Steadman Philippon Research Institute, Vail, Colorado, USA.
The Steadman Clinic, Vail, Colorado, USA.
Am J Sports Med. 2023 May;51(6):1588-1595. doi: 10.1177/03635465231163148. Epub 2023 Apr 5.
Glenoid bone loss is a critical factor in the management of anterior shoulder instability (ASI). Computed tomography (CT) is often considered the gold standard to evaluate glenoid bone loss, but it is associated with negative factors such as radiation. Thus, interest exists as to when orthopaedic surgeons need a CT scan to guide decision-making when treating ASI.
To determine whether information gained from a shoulder CT scan alters orthopaedic surgeons' management plan for ASI and, secondarily, to determine whether surgeon- and patient-specific factors affect whether a CT scan changes treatment and which clinical factors are most important in surgical decision-making.
Cross-sectional study.
A questionnaire composed of 24 ASI vignettes was administered to Herodicus Society members, American Shoulder and Elbow Surgeons Neer Circle members, and sports medicine fellowship-trained orthopaedic surgeons. Participants chose their recommended surgical treatment from the options of arthroscopic Bankart repair, open Bankart repair, bony reconstruction procedure, or other based on patient history, radiographs, and magnetic resonance imaging. Participants were then shown CT images and asked whether their treatment plan changed and, if not, whether the CT scan was not necessary or had reinforced their decision. Generalized linear mixed-effects logistic regression modeling was performed to assess the influence of vignette and respondent characteristics on treatment decisions.
A total of 74 orthopaedic surgeons completed the survey; 96% were fellowship trained (sports medicine, 50%; shoulder and elbow surgery, 41%), and 66% practiced in academic settings. CT imaging did not change the selected treatment strategy in 75.6% of responses. In cases when management did not change, surgeons reported that the CT scan reinforced their decision in 53.4% of responses and was not necessary for decision-making in 22.2% of responses. Decision-making was more likely to be changed after CT in male patients and those with off-track lesions.
Information gained from a CT scan did not alter treatment decision-making in three-quarters of vignettes among surgeons experienced in the management of ASI. The finding that CT scans did alter the treatment plan in nearly a quarter of cases is not insignificant, and it appears that in patients with borderline glenoid track status and few other risk factors for recurrence after arthroscopic stabilization, CT imaging is more likely to change management.
肩盂骨缺损是治疗肩关节前不稳定（ASIS）的关键因素。计算机断层扫描（CT）通常被认为是评估肩盂骨缺损的金标准，但它与辐射等负面因素有关。因此，当治疗 ASIS 时，骨科医生需要 CT 扫描来指导决策，这一点引起了人们的兴趣。
确定从肩部 CT 扫描中获得的信息是否会改变骨科医生对 ASIS 的治疗方案，其次，确定医生和患者的具体因素是否会影响 CT 扫描是否会改变治疗方案，以及哪些临床因素对手术决策最重要。
横断面研究。
向 Herodicus 学会成员、美国肩肘外科医师协会 Neer 圈成员和运动医学 fellowship培训的骨科医生发放了一份由 24 个 ASIS 病例组成的问卷。参与者根据病史、X 线片和磁共振成像结果，从关节镜下 Bankart 修复、开放 Bankart 修复、骨重建术或其他手术中选择推荐的手术治疗方法。然后向参与者展示 CT 图像，并询问他们的治疗方案是否发生了变化，如果没有，他们是否认为 CT 扫描没有必要，或者 CT 扫描是否加强了他们的决策。采用广义线性混合效应逻辑回归模型评估病例和受访者特征对治疗决策的影响。
共有 74 名骨科医生完成了调查；96%接受过 fellowship培训（运动医学，50%；肩肘外科，41%），66%在学术环境中工作。在 75.6%的情况下，CT 成像并未改变所选的治疗策略。在管理未发生变化的情况下，53.4%的医生报告 CT 扫描加强了他们的决策，22.2%的医生报告 CT 扫描对决策没有必要。在男性患者和肩盂轨迹异常的患者中，更有可能在 CT 后改变治疗决策。
在经验丰富的 ASIS 治疗骨科医生中，有四分之三的病例中，从 CT 扫描中获得的信息并未改变治疗决策。在近四分之一的病例中，CT 扫描确实改变了治疗方案，这一发现并非微不足道，而且似乎在那些肩盂轨迹状态临界、关节镜稳定后复发风险因素较少的患者中，CT 成像更有可能改变治疗方案。
