2007	USA	Prospective cohort	NA	NA	Surgical rotator cuff repair provides a mean lifetime gain of 0.81 (HUI) and 3.43 (EQ-5D) QALYs for total cost of $10,605
	Dattani⁴⁰	2013	UK	Prospective cohort	NA	NA	Arthroscopic capsular release for contracture of the shoulder provides 0.50 QALYs gained for £2204
	Mather⁴¹	2010	USA	Markov cohort	Dominant	$50,000/QALY	Total shoulder arthroplasty is a cost-effective alternative to hemiarthroplasty for glenohumeral osteoarthritis with $1,970 less costs and 0.77 more QALYs
	Pearson⁴²	2010	USA	Decision tree	Base case: $80,546/QALY; >9 years: $34,883/QALY	$50,000/QALY	ORIF of displaced, midshaft clavicular fractures can be a cost-effective alternative to nonoperative treatment if the incremental QALYs gained (0.014) persists beyond 9 years. At the base case, ORIF is not a cost-effective alternative

Arm	Corbacho⁴³	2016	UK	RCT	Dominated	£20,000/QALY	Surgical treatment for displaced, proximal humerus fractures in adults is not a cost-effective alternative to non-operative treatment with greater total costs and lower total QALYs (i.e. dominated)
Arm	Fjalestad⁴⁴	2010	Norway	RCT	£315,922/QALY	NA	Surgical treatment for displaced, proximal humerus fractures in adults did not produce statistically significant different costs or QALYs from nonoperative treatment.

Elbow	Coombes⁴⁵	2016	Australia	RCT	$30,287/QALY	$50,000/QALY	Physiotherapy-alone was a cost-effective alternative to corticosteroid injection with or without physiotherapy for chronic lateral epicondylalgia
	Giannicola⁴⁶	2013	Italy	Prospective cohort	NA	NA	Open surgical treatment of elbow stiffness produces 0.1539 annual increases in QALYs with an average cost of £3565
	Song⁴⁷	2012	USA	Decision tree	$2,265/QALY	$100,000/QALY	Simple decompression was the most cost-effective initial procedure for ulnar neuropathy of the elbow when compared to anterior subcutaneous and submuscular transpositions and medial epicondylectomy

Forearm	Karantana⁴⁸	2015	UK	RCT	£44,814/QALY	£10,000-£50,000/QALY	Volar locking plating was not a cost-effective alternative to percutaneous wire fixation for distal radius fractures
	Rockwell⁴⁹	2004	Canada	Markov cohort	Dominated	NA	Prophylactic plating of the donor radius after harvest of radial osteocutaneous flap is not a cost-effective alternative to treatment of fractures when they occur, producing higher cost ($2071 vs. $140) with lower QALYS (8.55 vs. 9.92)
	Shauver⁵⁰	2011	USA	Decision tree	$17,130/QALY	$50,000/QALY	ORIF dominated wire fixation and external fixation and was a cost-effective alternative to casting for distal radius fractures in the elderly
	Tubeuf⁵¹	2015	UK	RCT	£96,793/QALY	£30,000/QALY	Volar locking plating was not a cost-effective alternative to percutaneous Kirschner wire fixation for dorsally displaced distal radius fractures

Hand & Wrist	Baltzer⁵²	2013	Canada	Decision tree	Collagenase: $303,654/QALY; Fasciectomy: Dominated	$50,000-$100,000/QALY	Collagenase was not a cost-effective alternative to percutaneous needle aponeurotomy for Dupuytren’s contracture; partial fasciectomy was dominated by aponeurotomy
	Chen⁵³	2011	USA	Decision tree	Fasciectomy: $916,405/QALY; Collagenase: $55,865/QALY^; Aponeurotomy: $55,458/QALY^	$50,000/QALY	All compared to no treatment for Dupuytren’s contracture, open partial fasciectomy is not a cost-effective alternative; collagenase can be a cost-effective alternative if priced <$945; aponeurotomy can be cost-effective if success rate is 100%
	Chung²⁷	1998	USA	Decision tree	25-year-old: $293/QALY; 65-year-old: $1,042/QALY	$4836/QALY to $13,508/QALY	Endoscopic carpal tunnel release is a cost-effective alternative to open release for carpal tunnel syndrome
	Korthals-de Bos⁵⁴	2006	Netherlands	RCT	£469/QALY	£2,500/QALY	Surgery is a cost-effective alternative to splinting for carpal tunnel syndrome
	Thoma²⁸	2006	Canada	Decision tree	Main OR: $147,665/QALY; Day unit: dominant	$100,000/QALY	Endoscopic carpal tunnel release is not a cost-effective alternative to open release for carpal tunnel syndrome when endoscopic release is performed in the main operating room and when open release is performed in the day surgery unit. When both are performed in the day surgery unit, endoscopic release dominates open release.
	Cavaliere⁵⁵	2010	USA	Decision tree	TWA vs. nonsurgical: $2,512/QALY; TWA vs. arthrodesis: $2,564/QALY	$50,000/QALY	Total wrist arthroplasty (TWA) was a cost-effective alternative to both nonsurgical management and to total wrist arthrodesis for the rheumatoid wrist
	Chung⁵⁶	2010	USA	Decision tree	Prosthesis vs. transplant: dominant; Double-hand transplant vs. prosthesis: $426,808/QALY	$50,000-$100,000/QALY	Prosthetic use dominated hand transplantation for unilateral hand amputation. Double hand transplantation was preferred over prostheses (26.73 vs. 25.20 QALYs) for double hand amputation, but was not cost-effective.
	Davis⁵⁷	2006	USA	Decision tree	$7,135/QALY	$20,000/QALY	ORIF is a cost-effective treatment alternative to cast immobilization for acute nondisplaced mid-waist scaphoid fractures
	Sears⁵⁸	2014	USA	Decision tree	Single-digit: $145,643/QALY; 3-digit: $28,963/QALY; 4-digit: $25,413/QALY	$100,000/QALY	Replantation had greater costs and QALYs compared with revision amputation in all injury scenarios. Replantation of single-digit injuries was not a cost-effective alternative to revision amputation, whereas replantation of 3- or 4-digit amputations were cost-effective alternatives

General	Doan⁵⁹	2013	UK	Markov cohort	£11,130/QALY	£30,000/QALY	OnabotulinumtoxinA along with usual care was a cost-effective alternative to usual care for upper-limb post-stroke spasticity
General	Shaw⁶⁰	2010	UK	RCT	£119,049/QALY	£20,000/QALY	Addition of botulinum toxin A to a therapy program for upper-limb post-stroke spasticity was not cost-effective

RCT = cost-effectiveness analysis conducted alongside a randomized controlled trial; Prospective cohort = cost-effectiveness analysis conducted alongside a cohort or series of patients followed prospectively for data on outcomes; ICER = incremental cost-effectiveness ratio; QALY = quality-adjusted life-year; WTP = willingness-to-pay threshold; HUI = health utility index; ORIF = open reduction internal fixation.

^**

Note: adjusting ICER to 2016 values raised the ratio above the corresponding willingness-to-pay threshold