There is no consensus on immobilization protocols following shoulder surgery. The purpose of the study was to establish patterns of sling use in the United States and Europe and to identify factors associated with variation.
An online survey was sent to members of the American Shoulder and Elbow Society (ASES) and the European Society for Surgery of the Shoulder and Elbow (ESSSE) in April 2020. Demographic questions included: location of practice, years in clinical practice, and type and duration of sling use following arthroscopic Bankart repair (ABR), Latarjet procedure, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3cm and >3cm, anatomic total shoulder arthroplasty (aTSA), reverse TSA (rTSA) and isolated biceps tenodesis (BT). The relationships between physician location and sling type for each procedure were analyzed using Fisher's exact tests and post-hoc tests using Bonferroni-adjusted p-values. The relationships between a physician's experience and sling duration were analyzed using Spearman's correlation tests. All analyses were completed in RStudio ver. 1.1.456 using a two-sided level of significance of 0.05.
Responses were received from 499 surgeons with median years in practice of 15 (interquartile range 9-25). 54.7% of respondents were based in the US, with 45.3% of respondents based in Europe. Respondents from the US reported significantly higher use of abduction pillow slings than European respondents for ABR (62% vs 15%, p<0.0001), Latarjet (53% vs 12%, p<0.001), ARCR <3cm (80% vs 42%, p<0.001) and >3cm (84% vs 61%, <0.001), aTSA (50% vs 21%, p<0.001), rTSA with subscapularis repair (61% vs 22%, p<0.001) and without subscapularis repair (57% vs 17%, p<0.001), and isolated BT (18% vs 7%, p=0.006). Respondents from Europe reported significantly higher use of simple slings than US respondents for ABR (74% vs 31%, p<0.001), Latarjet (78% vs 44%, p<0.001), ARCR <3cm (50% vs 17%, p<0.001) and >3cm (34% vs 13%, p<0.001), aTSA (69% vs 41%, p<0.001) and rTSA with subscapularis repair (70% vs 35%, p<0.001) and without subscapularis repair (73% vs 39%, p<0.001). Increasing experience was negatively correlated with sling duration for ABR (r=-0.20, p<0.001), Latarjet (correlation coefficient -0.25, p<0.001), ARCR of tears <3cm (r=-0.14, p=0.014) and >3cm (r=-0.20, p<0.002), aTSA (r=-0.37, p<0.001), rTSA with subscapularis repair (r=-0.10, p=0.049) and without subscapularis repair (r=-0.19, p=0.022) meaning more experienced respondents tended to recommend shorter durations of sling use. US surgeons reported significantly longer sling durations for arthroscopic Bankart repair (4.8 vs 4.1wks, p<0.001), the Latarjet procedure (4.6 vs 3.6wks, p<0.001), ARCR <3cm (5.2 vs 4.5wks p<0.001) and >3cm (5.9 vs 5.1wks, p<0.001), aTSA (4.9 vs 4.3wks, p<0.001), rTSR without subscapularis repair (4.0 vs 3.6wks, p=0.031) and isolated BT (3.7 vs 3.3wks, p=0.012) than respondents from Europe. There were no significant differences between regions of both the US and Europe.
CONLUSIONS: There is significant variation in the type and duration of immobilization advocated by surgeons following shoulder surgery with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery.