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.
