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

Background: 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.

Methods: A discrete choice experiment was conducted among all 94 members of the Belgian Elbow and Shoulder Society. Surgeons completed 15 choice tasks, each involving three instability cases, and were asked to select the most appropriate indication for surgery. Each case included six 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.

Results: Fifty-five surgeons completed the survey. Of these, 31% had less than five 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.

Conclusions: 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.

Level Of Evidence: Level V; Consensus Study using Choice-Based Conjoint (CBC) Analysis.