Bony Versus Soft Tissue Reconstruction for Anterior Shoulder Instability: An Expected Value Decision Analysis

Area of Science:

• Orthopedic Surgery
• Decision Analysis
• Biomedical Engineering

Background:

• Anteroinferior glenohumeral dislocation can cause critical bone defects, leading to recurrent instability.
• Surgical management of these defects remains controversial due to the trade-offs between open and arthroscopic approaches.
• Patient preference is influenced by recurrence rates, procedure morbidity, and individual factors.

Purpose of the Study:

• To determine the optimal surgical strategy for glenohumeral instability with bone defects based on patient-specific probabilities of recurrence.
• To compare the expected value of arthroscopic versus open surgical repair for shoulder instability.
• To identify thresholds for recurrence and complication rates that influence treatment preference.

Main Methods:

• A decision tree model was developed to analyze outcomes of open and arthroscopic surgery.
• Literature review determined probabilities of specific outcomes.
• Patient surveys (n=50) provided utility values for different outcomes.
• Fold-back and sensitivity analyses identified optimal treatment strategies and decision thresholds.

Main Results:

• Arthroscopic surgery demonstrated a higher overall expected value (87.17) compared to open surgery (81.64).
• Open surgery becomes preferred if the probability of recurrence after arthroscopic treatment reaches or exceeds 23.8%.
• Open surgery is also preferred if the no-complication rate for open procedures is 97.6% or higher.

Conclusions:

• Arthroscopic surgery is a viable option for managing shoulder instability with bone defects when the recurrence rate is 23.8% or less.
• The technical challenges of arthroscopic fixation for complex defects necessitate further research.
• More clinical outcome studies are required to refine predictions for optimal operative treatment selection.