Geographic Distribution of Shoulder Arthroplasty in the United States: A Rural-Urban Analysis

Shoulder arthroplasty is among the fastest-growing procedures in orthopaedic surgery. The purpose of this study was to characterize national trends in the geographic distribution of surgeons performing shoulder arthroplasty across rural-urban commuting area (RUCA) settlement types and to evaluate how surgeon distribution relates to procedural volume and procedures per surgeon. We hypothesized that the urban proportion of surgeons would decline over time.

The Medicare Provider Utilization and Payment Data: Physician and Other Practitioners dataset was queried to identify orthopaedic surgeons performing shoulder arthroplasty from 2013 to 2024 using Healthcare Common Procedure Coding System codes (23470, 23472, 23473, 23474). Surgeons were counted as unique National Provider Identifiers and non-physician providers were excluded. RUCA classifications supplied within the dataset were categorized as urban/metropolitan, large town, small town, or rural. Temporal trends in surgeon distribution were assessed using Kendall's tau rank correlation. Trends in procedures per surgeon were evaluated using Mann-Kendall testing with Sen's slope estimation. P values were corrected for multiple comparisons using the Benjamini-Hochberg procedure, with significance defined as q < 0.05.

A total of 533,569 shoulder arthroplasty procedures were performed during the study period, increasing from 23,758 in 2013 to 76,013 in 2024, a 3.2-fold increase, while the number of surgeons increased from 974 to 2,649. Surgeons were predominantly located in urban regions (88.9%), followed by large town (9.4%), small town (1.4%), and rural areas (0.3%). Procedural growth was driven primarily by urban and large town regions, while rural volume did not increase significantly (CC = 0.412, q = 0.071). The urban proportion of surgeons declined from 91.0% to 89.0% (CC = -0.758, q < 0.001) while small town and large town proportions increased; the rural proportion did not change (CC = -0.030, q = 0.947). Median procedures per surgeon were highest in rural areas throughout, with no significant decline in any settlement type. Revision shoulder arthroplasty was performed almost exclusively in urban centers, with no cases in rural or small town regions.

Despite substantial growth in shoulder arthroplasty utilization, surgeons remain highly concentrated in urban regions. Growth extended into large and small towns while the rural proportion of the workforce did not change. Revision shoulder arthroplasty was performed almost exclusively by urban surgeons, although the reporting threshold applied to this dataset limits what can be concluded from revision counts. Growth in shoulder arthroplasty has therefore reached less urbanized communities but not rural ones.

Level IV, Descriptive Epidemiology Study.