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A letter to ASES membership on the development of a formal certification pathway
Dear Colleagues,
Our field is changing rapidly. The complexity of shoulder and elbow pathology, surgical techniques, and postoperative care has grown substantially — and with that growth comes a responsibility to ensure patients are cared for by surgeons with the right depth of training. I believe we have a meaningful opportunity to make that expertise more visible and more valued.
The Growth of Shoulder and Elbow Surgery
The numbers tell a striking story. Shoulder and elbow surgery has expanded dramatically over the past two decades — and the trajectory is only steepening.
~104% increase in primary shoulder arthroplasties between 2011 and 2017, with more than 823,000 Americans now living with a shoulder replacement. (Wagner et al., J Shoulder Elbow Surg, 2020; JBJS Open Access, 2021)
~800% growth in primary TSA procedures between 2000 and 2019, with projections suggesting annual volume could exceed 10 million procedures under Medicare alone by 2060. (JSES International, 2024)
Reverse TSA volume nearly tripled between 2012 and 2017, rising from 22,835 to 62,705 procedures annually.
Best et al., J Shoulder Elbow Surg, 2021; Wagner et al., J Shoulder Elbow Surg, 2020
Projections suggest this growth will accelerate further. By 2060, annual primary TSA volume under Medicare alone could exceed 10 million procedures — more than an 8,000% increase from 2019 levels.
JSES International, 2024
Shoulder and elbow surgery is not a niche subspecialty — it is a high-volume, rapidly expanding domain of orthopedic care with real and growing public health implications.
The Evidence: Expertise Matters
The data confirm what most of us already know from practice: volume and expertise matter. Surgeons who perform higher volumes of shoulder and elbow procedures consistently achieve better outcomes with fewer complications — and the evidence is substantial.
Significantly lower overall complication rates were observed for high-volume vs. low-volume TSA surgeons in a nationwide study of 155,560 patients, with high-volume surgeons significantly more likely to have completed a Shoulder & Elbow fellowship (p < .001). (Harkin et al., J Shoulder Elbow Surg, 2025)
Fewer than 5 arthroplasties per year defines a low-volume surgeon threshold associated with significantly increased complications, longer length of stay, and higher cost. (Systematic review, J Shoulder Elbow Surg, 2017)
The same pattern holds for elbow arthroplasty. A systematic review found that surgeons performing more than 10 procedures annually and centers performing more than 20 have consistently lower revision and complication rates.
Prkić et al., EFORT Open Reviews, 2023
High-volume centers consistently show the lowest 90-day complication, revision, and non-home discharge rates — a reflection of surgeon experience, team coordination, and institutional familiarity with these complex procedures.
Eichinger et al., J Shoulder Elbow Surg, 2021
For rotator cuff surgery, a systematic review similarly found that surgeons performing fewer than 12 repairs per year had increased rates of reoperation, longer operative times, and extended lengths of stay compared to higher-volume peers.
Systematic review, J Shoulder Elbow Surg, 2017
The Evolution of Fellowship Training
Shoulder and elbow fellowship training has evolved substantially over the past few decades. Today’s programs offer focused, rigorous education across advanced surgical techniques, complex reconstruction, arthroscopy, fracture management, and revision surgery — preparing fellows to handle the full breadth of modern shoulder and elbow pathology.
Fellowship pursuit has grown alongside the specialty: between 2003 and 2013, the proportion of orthopedic graduates seeking fellowship training rose from 76% to 90%, with ASES-recognized shoulder and elbow programs expanding in number, scope, and case volume.
Arthroscopy, Sports Medicine, and Rehabilitation, 2023
Yet despite this progress, that specialized training is often invisible to the broader healthcare environment. Patients, hospitals, administrators, and referring providers frequently lack a clear way to identify surgeons with dedicated shoulder and elbow expertise.
A Certification Pathway for Shoulder and Elbow Surgery
From the outset, we were committed to making this an inclusive, membership-driven process. To that end, we established a dedicated task force — chaired by Grant Garrigues and including Ronald Navarro, Rob Gillespie, Brad Bushnell, and Michael Hachadorian, a recent fellowship graduate who brought a valuable early-career perspective. They have approached this work with tremendous thoughtfulness and dedication, and I am grateful for their efforts.
We also wanted to hear directly from you. ASES surveyed its membership on whether to pursue a certification process, who it should include, and what it should look like — and the response was unambiguous: 83.15% of respondents strongly supported the development of a broad-based shoulder and elbow certification process. That mandate gave us the confidence to move forward.
We are now developing a structured certification pathway to formally recognize specialization in shoulder and elbow surgery — one that reflects the highest standards of our field while remaining practical and accessible.
Guiding Principles
Four principles are guiding our work:
- Inclusive and Merit-Based Process – The pathway should recognize surgeons who have demonstrated meaningful commitment, training, and experience in shoulder and elbow surgery.
- Clear Value to the Certification Holder – Certification should serve as a recognizable indicator of expertise for patients, healthcare systems, and professional colleagues.
- Manageable and Not Burdensome – The process should be thoughtful and rigorous without imposing unnecessary administrative or logistical barriers.
- Objective Parameters – Credentialing criteria should rely on measurable standards such as training, case volume, professional engagement, and commitment to ongoing education.
After thorough discussion of these principles, the ASES task force reached consensus and received formal Board approval to move forward. We are now in the process of hiring an experienced certification consultant — someone with deep expertise in designing and implementing specialty credentialing programs. That search is complete and we have now started the process of organizing a process that adheres to the principles that we established at the onset of this initiative. We will keep you updated as this process moves along but are very excited about the progress and momentum we have established.
Practical Considerations in a Changing Healthcare Landscape
Beyond recognizing expertise, there are real practical stakes here. Healthcare systems, insurers, and government agencies are placing increasing weight on demonstrable qualifications when shaping provider networks, reimbursement structures, and care delivery models.
As healthcare moves toward value-based care and credential-driven differentiation, formally documented subspecialty expertise can help ensure that shoulder and elbow specialists are appropriately included in provider networks and fairly reimbursed for the complexity of the care they deliver.
Institutions are also increasingly factoring subspecialty training and procedural complexity into compensation and advancement. Surgeons with shoulder and elbow fellowship training are routinely expected to manage the most complex cases and serve as referral resources — and it matters that this level of expertise is clearly recognized.
A Call to Action for Our Community
I want to be clear: this effort is not about exclusion. It is about recognition — giving formal visibility to the expertise that so many of you have built through years of focused training and practice.
As orthopedics moves toward greater subspecialization, the ability to clearly articulate the value of that training becomes increasingly important — for our patients, our institutions, and the future of this field.
By formally recognizing specialization, we strengthen shoulder and elbow surgery as a distinct and highly skilled discipline within orthopedics — and reaffirm our collective commitment to delivering the highest level of care to every patient who trusts us.
In the months ahead, I will be sharing more details, and I genuinely welcome your input. This work belongs to all of us, and your engagement will make it stronger.
With gratitude for your dedication to this specialty and to our patients,
Anthony Miniaci, MD, FRCSC
President, American Shoulder and Elbow Surgeons
Selected References
Harkin W, et al. The effect of surgeon volume on complications after total shoulder arthroplasty: a nationwide assessment. J Shoulder Elbow Surg. 2025 Apr;34(4):1112-1119.
Prkić A, et al. Is there a relationship between surgical volume and outcome for total elbow arthroplasty? A systematic review. EFORT Open Reviews. 2023;8(1):45-51.
Eichinger JK, et al. Assessing the hospital volume-outcome relationship in total elbow arthroplasty. J Shoulder Elbow Surg. 2021;30(9):2127-2133.
Wagner ER, et al. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. J Shoulder Elbow Surg. 2020;29(12):2601-2609.
Best MJ, et al. Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2021;30(5):1159-1166.
Day JS, et al. Prevalence of shoulder arthroplasty in the United States and the increasing burden of revision shoulder arthroplasty. JBJS Open Access. 2021.
Singh R, et al. Projections of utilization of primary and revision shoulder arthroplasty in the United States in the next 40 years. JSES International. 2024.
Petrigliano FA, et al. The relationship between surgeon volume and major surgical complications after total shoulder arthroplasty: an evaluation of 3177 US orthopedic surgeons. Orthopedics. 2025;48(1):e15-e21.
Mulcahey MK, et al. Pursuing subspecialty fellowship training following orthopaedic surgery residency. Arthroscopy, Sports Medicine, and Rehabilitation. 2023.
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