Variation in Nonsurgical Treatment Recommendations for Common Upper Extremity Conditions

Lisanne Johanna Henrica Smits, MD; Suzanne Caroline Wilkens, MD, PhD; David Ring, MD, PhD; Thierry Guillaume Guitton, MD, PhD; Neal Chen, MD; Science of Variation Group


J Am Acad Orthop Surg. 2019;27(15):575-580. 

In This Article

Abstract and Introduction


Background: In orthopaedic surgery, there is known surgeon-to-surgeon variation in recommendations for surgery. Variation in recommendations for nonsurgical treatment of common upper extremity conditions for which surgery is discretionary remains unclear.

Methods: One hundred eighty-three surgeons were included after completing six questions on six scenarios of upper extremity conditions regarding nonsurgical treatment recommendations. For one scenario, we measured the influence of reading a summary of preferred practice before making recommendations.

Results: Variation in nonsurgical treatment recommendations was observed between surgeons and between upper extremity conditions. Surgeons that reviewed a decision support paragraph were more likely to opine that surgery would eventually be beneficial.

Discussion: The notable variation in nonsurgical treatment recommendations indicates a substantial influence of surgeon bias in decision-making. To help ensure that decisions are consistent, surgeons may benefit from decision support and guidelines to help limit practice variation.


In orthopaedic surgery, as in other medical fields, there is unexplained surgeon-to-surgeon variation in recommendations for tests and treatments.[1–7] The existing literature can be confusing: surgical treatments are studied more often than nonsurgical treatments, studies with positive results are more commonly reported than studies that report no difference or negative results, and conditions that are infrequent or difficult to treat are over-represented. Variations in recommendations of nonsurgical treatment in upper extremity conditions remain unclear, especially when evidence is inconclusive and treatment recommendations are preference sensitive.

The concept of evidence-based medicine holds that physicians offer patients treatment options based on a combination of the best available evidence and practice experience.[8] Clinical guidelines based on the best available evidence can help simplify and assist physician adherence to evidence-based medicine.[9] Combined with appropriate involvement of the patient in the decision-making process, limited surgeon-to-surgeon variation should exist in care in well-defined clinical situations.

On the one hand, it has been demonstrated that articles with a high level of evidence, published in eminent journals, do sometimes influence clinical practice.[10–12] On the other hand, institutions do not consistently implement the findings of their own research studies into their daily practice.[13] Moreover, previous research suggests that physicians' opinions and recommendations do not always correspond with clinical guidelines or the best available evidence.[1,14–18] Additional studies are needed to measure the influence of best available evidence and clinical guidelines on physician recommendations to determine if the variation in treatment can be reduced.

This study assessed the primary null hypothesis that no surgeon-to-surgeon variation exists in nonsurgical treatment recommendations for common conditions of the upper extremity. We also measured the influence of reading a short summary of preferred practice before making treatment recommendations for carpal tunnel syndrome, hypothesizing this would reduce variation in treatment recommendations.