Surgeon variation in the use of pre-operative imaging, 3D-based planning, and enabling technologies in shoulder arthroplasty

Background: Conference narratives and publications frequently portray widespread utilization of advanced imaging, 3D-based planning, and enabling technologies in shoulder arthroplasty, but surgeon adoption in day-to-day practice is not well characterized. This study sought to characterize surgeon variation in the use of these tools, delineate perceived benefits and barriers to 3D planning, and identify surgeon characteristics associated with lower utilization.MethodsA 16-question survey was created using Google Forms and distributed to 161 shoulder surgeons members of the PacWest Shoulder and Elbow Society. The survey asked questions regarding fellowship training, years in practice, practice type, surgical volume, and patterns of pre-operative advanced imaging (computed tomography [CT], magnetic resonance imaging), 3D CT–based planning for primary and revision arthroplasty, and intraoperative enabling technologies (patient-specific instrumentation, navigation, mixed/augmented reality, robotics). Routine use was defined as ≥75% of cases. Associations between surgeon characteristics and low use of 3D planning (<25% of cases) were evaluated.ResultsIn total, 53% of surgeons completed the survey (85 of 161). Pre-operative CT was routinely obtained by 71% of surgeons. Routine acquisition of both CT and magnetic resonance imaging was uncommon (9.5%). Routine 3D planning was reported by 60% for primary arthroplasty, with 25% never or rarely using it. Routine 3D planning for revision cases was reported by 47%. Routine use of patient-specific instrumentation guides was infrequent (15%), and there was low adoption of navigation (13%), mixed reality (7%), and robotics (6%). Interest in robotics was high (62%), most often motivated by perceived gains in implant accuracy. There was no consensus on whether 3D planning is standard of practice (55% yes, 45% no). Reported benefits of 3D planning included implant accuracy (91%), fewer outliers (67%), education (33%), and operative time savings (32%). Barriers included imaging acquisition/protocol issues (68%) and time required to plan (47%). Surgeons in practice >10 years were more likely to report low utilization of 3D planning (P = .034).ConclusionPre-operative CT and 3D-based planning are common but not universal, with about 30% and 40% of surgeons not routinely using them, respectively, highlighting practice heterogeneity and a disconnect between scholarly discourse and day-to-day practice. Use of CT-based enabling technology is low, but there is interest in the nascent field of robotics. Practice variation appears shaped by workflow constraints, evidentiary uncertainty, and surgeon-specific beliefs and experience. Research that connects planning and its execution to patient outcomes is warranted, as it may change the value proposition.