Editorial Commentary: Can Orthopaedic Surgeons Agree on Choice of Procedure for Anterior Shoulder Instability Based on Risk Factors? Personal and Training Biases Confound Our Surgical Decision Making

Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability

Background

This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality.

Methods

Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys.

Results

The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8).

Discussion

The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management.

Conclusion

This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

Editorial Commentary: Wider Acceptance of Medical Expert Consensus Research Requires Strict Adherence to Delphi Panel Methodology

The diagnosis and treatment of an anterior glenohumeral instability remains controversial. Currently, there is no universally globally accepted approach. In addition to individual surgeon's experiences and preferences, surgical training, regional differences in patient's expectations, and demands confound decision-making. Evidence-based medicine and large randomized trials are not helpful, as they cannot possibly account for all potential confounders. The Delphi technique is an expert consensus-based evidence approach and a reasonable alternative to randomized trials. It pools the experience of experts in the field in a scientific fashion but has been criticized for only producing the lowest common denominator, resulting in oversimplification of a complex problem. However, this criticism is commonly a result of inadequate execution of the methods rather than the methodology itself. It could be that strict adherence to Delphi methodology could result in greater acceptance of Delphi (rather than "modified" Delphi) findings; a stricter approach also may lead to lower agreement between participating experts.