Management of a first time anterior shoulder dislocation: the decision-making process of a surgeon

Management of a first-time anterior shoulder dislocation in young and active patients remains a topic of ongoing debate. This study aims to use choice-based conjoint analysis to identify the factors influencing a surgeon's decision-making process and explore potential heterogeneity in the identified decision patterns.

A discrete choice experiment was conducted among all 94 members of the Belgian Elbow and Shoulder Society. Surgeons completed 15 choice tasks, each involving 3 instability cases, and were asked to select the most appropriate indication for surgery. Each case included 6 patient characteristics: gender, age, type and level of sports played, glenoid bone loss, and presence/absence of a Hill-Sachs lesion. The relative importance of each characteristic was quantified using two-level Bayesian hierarchical modeling. Latent class analysis was employed to assess heterogeneity in choice patterns. Subgroup analyses examined how experience and subspecialty of a surgeon influenced their decision-making. Two-way interactions were tested using the Chi-squared test.

Fifty-five surgeons completed the survey. Of these, 31% had less than 5 years of experience, 38% had 5-20 years of experience, and 31% had more than 20 years of experience. All respondents regularly treated shoulder pathologies, with the majority managing a diverse patient population, including both sports-related and degenerative lesions. Only 27% primarily treated degenerative lesions. Glenoid bone loss had the highest relative importance on decision-making (24.6%), followed by the type of sports played (22.1%) and the presence of a Hill-Sachs lesion (21.2%). Heterogeneity in decision patterns was primarily attributed to differing views on the importance of off-track Hill-Sachs lesions. Subgroup analysis revealed that younger surgeons were more likely to prioritize the glenoid track concept in their decision-making. Additionally, an interaction between glenoid bone loss and Hill-Sachs lesions resulted in a 118% increase in effect among younger surgeons. The surgeon's focus on sports pathology in their practice did not significantly affect their decision-making process.

Our findings highlight the significant role of bony lesions, including glenoid bone loss and Hill-Sachs lesions, in shaping surgical treatment decisions. Younger surgeons are more likely to incorporate the glenoid track concept into their decision-making compared to their older counterparts. However, most surgeons adopt a comprehensive approach, considering not only bony pathology but also the type and level of sports played, as well as the patient's age. This reflects a growing trend toward individualized treatment strategies for first-time anterior shoulder dislocations, tailored to the specific clinical and functional needs of the patient.