High-volume surgeons may yield superior outcomes for TSA vs. low-volume surgeons
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Key takeaways:
- High-volume surgeons may yield fewer complications after shoulder arthroplasty vs. low-volume surgeons.
- Researchers noted the proportion of cases performed by high-volume surgeons has decreased since 2016.
Published results showed total shoulder arthroplasty performed by a high-volume surgeon may decrease medical and surgical complications compared with those performed by low-volume surgeons.
William Harkin, MD, an orthopedic surgery resident at Rush University Medical Center, and colleagues used the PearlDiver Mariner database to perform a retrospective cohort comparison of data for 155,560 patients who underwent TSA between 2010 and 2022.
Harkin and colleagues assessed outcomes for patients who underwent TSA with high-volume surgeons, defined as surgeons who had performed 112 cases or more, vs. low-volume surgeons, defined as surgeons who had performed between 10 and 112 cases. Overall, 358 high-volume surgeons performed a total of 68,531 TSAs, while 3,163 low-volume surgeons performed a total of 87,029 TSAs.
Harkin and colleagues found high-volume surgeons were significantly more likely to operate on patients with a lower Charlson Comorbidity Index (CCI) compared with low-volume surgeons (CCI = 1.85 vs. 2.01, respectively). According to the study, low-volume surgeons were more likely to operate on patients with hypertension, pulmonary disease, chronic kidney disease, diabetes, obesity, depression, hypothyroidism, vascular disease and anemia.
After adjusting for variables, such as age, CCI and tobacco use, Harkin and colleagues found high-volume surgeons were associated with significantly fewer patient readmissions at 90 days (OR = 0.90), reoperations at 90 days (OR = 0.75) and reoperations at 1 year (OR = 0.86) compared with low-volume surgeons.
Harkin and colleagues also found high-volume surgeons were associated with significantly decreased rates of all complications, prosthetic joint infections and periprosthetic fractures compared with low-volume surgeons. However, they noted the proportion of TSAs performed by high-volume surgeons has decreased since 2016.
Harkin and colleagues hypothesized that the increased complication rates associated with low-volume surgeons “could be explained by more stringent contraindications amongst higher-volume surgeons,” they wrote in the study.
“Alternatively, it is possible that patients with more comorbidities were not deemed healthy enough to undergo surgery at the outpatient facilities higher-volume surgeons have moved toward operating in,” Harkin and colleagues concluded.
Perspective
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The manuscript by William Harkin, MD, and colleagues compellingly validates the claim that higher-volume surgeons demonstrate improved outcomes and decreased perioperative and postoperative complications compared with lower-volume surgeons. The challenge that currently exists is what truly defines a lower-volume surgeon. Surgeon inclusion required greater than 10 shoulder arthroplasties annually, with high-volume surgeons yielding more than 112 arthroplasties per year. The clinically relevant volume to provide safe and cost-effective shoulder arthroplasty remains undetermined.
In addition, the data would suggest lower-volume surgeons should amplify their emphasis on preoperative surgical optimization targets in patients with greater comorbidities. Multiple studies in the hip and knee literature have demonstrated that a multidisciplinary collaborative approach to modifiable risk factors can significantly lower postoperative complications, length of stay, improve quality of care and permit expanded ambulatory opportunities. These principles should be a straightforward extrapolation into the world of shoulder arthroplasty.
Furthermore, as the prevalence of shoulder arthroplasty intensifies, it is incumbent on all of us to collaborate and define specific education and practice parameters that will enhance the patient experience. The ultimate analysis would define the tipping point where baseline surgical volumes and training significantly mitigate postoperative complications while optimizing patient outcomes.
References:
Bersten DN, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.08.018.
Dietz MJ, et al. J Arthroplasty. 2024;doi:10.1016/j.arth.2024.01.013.
Dlott CC, et al. J Arthroplasty. 2020;doi:10.1016/j.arth.2020.01.083.
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