Rotator cuff tears are a common cause of shoulder pain, especially among older adults [1]. Most cases are degenerative, atraumatic injuries that can be asymptomatic; however, when symptoms arise, they can cause reduced active range of motion; significant pain, especially with overhead activities; and functional limitations in activities of daily living [1]. The management of rotator cuff pathology is typically conservative at first, primarily comprising physical therapy and nonsteroidal anti-inflammatory drugs [2,3]. For patients who do not respond to nonoperative management, however, surgical repair is considered [4,5]. Approximately 250,000 rotator cuff repairs (RCRs) are performed each year in the United States, with the vast majority being conducted arthroscopically, according to recent estimates [6-8]. Studies have demonstrated that arthroscopic RCR carries lower rates of short-term postoperative complications and better short-term recovery of range of motion and pain compared to open RCR, although the approaches have similar long-term outcomes [3,9-11].

While prior studies have compared clinical outcomes between arthroscopic and open RCR, few to date have investigated differences in surgical efficiency, physician work effort, and reimbursement. Work relative value units (wRVUs) are a standardized metric used in the United States to measure physician labor for a particular service or procedure and are determined by a combination of factors, including complexity of the task, time, technical skill, and physician effort [12,13]. wRVUs directly impact physician compensation and practice economics, as they determine reimbursement under Medicare and private insurers [14].

The purpose of this study was to evaluate and compare operative times, wRVU generation, reimbursement rates, and short-term postoperative complication rates between arthroscopic and open RCR using a large cohort from a robust national database. Balancing surgical time, financial value, and clinical outcomes is critical for optimizing surgical decision-making, resource allocation, and clinical reimbursement structures. This study contributes a new analysis of the relative efficiency, safety, and cost of arthroscopic versus open RCR. 

This retrospective study sourced information from a publicly available national database without identifying patient details and thus did not require institutional review board approval and informed consent.

wRVUs serve as the basis of physician reimbursement in the United States, with a value assigned to every service that a physician can perform [16]. Over the past two decades, reimbursements for orthopedic surgeries have consistently decreased, with those for shoulder arthroscopies experiencing the greatest decline [17,18]. Given the high use of RCR in the United States, this study sought to compare reimbursement rates between open and arthroscopic RCR. The present study’s results indicate that arthroscopic RCR is reimbursed at a higher rate and displays lower complication rates compared to open RCR.

The primary result of this study was that arthroscopic RCR was reimbursed at a higher rate than open RCR. Although arthroscopic RCR cases had longer operative times than open RCR cases, both the total wRVUs and wRVUs per minute were higher on average for arthroscopic cases than for open cases. This finding is largely consistent with conclusions in the broader orthopedic literature. In an analysis of common procedures performed by sports medicine–trained orthopedic surgeons, Simcox et al. found that arthroscopic procedures broadly received greater reimbursement amounts than open procedures [19]. Among common shoulder and elbow procedures, Nayer et al. similarly found that arthroscopic procedures were more highly valued compared to other surgeries [20]. The present study’s results add to the existing literature by demonstrating that the current Medicare Fee Schedule provides higher reimbursement amounts for arthroscopic RCR than for open RCR. This observed financial differential is consistent with existing reports and suggests that the fee schedule acknowledges the increased complexity, time, and technical skill associated with the arthroscopic approach. Orthopedic surgeons without specialized training are often less familiar with arthroscopic RCR than with open RCR [21,22]. Arthroscopy is a demanding procedure, requiring surgeons to operate in a three-dimensional environment from a small two-dimensional camera image. In addition, the restricted range of movement associated with arthroscopy’s small incisions poses another challenge.

The present study reveals an important clinical trade-off: although arthroscopic RCR requires greater operative times and resources compared to open RCR, these investments are justified by its significantly lower short-term complication rates. This trend is largely driven by the decreased rates of deep and superficial surgical site infections observed following arthroscopic cases. Again, these findings are consistent with the literature, with several multi-center studies reporting higher infection rates in patients receiving open RCR compared to those receiving arthroscopic RCR [23-25]. The present study further demonstrated that there were otherwise no differences between RCR cohorts in the 30-day incidence of mortality, urinary tract infections, deep vein thrombosis, bleeding resulting in transfusion, pulmonary complications, myocardial infarction, stroke, sepsis, or renal failure. Ultimately, this indicates that the arthroscopic approach to RCR may offer clinical advantages without compromising patient safety in other domains. These findings support the continued shift toward applying minimally invasive techniques in shoulder surgery and may inform decision-making for both surgeons and healthcare systems aiming to implement value-based care [26].

Beyond the context of US-based reimbursement, the efficiency and safety differences observed between arthroscopic and open RCR may carry important implications for healthcare systems worldwide. In diverse global settings, where reimbursement structures vary, the demonstrated reduction in complication rates with arthroscopic RCR may translate to substantial clinical and economic benefits, including reduced postoperative morbidity, shorter hospital stays, and decreased need for reinterventions. These advantages may support the broader adoption of arthroscopic techniques, especially where surgical safety outcomes are prioritized. Moreover, the use of relative metrics, such as percent differences in complication rates and efficiency, provides a framework for evaluating procedural value across varying healthcare models, making these findings relevant for international surgeons and policymakers. Nevertheless, these implications may be speculative, given that the reimbursement modeling in this study was based solely on data from hospitals in the United States.

Despite these findings, the results of this study should be considered in the light of several important limitations. First, this study only assessed the incidence of complications in the first 30 days following RCR. As such, cohort-specific differences in complication rates over a longer period of time may have been omitted. The NSQIP database does not include functional outcomes, so differences in range of motion, pain, and other patient-reported outcome measures may exist between cohorts but could not be evaluated. However, it is unlikely there are actual differences in these characteristics, as prior studies have demonstrated no significant difference in long-term functional outcomes, retear rates, or complication rates between patients receiving arthroscopic RCR and those receiving open RCR [11]. This study’s use of the NSQIP database is also a limitation, as any retrospective analysis of this database is limited by the accuracy of its coding. Nonetheless, the use of the NSQIP database provides key advantages over single-center studies, including broader generalizability across diverse patient populations and practice settings. Furthermore, while the outcomes in this study were statistically significant, the absolute difference between groups was modest, and so any associated clinical impact may be limited. Finally, the NSQIP database does not capture important details such as rotator cuff tear size, chronicity, or number of tendons involved. Open RCR is often selected for more complex or larger tears, which may influence outcomes and resource usage. As a result, these variables can substantially influence resource usage and perioperative outcomes such as operative time and risk of complications, and their absence may lead to unmeasured confounding. Similarly, surgeon experience and expertise, both of which were not recorded in the NSQIP database, may have influenced the choice of technique and postoperative results.

This study demonstrates notable differences in reimbursement between RCR techniques, with arthroscopic RCR generating higher wRVUs and revenue than open RCR, despite having lower short-term complication rates. These findings suggest that the current Medicare Fee Schedule may appropriately compensate the arthroscopic approach for its increased complexity and clinical advantages. Future research should investigate whether these financial and clinical advantages persist across different tear characteristics, including size and chronicity, as well as assess their impact on long-term functional outcomes and healthcare costs.