Factors influencing surgeons’ decision-making in the treatment of SLAP lesions: a case-vignette study

Abstract BACKGROUND There is uncertainty about the management of isolated superior labral anterior-posterior (SLAP) lesions. Recent studies show that SLAP lesions are often present in asymptomatic patients and that current operative techniques may not outperform sham surgery. Given this uncertain scientific landscape, this study aims to assess the clinical and contextual factors influencing surgeons' decisions for non-operative versus operative management, and their subsequent choice of surgical technique. Providing an overview of the current state of practice regarding isolated SLAP lesions. METHODS This case-vignette study using 72 hypothetical clinical scenarios examined the influence of seven variables that can play a role in surgical decision making in patients with SLAP lesions. Attendees of an international shoulder surgery congress were requested to complete a questionnaire, choosing their preferred treatment for 12 cases. Generalized linear mixed models were used to assess the influence of factors on the preferred management. RESULTS A total of 126 orthopedic surgeons participated. The decision to operate was least likely for patients without prior non-operative treatment (odds ratio (OR)=0.07, 95% confidence interval (CI): 0.05–0.10, p<0.001) and most likely for SLAP type III/IV lesions (OR=4.52, 95%CI: 3.39–6.02, p<0.001). Other factors favoring surgery included failed non-operative treatment, overhead pain, high activity levels, positive SLAP tests, and a suggestive trauma mechanism. When surgery was chosen, participants were more likely to opt for tenodesis or tenotomy over SLAP repair in older patients. A lower activity level was associated with choosing tenotomy. The type of SLAP lesion, surgeon expertise, and hospital type did not influence the choice of surgical procedure. CONCLUSION Treatment decisions for SLAP lesions are driven primarily by the presence of pain, overhead activity level, and prior non-operative management. The decision to operate was relatively consistent based on these factors. However, variability was observed in the choice of surgical technique, which is influenced primarily by patient age and activity level. These findings highlight the need for consensus on which treatment is most suitable for specific patients to achieve more consistent outcomes. Level of evidence Level V, Case-vignette study