Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons

The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD. The Neer Circle is an organization of shoulder...

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Bibliographic Details
Published in:Journal of shoulder and elbow surgery 2020-12, Vol.29 (12), p.2429-2445
Main Authors: Tokish, John M., Kuhn, John E., Ayers, Gregory D., Arciero, Robert A., Burks, Robert T., Dines, David M., Duralde, Xavier A., ElAttrache, Neal S., Millett, Peter J., St. Pierre, Patrick, Provencher, Matthew T., Tibone, James E., Ticker, Jonathan B., Cordasco, Frank A.
Format: Article
Language:English
Subjects:
consensus
Delphi process
dislocation
First-time anterior glenohumeral dislocation
Neer Circle
shoulder instability
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Summary:The treatment of patients who sustain a first-time anterior glenohumeral dislocation (FTAGD) is controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after an FTAGD. The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 72 identified experts from this group was sought with a series of surveys using the Delphi process. The first survey used open-ended questions designed to identify patient-related features that influence treatment decisions after an FTAGD. The second survey used a Likert scale to rank each feature’s impact on treatment decisions. The third survey used highly impactful features to construct 162 clinical scenarios. For each scenario, experts recommended surgery or not and reported how strongly they made their recommendation. These data were analyzed to find clinical scenarios that had >90% consensus for recommending treatment. These data were also used in univariate and multivariate mixed-effects models to identify odds ratios (ORs) for different features and to assess how combining these features influenced the probability of surgery for specific populations. Of the 162 scenarios, 8 (5%) achieved >90% consensus for recommending surgery. All of these scenarios treated athletes with meaningful bone loss at the end of their season. In particular, for contact athletes aged > 14 years who were at the end of the season and had apprehension and meaningful bone loss, there was >90% consensus for recommending surgery after an FTAGD, with surgeons feeling very strongly about this recommendation. Of the scenarios, 22 (14%) reached >90% consensus for recommending nonoperative treatment. All of these scenarios lacked meaningful bone loss. In particular, surgeons felt very strongly about recommending nonoperative treatment after an FTAGD for non-athletes lacking apprehension without meaningful bone loss. The presence of meaningful bone loss (OR, 6.85; 95% confidence interval, 6.24-7.52) and apprehension (OR, 5.60; 95% confidence interval, 5.03-6.25) were the strongest predictors of surgery. When these 2 features were combined, profound effects increasing the probability of surgery for different populations (active-duty military, non-athletes, noncontact athletes, and contact athletes) were noted, particularly non-athletes. Consensus for recommending treatment of the FTAGD patient
ISSN:1058-2746
1532-6500
DOI:10.1016/j.jse.2020.08.011