Complications after total shoulder arthroplasty - the Surgeon is the Method

 

The quest for ways to make shoulder arthroplasty safer for future patients continues through Shoulder Arthroplasty Research. Here are some things we know: 

(1) most shoulder arthroplasties turn out well for the patient, thus our greatest opportunities to learn come from studying failures

(2) it is insufficient to focus on the type of failure (e.g. glenoid component loosening, rotator cuff failure); rather we need to hone in on what could have been done differently at the primary arthroplasty to lower the risk of component or cuff failure - this can be thought of as actionable intelligence.

(3) we want to avoid the assumption that technologies such as 3D CT based planning, patient specific instrumentation, robotics, virtual reality, augmented reality will lower failure risk until their effectiveness in vivo has been rigorously demonstrated

(4) our attention falls on the surgeon and the elements of care that are under her/his control

A recent article, The effect of surgeon volume on complications after total shoulder arthroplasty: a nation-wide assessment, provides some actionable intelligence. The authors retrospectively queried the Pearl Diver Mariner database for the years 2010 to 2022. Their analysis included 155,560 patients having primary anatomic total shoulder arthroplasty, excluding those younger than 40 years, those who underwent revision arthroplasty, cases of bilateral arthroplasty, and cases with a history of fracture, infection, or malignancy.

They included cases performed by surgeons with a minimum of 10 cases. 

The 90th percentile for surgeon volume was determined to be 112 cases during the study period. Surgeons above the 90th percentile (n 340) operated on 68,531 patients, whereas surgeons below the 90th percentile (n 3038) operated on 87,029 patients. Surgeons in the high-volume group were significantly more likely to have completed a Shoulder and Elbow fellowship and less likely to have no fellowship training or fellowship training outside of Shoulder and Elbow or Sports Medicine. 

Low-volume surgeons operated on patients with higher baseline comorbidities. Here's my summary of their data.

After adjusting for age, gender, CCI, obesity, and tobacco use, high-volume surgeons experienced lower rates of medical complications including renal failure, anemia, and urinary tract infection. All-cause readmission, reoperation at 90 days, and reoperation at 1 year were significantly lower among high-volume surgeons. Cases performed by high-volume surgeons exhibited lower rates of all complications including prosthetic joint infection and periprosthetic fracture. Here's my summary of their data. NB an odds ratio <1 means that cases operated by high volume surgeons had a lower rate of the complication than low volume surgeons.

Finally, the authors found that the proportion of shoulder arthroplaties performed by high volume surgeons has been decreasing with time.

Comment: This study appropriately puts the focus on the surgeon - the individual that decides which treatment is best suited for each patient, carries out the surgery, and manages the aftercare. In other words, the surgeon controls the modifiable variables for each patient. The surgeon is the method.

The authors characterize the surgeon in three dimensions: (1) case volume, (2) fellowship, and (3) the comorbidites of the patients the surgeon selects to have total shoulder arthroplasty. They then go on to compare complications for surgeons performing ≥ 112 arthroplasties to those performing < 112. 

Thus the data available are ripe for a multivariable analysis (MVA) characterizing the relationship among these variables - individually or in combination - to the occurrence of medical and surgical complications. Without such an analysis we cannot know the relative importance of each of these dimensions.

Let's look at each of these characteristics:

Surgeon case volume: One of the big questions in orthopaedics is whether more is more, i.e do we continue to get a bit better with each case, or is there a threshold above which we are "good"? In this light it might be more informative to characterize surgeon case volume as the number of cases rather an whether they exceeded a threshold for qualification as "high volume"?  This would get around the problem of having a surgeon performing 111 cases designated as "low volume" whereas if the surgeon had done one more case he/she would suddenly become "high volume". On reading this paper, a patient might ask "should I travel four hours to have an arthroplasty by a surgeon who has done 120 cases rather than sticking with my local surgeon who has done 110?  Numbers may be better than categories. An MVA should be able to sort this out.

Fellowship: The additional year of specialized training afforded by fellowship exposes trainees to a greater case volume and breadth. High volume surgeons were more than twice as likely to have taken a shoulder fellowship; however, fewer than 30% of high volume surgeons took a shoulder fellowship. As a result we do not know from the data presented whether taking a shoulder fellowship results in a significantly greater arthroplasty practice volume or whether taking a shoulder fellowship reduces the surgeon's complication rate. An MVA should be able to sort this out.

Comorbidities: The patient population of high-volume surgeons was significantly healthier, i.e., comorbidities as reflected by the Charlson Comorbidity Index were lower in patients operated by higher volume surgeons (perhaps because experience teaches to think carefully before offereing elective surgery to patients who are ill or perhaps high volume surgeons operate in outpatient centers that exclude sick patients). The question is whether a shoulder fellowship or being a high volume surgeon enables safer surgery on patients with comorbidites. An MVA should be able to sort this out.

Complications: This article presents data on medical and surgical complications in terms of odds ratios, but does not present data on the rate of each complication. In an MVA it may be easier to characterize complications in terms of their rates.

Arthroplasty choice: The authors point out that "distinctions between anatomic and reverse shoulder arthroplasty were not made because of limitations associated with CPT coding". This is an important shortcoming of the analysis, because experienced (and perhaps fellowship-trained shoulder surgeons), may be better at deciding which patients are the best candidates for each procedure in terms of avoidance of medical and surgical complications.  

Incremental value of each case: Numbers are not the only important thing. How much the surgeon learns from each case depends in large part on whether the sugeon conducts an After Action Report (AAR) after each case. An AAR is a structured process used to review the case to identify what happened, what went well, and what could be improved in future cases. We can assume that a 100 case surgeon who routinely conducts AARs will have better outcomes than a120 case surgeon who goes on to the next case without introspection. This is important because most shoulder arthroplasties are not operated on by high volume surgeons.

We can do a better job of helping our patients avoid problems.

Fresh Grizzly Bear Footprint

Devil's Gap, Alberta

Photo by Laura Matsen, M.D

8/23/2025

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Do higher case volumes make us safer and more effective surgeons?

I've always held that "the surgeon is the method", meaning that considering all of the variables that might affect the outcome of a given surgery for a given problem, the most important is the person making the decisions, carrying out the procedure, and analyzing the results = the surgeon. As surgeons we are engaged in the constant pursuit of learning to achieve better outcomes for our patients. We hope, as the saying goes, that experience is the great teacher and that practice makes us better at our art. But as we'll see below, the number of repetitions is not the only thing that matters.

My friend JP Warner pointed to this article, Higher Surgeon Volume is Associated With a Lower Rate of Subsequent Revision Procedures After Total Shoulder Arthroplasty: A National Analysis, the authors of which assessed the association between increasing surgeon volume and decreasing rate of revision for anatomic (aTSA) and reverse (rTSA) shoulder arthroplasty using the Centers for Medicare and Medicaid Services (CMS) fee-for-service inpatient and outpatient claims data from 2015 through 2021. 

They found that in comparison to an arthroplasty case volume of <4 per year, an annual surgeon case volume of

 ≥ 10 aTSAs was associated with a 27% decreased odds of a revision within 2 years

≥ 29 aTSAs was associated with a 33% decreased odds of a revision within 2 years

An annual surgeon volume of ≥ 29 rTSAs was associated with a 26% decreased odds of a revision within 2 years.

The figure below shows the trend line for revisions as function of surgeon case volume.

There are several interesting observations to be made on this graph: 

(1) the downward trend appears to continue out to surgeons performing over 100 shoulder arthroplasties per year, No end in sight for the effect.

(2) the effect of case volume on revision rate appears relative continuous: there is no obvious inflection point after which the volume effect starts to level off, 

(3) there is wide scatter in the data, indicating that there are factors other than annual case volume that are driving a surgeon's revision rate (some lower volume surgeons have lower revision rates than some higher volume surgeons).

So questions arise: 

(1) which is more important, the number of cases / year or the lifetime total number of cases ("how many do you do" vs "how many have you done")?

(2) how does a patient learn a surgeon's case volume? 

(3) how important should case volume be in a patient's choice of surgeon (e.g. how far should the patient travel or how much more should they be willing to pay to be cared for by a higher volume surgeon)?  

(4) what factors account for the high variability shown in this chart (note especially the three surgeon outliers at the top with over twice the average revision rate even though they're in the "high volume" category)? Should the patient be more concerned about the volume or the revision rate of their potential surgeon?

(5) if a large percentage of patients select their surgeon on volume, how do low volume surgeons become high volume surgeons? 

(6) is it experience (the number of cases) that is the determinant of revision rate?

In his books Noise a Flaw in Human Judgment and Thinking Fast and Slow Daniel Kahneman emphasized that experience does not automatically improve the outcome.  Over time, experienced surgeons may gain increased confidence but not necessarily increased competence, a phenomenon Kahneman calls the illusion of validity. Instead it is learning that leads to better outcomes. Learning, in turn, comes from quality, timely and accurate feedback. If a surgeon routinely takes and analyzes postoperative x-rays, she or he can learn how well the preoperative plan was executed - becoming smarter with each case. That's pretty easy to do. What's harder is to study each case that required revision to learn what went wrong - this is harder because the revision is delayed and memory fades. 

Each failure is a learning opportunity not to be passed up. Through the experience of studying the factors associated with each revision, the surgeon can reduce the risk of revisions in the future. There is safety in numbers, but its not the only thing that counts.

Dunlins Ocean Shores 2020

While there is safety in numbers, the peregrine falcon can usually cause an adverse event for one of them.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)
Shoulder rehabilitation exercises (see this link).

Surgeon and hospital shoulder arthroplasty volume affect patient outcome - more on this.

The recent article The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty and the post, The complex relationship between surgeon shoulder arthroplasty volume and outcome, have stimulated much needed thought and discussion. From this article we learned that 

(1) Low-volume facilities and surgeons had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high volume facilities. The patients of low-volume surgeons had longer hospital lengths of stay.

and that

(2) Older, Hispanic/African American, socially deprived, non-privately insured patients were more likely to be treated by low volume facilities and surgeons.

These observations suggest that, for multiple reasons, patients treated at low volume centers and by low volume surgeons are more likely to have adverse outcomes. Furthermore, low volume centers and low volume surgeons are disadvantaged by a more complex patient population with less favorable reimbursement.

"Fixing" these disparities is a daunting task. 

Some of the important aspects to consider are listed below

    (1) High volume centers and providers have many advantages, including streamlined pathways, dedicated and experienced staff, economies of scale, marketing, favorable implant price negotiations, experience-based patient selection criteria, support systems enabling efficient and safe outpatient surgery, active research programs focused on optimizing patient outcomes and a larger share of individuals with the means and motivation to travel in the anticipation of improved outcome. These assets also lead to cost-savings associated with shorter hospital stays.

    (2) It is likely that many patients would experience increased cost and inconvenience in moving from their local providers to seek care at higher volume providers.

    (3)  There may be barriers that impair access for more complex and less well insured patients to achieving care at higher volume facilities. This and item #2 above may contribute to disparities in health care for certain socioeconomic, ethnic and racial groups of patients. As pointed out by the authors of The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty "Patients without private insurance received treatment more often at low-volume facilities and from low-volume surgeons, which is another concerning finding considering that surgeon reimbursement for Medicare payments after shoulder arthroplasty has decreased substantially over the past decade. It is also important to acknowledge the possible influence of the geographic location of hospitals alongside any financial incentives for high-volume providers to attract patients with insurances which offer higher reimbursement rates, most of whom may be White"

    (4) "Volume shifting" has been suggested as an approach, however the mechanisms for accomplishing this are unclear. Furthermore,  moving patients from low volume surgeons to high volume surgeons impairs the ability of low volume surgeons (particularly those recently starting out in practice) to increase their volume. Loss of these surgical cases would also have a negative effect on the finances of the low volume surgeons. 

    (5) There is a need to investigate means by which the strategies and benefits of high volume can be shared with and implemented by lower volume centers and surgeons. For example, the increased risk of complications such as pneumonia, electrolyte imbalance, urinary tract infection and acute renal failure found in low volume centers may be addressed by educational programs for both the providers and the patients.

    (6) In that these issues are not unique to shoulder arthroplasty, our national organizations, such as the American Academy of Orthopaedic Surgeons, need to emphasize these important issues in their ongoing national meetings and educational programs. 

To add this blog to your reading list in Google Chrome, click on the reading list icon

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

The complex relationship between surgeon shoulder arthroplasty volume and outcome.

It is generally accepted that the outcomes of shoulder arthroplasty tend to be better in the hands of surgeons performing high volumes of these cases. In some ways this is similar to the observation that golfers who have hit more balls or anglers who have extensive experience in placing a dry fly in the "sweet  spot" will have better outcomes. 

However in surgery the volume effect is more multifaceted. High volume surgeons are more likely to have well trained support staff - clinic personnel, operating room nurses and technicians, physical therapists - along with well established pathways to optimize efficiency and safety. They are more likely to have optimal support from representatives of implant companies, to have access to special tools and instruments, to work in medical centers that receive volume discounts on arthroplasty components (resulting in better cost-effectiveness), to conduct clinical research on methods to optimize their outcomes, and to afford and benefit from modern marketing strategies. Finally, high volume surgeons have the ability to select the better candidates for shoulder arthroplasty as well as those patients with better reimbursing health care coverage.

However, as demonstrated by the authors of Distribution of High-Volume Shoulder Arthroplasty Surgeons in the United States: Data from the 2014 Medicare Provider Utilization and Payment Data Release, many patients do not have access to high-volume surgeons as can be seen in their figure reproduced below showing the number of high-volume TSA surgeons by U.S. metropolitan areas. The map identifies the number of high-volume surgeons per estimated number of Medicare beneficiaries and locations of ASES fellowship programs among major metropolitan areas.

See also: The distribution of shoulder replacement among surgeons and hospitals is significantly different than that of hip or knee replacement. 

Several interesting questions arise:

(1) Because it may be expensive and inconvenient for patients to travel to a high volume surgeon for both the surgery and followup, on what basis can they decide if it is worth it?

(2) All arthroplasty surgeons start out as "low-volume" surgeons; if most arthroplasty cases are directed to high volume surgeons, how does a young surgeon become "high-volume"?

(3) What is a useful definition of a "high volume" surgeon; does the relationship between surgeon volume and patient outcome look like this (more is always better)

or this (after a certain volume, the number of cases matters less)?

(4) Considering the patients living in a community with a young "low volume" surgeon for whom it is impractical to travel a considerable distance to a "high volume" surgeon, by what means can we lessen the effect of low volume on outcome so that neither the patient cared for by the "low volume" surgeon or the low volume surgeons themselves are disadvantaged?

(5) And perhaps most importantly, how much of the "volume effect" is due to solely to volume and how much is due to selection bias determining which patients are treated by low volume surgeons?

Some if these points were explored by the authors of The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty who sought to evaluate (1) the relationship between hospital and surgeon volumes of shoulder arthroplasty and complication rates and (2) patient demographics/socioeconomic factors that may influence access to high-volume shoulder arthroplasty care. They studied patients older than 40 years who underwent shoulder arthroplasty between 2011 and 2015 that were identified in the New York Statewide Planning and Research Cooperative System database.

7785 patients were included. Based on total annual volume, surgeons were assigned to the lowest 20% of the volume, middle 60% of the volume, or highest 20% of the volume.

Low-volume surgeons accounted for 1,666 procedures, and high-volume surgeons accounted for 1,642 procedures. They compared the practices of low and high volume surgeons.

There were two major findings:

(1) Older, Hispanic/African American, socially deprived, non-privately insured patients were more likely to be treated by low volume facilities and surgeons.

(2) Low-volume facilities and surgeons had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high volume facilities. Low-volume surgeons had patients with longer hospital lengths of stay.

What is not clear is to what degree #2 is related to #1.

Comment: This study identifies a selection bias influencing which patients are treated by low and high volume facilities and surgeons. However, the study does not clarify whether the rate of adverse outcomes is due to the differences in characteristics of the patients treated in low or high volume contexts or whether the rate of adverse outcomes is solely a factor of volume. 

In order to answer this important question it is necessary to perform a multivariate analysis of the factors potentially associated with adverse outcomes - these factors should not be confined to volume, but rather should also include age, sex, insurance, Charlson comorbidity score and social deprivation index. 

Such an analysis may reveal that low and high volume surgeons had relatively more comparable outcomes for patients that were comparable. Stated simply, it doesn't seem reasonable to compare the outcomes achieved by low-volume surgeons for patients with important risk factors to the outcomes achieved by high-volume surgeons on patients without these risk factors.

To add this blog to your reading list in Google Chrome, click on the reading list icon

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

How does surgeon experience relate to revision rate for shoulder arthroplasty?

Lower operating volume in shoulder arthroplasty is associated with increased revision rates in the early postoperative period: long-term analysis rom the Australian Orthopaedic Association National Joint Replacement Registry

These authors used the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) to assess the relationship between revision rates for shoulder arthroplasty and the annual volume of arthroplasties performed by the surgeon. They used 3 surgeon volume thresholds: <10, 10-20, and >20 shoulder arthroplasty cases per surgeon, per year.

They noted that 78.2% of the surgeons perform fewer than 10 arthroplasties per year.

As shown in the graphs below, the revision rates were higher for reverse total shoulders than for stemmed anatomic total shoulders.

Stemmed total shoulder. For the 1.5 years after stemmed total shoulder arthroplasty (TSA) for osteoarthritis (OA), there was a significantly higher rate of revision for the <10/yr group compared with the >20/yr group (hazard ratio 1.36). There were differences among the three most commonly used implants. The reasons for the paradoxical increase in the SMR complications with surgeon volume is not explained in the paper.

For the <10/yr group, instability/dislocation was the most common revision diagnosis (28.0%), with rotator cuff insufficiency being the second most common diagnosis (18.7%), followed by loosening (14.5%).

For the 10-20/yr group, rotator cuff insufficiency was the most common reason for revision 10-20/yr (27.0%). Instability/dislocation and loosening were 25.9% and 12.4% of the revision diagnoses for the 10-20/yr group.

For the >20/yr group, rotator cuff insufficiency was the most common reason for revision (22.3%). Instability/dislocation and loosening were 17.9% and 18.6% of revision diagnoses for the >20/yr group, respectively. 

There was a significantly higher risk of revision for instability/dislocation for the <10/yr and 10-20/yr groups compared with the >20/yr group. However, for the next 2 most common revision diagnoses rotator cuff insufficiency and loosening there was no difference in the rates of revision between any of the surgeon volume groups.

Reverse total shoulder.  For the first 3 months after reverse total shoulder arthroplasty (rTSA) for OA, there was a higher revision rate for the <10/yr compared with the >20/yr group for the first 3 months (HR 2.58). There were differences among the three most commonly used implants.

For the <10/yr group,  rTSA for cuff arthropathy had a significantly higher rate of revision for the <10/yr compared with the >20/yr group throughout the follow-up period (HR 1.66). The revision rate for instability/dislocation after rTSA for OA was significantly higher when undertaken by surgeons performing <10/yr compared with the 10-20/yr (HR 1.94) and >20/yr groups (HR 1.87)/ The <10/yr group also had a significantly higher rate of revision for fracture following rTSA for OA compared with the 10-20/yr group (HR 2.43)

Comment: There can be no question but that experience is the great teacher. With increasing case volumes surgeons not only become more technically adept, but also become better at patient selection and in recognizing and managing the more complex types of pathology. In addition, higher volume surgeons are more likely to have more experienced support staff, including nurses, therapists, surgical assistants, other members of the care team. However, the value of experience must in some cases be balanced against proximity: "how far should a patient have to travel to have how much better chance of a good outcome?". 

We are hopeful, that educational materials, such as those below, can help all surgeons achieve the best outcomes.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link.

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

How you can support research in shoulder surgery Click on this link.

Reverse total shoulders - how many cases does it take for a surgeon to get good at them?

A Complication-based Learning Curve From 200 Reverse Shoulder Arthroplasties

These authors note that early complication rates in reverse total shoulder arthroplasty have widely reported from 0% to 75%. Here is a distribution of some of these complications from the FDA database (left) and the Australian Orthopaedic Association database  (right).

The chart below shows some of the reported complication rates.

In the practice of an individual surgeon, these authors sought to (1) determine the types and rates of early complications in reverse total shoulder arthroplasty, (2) characterize an early complication-based learning curve for reverse total shoulder arthroplasty, and (3) determine whether revision arthroplasties result in a higher incidence of complications. 200 reverse total shoulder arthroplasties in 191 patients were included of which 40 were revision arthroplasties. 192 shoulders were available for minimum 6-month followup.

Nineteen shoulders involved local complications (9.9%), including seven major and 12 minor complications.

Nine involved perioperative systemic complications (4.7%), including eight major complications and one minor complication.

 

The local complication rate was higher in the first 40 shoulders (23.1%) versus the last 160 shoulders

(6.5%). 

Seven of 40 (17.5%) revision arthroplasties involved local complications, including two major and five minor complications compared to 12 of 152 (7.9%) primary arthroplasties, including five major and seven minor complications. Nerve palsies occurred less frequently in primary arthroplasties (0.6%) compared to revisions (9.8%).

The graph below shows the progressively lower complication rate with increasing surgeon experience. 

Comment: This is a remarkably candid and telling view of an accomplished, high volume shoulder surgeon's progressive mastery of the reverse total shoulder. It is important to recognize that each surgeon must navigate a similar learning curve. Experience is the great teacher.

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Total shoulder arthroplasty - availability of experienced surgeons

Trends and Variability in the Use of Total Shoulder Arthroplasty for Medicare Patients

These authors assessed the current application of total shoulder arthroplasty (TSA) and explored the geographic distribution of shoulder and medical center experience.

They used Medicare data from 2012 through 2014 to identify the case volume, locations, and names of surgeons performing >10 TSAs annually as well as the regional characteristics of the Medicare population

The number of surgeons performing >10 TSAs annually increased from 824 to 1,060—an increase ranging from 0.75 to 0.95 TSAs per 1,000 beneficiaries. 

In 2012, there were 59 hospital referral regions with no TSAs performed; this number decreased to 35 by 2014. 

The use of TSA varied widely across regions (range, 0.1 to 6.4 per 1,000 beneficiaries). A larger proportion of white patients and a smaller proportion of patients eligible for Medicaid were independent predictors for increased use of TSA. 

74.4% and 96.9% of the US population resided within 50 km and 200 km, respectively, of a surgeon performing at least 20 TSAs in Medicare patients annually.

Comment: This interesting paper prompts the reader to ask,  "how many TSAs/year are needed to assure surgeon and medical center expertise" and "how does a patient manage the tradeoff between accessing expertise on one hand and the cost and inconvenience of this access on the other?"

Here are some previously posted thoughts on the matter and another recent article

Distribution of High-Volume Shoulder Arthroplasty Surgeons in the United States: Data from the 2014 Medicare Provider Utilization and Payment Data Release.

These authors point out that high-volume TSA surgeons are reported to have superior outcomes. They studied patient access to these surgeons using 2012 Medicare Provider Utilization and Payment Data Public Use File (MPUPD-PUF). This data base provided volume and reimbursement data for procedures performed by individual physicians participating in Medicare. They studied surgeon prevalence, surgeon distribution, and factors associated with higher or lower surgeon prevalence in metropolitan areas. Data were extracted for all physicians who performed a minimum of 11 TSA procedures for Medicare beneficiaries

The MPUPD-PUF included 774 surgeons across the United States who performed an annual minimum of 11 TSA procedures covered by Medicare, with a combined total of 19,505 TSA procedures. The median annual number of Medicare service claims for TSA was 19 (range, 11 to 163), and the mean was 25 (SE, 0.7).

Of these surgeons, 45% practiced within major metropolitan areas with a population of >1 million. Surgeons who had completed an ASES fellowship had a higher volume of procedural claims (median, 26; range, 11 to 120) compared with other surgeons (median, 17; range, 11 to 163; p < 0.001). 

The distribution among major metropolitan areas was highly unequal, and more surgeons were present in cities with an ASES fellowship program.

Comment:  This study points to the challenges that patients in certain geographical areas have in accessing surgeons who perform at least 11 shoulder arthroplasties per year.

An interesting question arises from the use of an annual case volume of ≥11 as the definition of a 'high volume' surgeon. Historically, 'high volume' has been defined arbitrarily:

Surgeon Experience and Clinical and Economic Outcomes for Shoulder Arthroplasty categorized surgeons according to the total number of procedures performed within the total 6 year ( 1994 to 2000) study period  with one to five procedures considered low volume; six to thirty procedures, medium volume; and more than thirty procedures, high volume.

The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty defined a 'high volume' surgeon as one who performed 5 or more cases per year.

This study defines 'high volume' as ≥ 11 cases per year. The number is creeping up.

Last month this article was published:

Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty

These authors used a database of 289,976 patients undergoing primary total knee arthroplasty from an administrative database, they applied stratum-specific likelihood ratio (SSLR) analysis of a receiver operating characteristic (ROC) curve to generate sets of volume thresholds most predictive of adverse outcomes. The outcomes considered for surgeon volume included 90-day complication and 2-year revision.

They identified four volume categories: 0 to 12, 13 to 59, 60 to 145, and ≥146 total knee arthroplasties per year. 

Complication rates decreased significantly (p < 0.05) in progressively higher-volume categories without a 'bottom' in sight:

Revision rates followed a similar pattern.  This study supports the use of SSLR analysis of ROC curves for risk-based volume stratification in total knee arthroplasty volume-outcomes research. SSLR analysis established meaningful volume definitions for low, medium, high, and very high-volume total knee arthroplasty surgeons.

The question then arises, 'if a high volume knee arthroplasty surgeon is defined as one performing ≥65 cases per year, shouldn't the same threshold apply to shoulder arthroplasty surgeons?' Is there any reason to believe that the annual number of cases of shoulder arthroplasty necessary to achieve and maintain excellence should be lower than that for knee arthroplasty? Is a shoulder arthroplasty easier to learn and master than a total knee?

It is apparent that the higher the standard for 'high volume', the greater the challenge of finding a high volume surgeon.  

Never the less, there is no denying the benefits of volume. More practice

increases the chances of a good result

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