Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
J Shoulder Elbow Surg. 2023 Jul;32(7):e329-e342. doi: 10.1016/j.jse.2023.01.009. Epub 2023 Jan 31.
The purpose of this study was to implement a modified Delphi technique among a group of experts affiliated with American Shoulder and Elbow Surgeons (ASES) and European Society for Surgery of the Shoulder and Elbow (SECEC) to determine areas of consensus regarding what factors influence their decision to manage a patient surgically and what specific treatment modalities they utilize for patients ≤50 years of age with glenohumeral arthritis.
The panel of experts comprised 168 shoulder and elbow specialists, 138 ASES and 30 SECEC members. In the first round, an open-ended questionnaire was utilized to solicit features that are important in making decisions regarding treatment. The second round involved ranking the features identified in the first round as to their importance in helping decision making for surgery. The results of round 2 were then utilized and 18 complex surgical cases previously treated by one of the lead authors were provided for the study. One additional case was included to address the management of Cutibacterium acne infection.
A total of 159 (95.0%) participants completed the round one survey, 142 (89%) responded to the second and third round surveys. In total 50 individual factors were positively associated with the decision to proceed with surgery. Ten of these were strongly supportive of surgery. Eight out of 18 clinical cases demonstrated > 80% agreement on the surgical treatment modality chosen. Over 90% of respondents chose reverse total shoulder arthroplasty (TSA) to manage pathology when an incompetent rotator cuff was present. Over 90% of respondents managed avascular necrosis with hemiarthroplasty. Over 70% of respondents chose anatomic TSA for inflammatory arthritis with low demand on their shoulder. Overall, 79% of respondents chose a stemless humeral component when a hemiarthroplasty or anatomic TSA was chosen in response to the proposed surgical cases. If arthroscopy was chosen then there was good agreement on 5 core procedures. There was only fair consensus on the approach to C. acnes in patients with glenohumeral osteoarthritis ≤ 50 years of age.
The optimal treatment of glenohumeral arthritis in patients ≤ 50 years of age remains controversial, and there are many treatment options to consider when responding to the variety of clinical presentations and anatomic pathologies. While physicians and patients engage in the shared decision-making process regarding the final choice for management, this consensus statement serves as a basis for discussion amongst colleagues and between patients and surgeons though it clearly demonstrates that the topic must be further investigated prospectively and with large cohorts.
本研究旨在通过美国肩肘外科医师学会（ASES）和欧洲肩肘外科医师学会（SECEC）的一组专家采用改良 Delphi 技术，确定影响其手术治疗决策的共识领域，以及他们为≤50 岁肩关节炎患者使用的具体治疗方式。
专家组由 168 名肩肘专家组成，其中 138 名 ASES 成员，30 名 SECEC 成员。在第一轮中，采用开放式问卷征集对治疗决策重要的特征。第二轮涉及对第一轮确定的特征进行排名，以确定其对手术决策的帮助程度。第二轮的结果被用于研究，并提供了一位主要作者之前治疗的 18 例复杂手术病例。为解决痤疮丙酸杆菌感染的治疗问题，又增加了 1 例病例。
共有 159 名（95.0%）参与者完成了第一轮调查，142 名（89%）对第二轮和第三轮调查做出了回应。总共 50 个个体因素与手术决策呈正相关。其中 10 个因素强烈支持手术。18 个临床病例中有 8 个在选择手术治疗方式上达成了>80%的一致。超过 90%的受访者选择反向全肩关节置换术（TSA）来处理存在肩袖无力的情况。超过 90%的受访者选择半肩关节置换术治疗缺血性坏死。超过 70%的受访者选择解剖型 TSA 治疗对肩部要求较低的炎症性关节炎。总体而言，79%的受访者在为所提出的手术病例选择半肩关节置换术或解剖型 TSA 时，选择了无柄肱骨组件。如果选择关节镜手术，则在 5 种核心手术上达成了较好的共识。对于≤50 岁的肩关节炎患者，在处理痤疮丙酸杆菌的方法上，仅有适度的共识。
对于≤50 岁的肩关节炎患者，最佳治疗方法仍存在争议，在应对各种临床表现和解剖病理学时，有许多治疗方案可供选择。虽然医生和患者在管理的最终选择上进行了共同决策，但该共识声明为同事之间以及患者和外科医生之间的讨论提供了依据，尽管它清楚地表明，该主题必须通过前瞻性研究和大样本进一步调查。
