Patient Outcomes as a Function of Shoulder Surgeon Volume: A Systematic Review

Purpose To examine surgical complications, length of stay, surgical time, cost, revision rates, clinical outcomes, current surgical trends. and minimum number of cases in relationship to surgeon volume for shoulder arthroplasty and rotator cuff repair. Methods We performed a systematic review of studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that met inclusion criteria from January 1990 to January 2016 were included. Inclusion criteria included Level IV evidence or greater, contained specific surgeon volume, and were written in or translated into English. Exclusion criteria included non-English manuscripts, abstracts, and review papers. A written protocol was used to extract relevant data and evaluate study results. Data extracted included volume-specific data pertaining to length of stay, operating time, complications, and cost. Results A total of 10 studies were included. Seven studies evaluated arthroplasty with 88,740 shoulders, and 3 studies evaluated rotator cuff repair with 63,535 shoulders. Variation was seen in how studies defined low- versus high-volume surgeon. For arthroplasty, <5 cases per year met the criteria for a low-volume surgeon and were associated with increased length of stay, longer operating room time, increased in-hospital complications, and increased cost. Mortality was not significantly increased. In rotator cuff surgery, <12 surgeries per year met the criteria for low volume and were associated with increased length of stay, increased operating room time, and increase in reoperation rate. Conclusions Our systematic review demonstrates increased surgical complications, length of stay, surgical time, and surgical cost in shoulder arthroplasty and rotator cuff repair when performed by a low-volume shoulder surgeon, which is defined by those performing <5 arthroplasties and/or <12 rotator cuff repairs per year. Level of Evidence Level III, systematic review of Level II and III studies.