CORR Insights®: Higher Surgeon Volume is Associated With a Lower Rate of Subsequent Revision Procedures After Total Shoulder Arthroplasty: A National Analysis

Where Are We Now?

The study by Best et al. [1] in this month’s Clinical Orthopaedics and Related Research® adds support to the growing body of evidence demonstrating that the outcomes of orthopaedic surgical procedures depend, in part, on the annual volume of the specific procedure performed by the surgeon. It has been well documented and is now widely recognized that higher surgical volume correlates with fewer complications, lower costs, and less-frequent revisions after hip and knee arthroplasty [2-5]. Best et al. [1] provide convincing data that the rate of revision surgery for anatomic and reverse TSA depends partly on the volume of these procedures performed by each surgeon. The inflection point appears to be at least 10 procedures per year for anatomic TSA and at least 29 procedures per year for reverse TSA. The decreased odds of revisions for both procedures are based on a comparison with surgeons who performed fewer than four per year. The authors [1] did not find an association between the hospital volume and odds of a revision procedure.

The conclusions of this study were based on an analysis of Medicare fee-for-service patients who represent a subset of patients undergoing shoulder arthroplasty. Although the study did not include shoulder arthroplasties performed on patients insured by Medicare Advantage programs, Medicaid, commercial insurances, no fault, or workers compensation, in my opinion, it is very reasonable to extend their findings to all patients undergoing shoulder arthroplasty and to those surgeons performing this procedure. The information that is unknown is how many additional shoulder arthroplasty procedures were performed by the surgeons included in this study, which could impact the volume parameters that were determined. Even in the absence of these data, the information reported is important, meaningful, and worthy of further consideration, particularly because of the rapid increase in the use of these operations and the expanding indications for reverse TSA [6]. In the United States, projections suggest that more than 150,000 shoulder arthroplasty procedures will be performed this year, and most of those will be reverse TSAs. Although this is far lower than the volume of hip and knee replacements, the rate of increase in shoulder arthroplasty is much greater than it is for these procedures [6]. This is a rapidly expanding area of orthopaedic surgery, and the goal should be to use the data to improve patient outcomes. Best et al. [1] are sending a clear message to our specialty that TSA needs to move into the mainstream of orthopaedic practice and training so it is performed with the same expertise and anticipated outcomes as primary hip and knee arthroplasty. Although Best et al. [1] reported a threshold of 10 procedures for anatomic TSA and 29 for reverse TSA, the goal must be to drive those numbers down, and the way to achieve that goal is through training, education, and experience.

Where Do We Need To Go?

One possible next step based on this study could be to divert shoulder arthroplasties to a smaller number of surgeons whose volumes are high enough to achieve the kinds of reductions in complications observed in this study [1]. The authors suggest that the volume-revision relationship shown may support “programs such as employer healthcare plans that partner with high-volume centers of excellence.” However, this is not practical, nor is it a long-term plan. It has the potential to disadvantage patients depending on the distance from the “high-volume center.” In addition, if a complication occurs, distance from the operating surgeon can interfere with proper care and potentially negate the anticipated benefits. This approach has been tried by employers and payors, but its use has been limited primarily for the reasons cited. Best et al. [1] also suggest that new technology may be beneficial to less-experienced surgeons but also recognize this is speculative. The reality is that most shoulder arthroplasties in the United States are performed by individuals who perform fewer than 10 per year. The goal should be to improve the training of orthopaedic surgeons in practice and those in training so they are better prepared to address the rapidly increasing volume of patients who are expected to undergo these procedures.

How Do We Get There?

Educating orthopaedic surgeons in practice and in training will be the key to making anatomic TSA and reverse TSA safer and more effective for our patients. This requires providing ample opportunities for orthopaedic surgeons to obtain additional training and experience in performing the procedure and the willingness of orthopaedic surgeons to use these resources in practice. Orthopaedic surgeons who perform these procedures must consider it a professional obligation to seek the necessary training and education needed to perform these procedures safely and well. There is no shortage of educational opportunities either through continuing medical education or industry-sponsored meetings to instruct orthopaedic surgeons in the finer points of surgical techniques. Cadaver-based learning opportunities as well as visits with experienced shoulder arthroplasty surgeons are effective approaches to closing the knowledge gap.

However, it’s essential we ensure that residency programs provide opportunities for all surgical learners to become proficient in these procedures. There was a time when primary and revision hip and knee arthroplasty were not as commonly performed during residency, and residents relied on fellowship programs to gain sufficient experience to perform these procedures. However, the increasing volume of hip and knee arthroplasties has made it part of “general” orthopaedic surgery. All residents on completion of residency training should be well-prepared to perform most hip and knee arthroplasties. We should have the same goal for shoulder arthroplasty. As the volumes increase and more faculty members become experienced in these procedures, we should be able to graduate orthopaedic residents who are equally well-trained. This will occur over time, and the results should be the same as for hip and knee arthroplasties.

The relationship between the volume of shoulder arthroplasty performed and the outcomes of the procedure (including revisions) requires continued study to enhance our understanding of the factors involved. Because this study [1] included only Medicare fee-for-service patients, expanding the study to all patients undergoing arthroplasty will be important to confirm the findings of this study.

As orthopaedic surgeons who strive to provide the best possible care for our patients, achieving successful outcomes in our patients undergoing shoulder arthroplasty is our responsibility, and obtaining the necessary education and experience is an essential component of our professionalism.