Original Research

Shoulder Instability Management: A Survey of the American Shoulder and Elbow Surgeons

Am J Orthop. 2016 March;45(3):E91-E97

Despite an abundance of peer-reviewed literature, there is wide surgical practice variability for symptomatic shoulder instability. In this study, we identified consensus trends among specialists in glenohumeral instability. A survey was distributed to 417 members of the American Shoulder and Elbow Surgeons (ASES). Surveys consisted of 3 sections: surgeon demographics, presentation of 5 case scenarios, and instability management. Consensus responses were defined as more than 50% of participants giving a single response with more than 2 answer choices or more than 67% of participants giving a single response when 2 answer choices were available. We assessed 125 completed surveys (29.9% response rate); 68% of questions reached a consensus answer. Arthroscopic Bankart repair was the preferred technique for young noncontact (82%), young contact (57%), and weekend-warrior athletes (60%). In the setting of glenoid bone loss, 72.8% recommended the Latarjet procedure. Remplissage was the procedure of choice (60%) for engaging Hill-Sachs lesions. The ASES members favored arthroscopic Bankart repair in the absence of glenoid bone loss or engaging Hill-Sachs lesion, regardless of age (20 to 35 years) or nature of sport (contact vs noncontact). For Hills-Sachs lesions, consensus response favored remplissage, while a Latarjet procedure was advocated for glenoid lesions.

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References

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Despite an abundance of peer-reviewed resources, there is wide variation in the surgical management of shoulder instability.^1,2Current American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines regarding the shoulder address only generalized shoulder pain, glenohumeral osteoarthritis, and rotator cuff injuries,^3,4 and treatment algorithms focus on conservative treatment, rather than surgical recommendations.^4-7

Shoulder instability most commonly results from 1 or more of 4 common lesions (capsular laxity, glenoid bone loss, humeral bone loss, and capsulolabral insufficiency).⁸ While it is a relatively common condition that represents 1% to 2% of all athletic injuries,^9,10 little consensus exists about surgical indications, ideal treatment algorithms, or optimal operative technique. This is a critical issue because more than 50% of patients with glenohumeral instability will undergo surgical intervention.¹¹ Chahal and associates⁶ surveyed 44 shoulder experts and reported strong consensus about diagnosis, but little agreement regarding surgical management. Owens and colleagues¹ have also evaluated current trends for surgical treatment of this pathology. Randelli and associates⁵ attempted to categorize operative management based upon case-specific shoulder scenarios through online surveys. Their survey, however, covered a broad range of shoulder injuries rather than instability in particular. In this study, we assess trends for surgical management of glenohumeral instability in a case-based survey of shoulder experts.

Materials and Methods

Survey Information

An online survey (Survey Monkey) of 417 active members of the American Shoulder and Elbow Surgeons (ASES) was administered on May 1, 2014. Respondents were blinded to the institution and co-investigators conducting the survey. The survey link was distributed via email because it has been shown to be a more efficacious conduit than standard postal mail.¹² The case-based, 25-question survey (Appendix) was designed to assess respondents’ selection of surgical intervention. Section 1 determined member demographics, including fellowship training, arthroscopy experience, and years of practice. Section 2 involved the presentation of 5 case scenarios. For each case, respondents were asked to identify the optimal surgical procedure in both primary and revision settings. Section 3 posed several general questions regarding shoulder-instability management.

Statistical Analysis

Data were stored using Microsoft Excel (Microsoft) and analyzed using SAS Software version 9.3 (SAS Institute, Inc.). Demographic survey responses were reported using descriptive statistics. Responses to clinical survey questions were reported using frequencies and percentages. To identify when a majority consensus was achieved for a given question, responses were flagged as reaching consensus when more than 50% of participants gave the same response.¹³In the event that only 2 response options were available, reaching consensus required 67% of respondents to choose a single answer (since, by default, a consensus would be reached with only 2 response options). Because this was an analysis of all respondents, an a priori power calculation was not performed. Associations between training and practice demographics and responses to clinical questions were investigated using chi-square analyses. All comparative analyses were two-tailed and used P = .05 as the threshold for statistical significance.

Results

Demographics

One hundred and twenty-five (29.9%) ASES members responded to the survey. Of the respondents, 71.2% reported at least 15 years of experience, and 71% performed more than 150 shoulder cases annually. Surgeons came from academic institutions (41.6%), private practice (24.8%), or mixed (33.6%). The majority of respondents were fellowship-trained in shoulder/elbow surgery (52.8%), while fewer had completed a sports-medicine fellowship (24.0%). For arthroscopic procedures, responses were nearly divided between those who preferred beach-chair positioning (47.2%) and those who preferred the lateral decubitus position (46.4%). The majority (70.4%) of respondents practiced in the United States and with a relatively even distribution among states and region. The remaining 29.6% of those surveyed practiced abroad.

Degree of Consensus Responses and Cases

Of the 25 survey questions, 6 questions were omitted from consensus calculations because these were designed for demographic categorization rather than professional opinion (questions 1-5, 8). Thirteen of the remaining 19 questions (68%) reached consensus response. All clinical case scenarios (5 of 5) reached consensus for selection of technique for the primary procedure; however, only 40% (2 of 5) of cases had a consensus in the revision setting.

In case 1, a young soccer player (noncontact athlete) with negligible bone loss, arthroscopic Bankart repair was recommended by 81.6% of respondents. In the event of revision surgery, only 22.4% recommended arthroscopic Bankart repair, and the remainder split between open Bankart repair with possible capsular shift (36%) or Latarjet procedure (32.8%).

In case 2, a college American football player (contact athlete) with negligible bone loss, arthroscopic Bankart repair was recommended by 56.8%. In the event of revision surgery, a majority of members (51.2%) suggested a Latarjet procedure.