Surgical Treatment for Recurrent Shoulder Instability: Factors Influencing Surgeon Decision Making

ABSTRACT Background The optimal surgical approach for recurrent-anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to utilize a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent-anterior shoulder instability. Methods A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained eight patient factors. The factors included: 1) age, 2) sex, 3) hand dominance, 4) number of previous dislocations, 5) activity level, 6) generalized laxity, 7) glenoid bone loss, and 8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures. Results 70 orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥ 10 years and 48% Conclusion The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability. Level of Evidence Survey Study; Experts