As shoulder replacement surgery rapidly expands across the U.S., a growing body of research is raising a difficult question for orthopedic care: How much does surgeon experience actually matter?
According to an analysis of more than 330,000 patients, the answer may be more significant than many health systems, and patients,realize.
The study, published in the June 2026 issue of the Journal of Shoulder and Elbow Arthroplasty, found that surgeons performing fewer than five shoulder replacements annually had substantially higher rates of complications and revision surgery compared to surgeons performing more than 28 procedures a year.
For Hafiz Kassam, MD, senior author of the study and director of shoulder reconstruction at Irvine, Calif-based Hoag Orthopedic Institute, the findings reinforce a broader shift already unfolding inside orthopedics.
“Shoulder arthroplasty is no longer a generalist procedure,” Dr. Kassam said. “It’s become a highly specialized operation, and volume and experience clearly matter when it comes to outcomes.”
The analysis pooled data from eight separate studies encompassing 332,542 patients to establish clearer volume thresholds for shoulder arthroplasty outcomes, an area where previous research often produced conflicting benchmarks.
“We wanted to define what low volume and high volume actually meant based on all the data that exists,” Dr. Kassam said. What emerged, he said, was a more concrete benchmark for what patients and health systems should consider experienced care.
The threshold reshaping shoulder surgery
The idea that higher surgical volume improves outcomes is not new in medicine. But in shoulder replacement surgery, previous studies produced inconsistent benchmarks, with some suggesting thresholds as low as 10 procedures annually while others proposed much higher numbers.
Dr. Kassam said the goal of the new study was to aggregate all available evidence into a single, more definitive analysis.
The findings ultimately identified three broad tiers of surgical volume. Surgeons performing fewer than five shoulder replacements annually had significantly higher complication and revision rates, while outcomes improved meaningfully once surgeons exceeded 28 procedures a year. “There is a floor,” Dr. Kassam said. “There is a difference with volume, and this kind of sets that floor.”
The findings arrive as shoulder arthroplasty becomes one of the fastest-growing orthopedic procedures in the country, fueled by an aging population, increasing rates of osteoarthritis and rising demand from younger, more active patients. Projections suggest more than 250,000 shoulder replacements could be performed annually in the U.S. by the end of 2026. Yet according to prior data cited by Dr. Kassam, roughly half of all shoulder replacements nationally are still performed by surgeons doing fewer than 20 cases per year.
Why shoulder surgery became its own specialty
According to Dr. Kassam, one of the biggest shifts in shoulder arthroplasty over the past two decades has been the rise of dedicated shoulder and elbow specialization itself.
Historically, shoulder replacement procedures were often performed by general orthopedic surgeons, sports medicine specialists or hand surgeons as part of broader practices. “That’s probably been the biggest change, dedicated training,” he said.
Today, shoulder and elbow fellowships, subspecialty societies and advanced reconstruction programs have increasingly separated shoulder arthroplasty from general orthopedic practice. “This is really trying to define shoulder arthroplasty as not a generalist procedure,” Dr. Kassam said. “This is a specialist procedure.”
At Hoag Orthopedic Institute, where surgeons collectively performed more than 670 shoulder replacements last year, that specialization has been paired with investments in research, fellowship training and advanced surgical technologies.
“We’ve leaned into specialization,” Dr. Kassam said. “Not just high-volume surgery, but a high-volume, cutting-edge academic shoulder program.” He believes that combination of surgical repetition, subspecialty training and academic infrastructure increasingly shapes modern orthopedic outcomes.
Can robotics close the experience gap?
As robotics and mixed reality technologies enter shoulder surgery, one major unanswered question is whether technology can compensate for lower surgical volume.
Dr. Kassam believes that remains unclear. “Experience still seems to be the most important driving factor for outcomes,” he said. Still, he said robotics, AI-assisted planning and mixed reality platforms may eventually help standardize portions of the procedure.
“There’s a thought that maybe technology can help shorten that gap,” he said. “Maybe surgeons doing lower volumes can achieve better outcomes because technology helps bridge the experience gap.”
But the reverse may also prove true. “Maybe surgeons who already have more experience use technology and become even better,” he said. “We really don’t know yet.”
Dr. Kassam, who performed one of California’s first robotic-assisted shoulder replacements, said the field is only beginning to understand how enabling technologies may reshape outcomes over the next decade.
In the short term, he sees robotics and mixed reality improving implant positioning and surgical precision. Longer term, he believes AI may increasingly help surgeons predict which patients are most likely to benefit from surgery, or face complications. “The next step is using AI for risk stratification,” he said. “Which patients are going to do better? Which are going to do worse? How do we mitigate that risk before surgery?”
Eventually, he believes those technologies may merge into a broader “continuum of care” model integrating predictive analytics, intraoperative guidance and postoperative monitoring into a single system.
“That’s probably the next decade,” he said.
The debate facing health systems
For patients, Dr. Kassam said the study offers a clearer framework for evaluating surgeons. “Patients ask all the time, ‘How many of these have you done?’” he said. “Now at least there’s a benchmark for what a minimum should look like.”
But for hospitals and health systems, the implications are more complicated. If complication rates meaningfully improve above certain volume thresholds, should low-volume surgeons continue performing those procedures?
“That becomes a credentialing question,” Dr. Kassam said.
Health systems already restrict certain highly specialized procedures based on experience requirements. Dr. Kassam believes shoulder arthroplasty may increasingly move into that category as well. Still, he acknowledged the findings may be uncomfortable for some surgeons.
“I knew the study had the potential to be controversial and rustle some feathers,” he said. He emphasized the research was not intended to disparage lower-volume orthopedic surgeons, but rather to encourage reflection about how procedural volume affects patient outcomes.
“It really wasn’t meant to be disparaging for generalists, or maybe even disqualifying for people who do less. It was really meant to be a mirror to people’s practices.”
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