Worldwide, programs dealing with musculoskeletal health are required to set priorities and allocate resources within the constraint of limited funding. There is increasing pressure for medical technology assessment, which traditionally has involved evaluating safety and effectiveness, to also include consideration of cost effectiveness. We updated our database of orthopaedic cost-effectiveness studies, critically reviewed their methods, and examined trends over time. Current analyses have numerous shortcomings, such as the inclusion of relatively few studies, inconsistent methodologic approaches, and lack of transparency. The wide variation in cost-effectiveness ratios observed among current interventions suggests efficiency can be improved. Despite reimbursement authorities in many other countries formally considering cost-effectiveness when determining coverage of new technologies, Medicare has been resistant to considering costs of treatments. Regardless of this policy deficiency, conducting cost-effectiveness analyses represents a prudent step forward in illuminating the tradeoffs involved in difficult resource allocation decisions, and there is an urgent need to consider economic impact in future studies using standardized and transparent methods.