The Journal of Bone and Joint Surgery (American). 2005;87:1978-1984.
doi:10.2106/JBJS.D.02944
© 2005 The Journal of Bone and Joint Surgery, Inc.
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Variation in Orthopaedic Surgeons' Perceptions About the Indications for Rotator Cuff Surgery

Warren R. Dunn, MD, MPH1, Bruce R. Schackman, PhD2, Colin Walsh, BS3, Stephen Lyman, PhD3, Edward C. Jones, MD3, Russell F. Warren, MD3 and Robert G. Marx, MD, MSc, FRCSC3

1 Vanderbilt Sports Medicine, 2601 Jess Neely Drive, Nashville, TN 37212. E-mail address: warren.dunn{at}vanderbilt.edu
2 Division of Outcomes and Effectiveness Research, Department of Public Health, Weill Medical College of Cornell University, 411 East 69th Street, New York, NY 10021
3 Sports Medicine and Shoulder Service (E.C.J., R.F.W., and R.G.M.) and the Foster Center for Clinical Outcome Research (C.W., S.L., E.C.J., and R.G.M.), The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021

Investigation performed at The Hospital for Special Surgery, New York, NY

In support of the research or preparation of this manuscript, W.R. Dunn received the American Academy of Orthopaedic Surgeons/Orthopaedic Research and Education Foundation Health Services Research Fellowship Grant. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Epidemiologic studies have demonstrated substantial variations in per capita rates of many surgical procedures, including rotator cuff repair. The purpose of the current study was to characterize orthopaedic surgeons' attitudes concerning medical decision-making about rotator cuff surgery and to investigate the associations between these beliefs and reported surgical volumes.

Methods: A survey was mailed to randomly selected orthopaedic surgeons listed in the American Academy of Orthopaedic Surgeons directory. Only individuals who had treated patients for a rotator cuff tear, or had referred patients for such treatment, within the previous year were asked to complete the two-page survey. The survey comprised fifteen questions regarding clinical opinion, including four regarding hypothetical cases. Clinical agreement was defined as >80% of the respondents answering similarly.

Results: Of the 1100 surveys that were mailed, 539 were returned (a response rate of 49%). Of the 539 respondents, 316 (58.6%) had treated or referred patients with a rotator cuff tear in the previous year. There was a significant negative correlation between the surgeon's estimation of the failure rate of cuff repairs in the United States and that surgeon's procedure volume (r = –0.21, p = 0.0003), indicating that surgeons with a lower procedure volume are more pessimistic about the results of surgery than are those with a higher procedure volume. Arthroscopic, mini-open, and open cuff repairs were preferred by 14.5%, 46.2%, and 36.6% of the respondents, respectively. Surgeons who performed a higher volume of procedures were less likely to perform open surgery (p < 0.0001). There was clinical agreement regarding only four of the nine clinical questions and none of the four questions about the hypothetical vignettes.

Conclusions: We found significant variation in surgical decision-making and a lack of clinical agreement among orthopaedic surgeons about rotator cuff surgery. There was a positive correlation between the volume of procedures performed by the surgeon and the surgeon's perception of outcome, with surgeons who had a higher procedure volume being more enthusiastic about rotator cuff surgery than those who had a lower procedure volume.


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