In case 3, the weekend warrior with significant bone loss, most respondents recommended a Latarjet procedure for both primary (72.8%) and revision surgery (79.0%).
In case 4, a weekend warrior with multidirectional instability, 60% of respondents suggested arthroscopic Bankart repair, 21.6% recommended rotator interval closure, and 10.4% chose a capsular shift. As a revision procedure, there was less agreement, with a split between open Bankart repair (39.2%) and capsular shift only (39.2%).
In case 5, the weekend warrior with large engaging Hill-Sachs lesions, 60% of respondent selected a remplissage procedure. If revision was required, a Latarjet procedure was the choice of 48.8% of respondents (Table).
General Questions
For contact athletes, most respondents (87.2%) would allow return to play in the same season and recommended surgery after the end of the season. After surgical intervention, 56.8% prescribed 4 weeks of immobilization. When counseling a return to contact sports, 51.2% recommended waiting for 4 to 6 months.
The ASES members were divided on conservative management of instability injuries. Responses included immobilization in internal rotation (39.2%), no immobilization (39.2%), and external-rotation bracing (21.6%).
Finally, members thought the most important factor in choosing surgical technique was the patient’s pathology, then age; the least influential criteria was the patient’s sports participation.
Analysis of Training Demographics and Surgical Technique Preferences
Chi-square analyses demonstrated that respondents who completed a sports fellowship were more likely to do at least 50% of cases arthroscopically (odds ratio [OR], 15.3; P < .001) and were more likely to use the lateral decubitus position (OR, 2.8; P < .021). Furthermore, American respondents had a higher likelihood of having completed either a sports fellowship (OR, 12.8; P < .001) or a shoulder/elbow fellowship (OR, 4.6; P = .002) when compared with foreign respondents.
Discussion
In the absence of formal clinical practice guidelines, most surgeons formulate treatment strategy based upon a combination of experience and peer-reviewed evidence. The cohort analyzed in the current study was highly experienced, with more than 70% performing 150 shoulder cases annually and having more than 15 years of experience. We found a consensus response in 68% of questions and all primary surgical techniques for our shoulder instability scenarios. While expert consensus reported here is not equivalent to evidence-based clinical practice guidelines, it does provide important information to consider when treating anterior shoulder instability.
Specific responses to our case scenarios invite further reflection. Considering young (both noncontact and contact) athletes without bony pathology (cases 1 and 2, respectively), the ASES surgeons recommended arthroscopic Bankart repair for both. Randelli and associates5 found 71% of survey respondents recommended arthroscopic Bankart repair in a similar setting. It is interesting to note that consensus persisted regardless of the sport in which they engaged. Contact athletes have the highest rates of dislocation (up to 7 times higher incidence) compared with the general population.14 In addition, they have a higher recurrence rate after surgery.15 It should be noted, however, that although both cases reached consensus, the percentage of experts who recommended an arthroscopic procedure fell from 82% in the noncontact athlete to 57% in the contact athlete. This concurs with a recent review by Harris and Romeo,16 who recommended similar treatments for athletes without bony defects. In an older patient population with recurrent instability (case 3), responses varied more widely but still reached a consensus on primary surgical techniques. Respondents agreed that, even for patients with multidirectional instability, initial management should consist of arthroscopic capsulolabral repair. Overall, the agreement for arthroscopy for cases 1 through 3 mimics recent US practice patterns, showing 90% of stabilizations are being performed arthroscopically.17 Additionally, a recent meta-analysis by Harris and associates18 favored arthroscopic Bankart repair, showing no significant difference vs open stabilization even on long-term follow-up.
Glenoid bone loss is a difficult clinical scenario and that is reflected in this study’s findings. The literature suggests that arthroscopic Bankart repair, in this setting, is usually not sufficient and may result in a recurrence rate up to 75%, if bone loss greater than 20% is unaddressed.19 Our study supports this trend because ASES members recommended a Latarjet procedure when there is substantial bone loss.
While open Latarjet procedure was the consensus for dealing with glenoid bone loss, arthroscopic techniques were strongly favored for humeral head defects. This change in practice patterns results from the introduction of the arthroscopic remplissage technique.20 Two recent systemic reviews have supported this technique, reporting good functional outcomes for engaging Hill-Sachs lesions.21,22 Our study had similar agreement, with most respondents recommending remplissage for these patients.
This study found the lowest rates of expert consensus in the setting of revision surgery, likely caused, in part, by the paucity of available large cohort studies. This is a major void in the literature, and more studies are needed to help guide surgeons on the best techniques to deal with this difficult patient population.