Should We Be Concerned About Who Is Performing Hip Arthroscopy?: Commentary on an article by Kyle R. Duchman, MD, et al.: "Who Is Performing Hip Arthroscopy? An Analysis of the American Board of Orthopaedic Surgery Part-II Database".

Abstract

Commentary The utilization of hip arthroscopy surgery has increased by 365% in the United States in recent years, with the majority of cases performed in patients 20 to 39 years of age1. The increased rate can most likely be attributed to increased awareness of the procedure, diagnostic improvements, technical advances that make hip arthroscopy easier to perform, a broadening of indications to treat conditions that were previously treated with open procedures (e.g., femoroacetabular impingement [FAI]), and an increase in the number of fellowship programs offering hip arthroscopy training1,2. Duchman et al. used the American Board of Orthopaedic Surgery (ABOS) Part-II database to design their study, with the primary aim of providing an update on hip arthroscopy utilization by ABOS Part-II candidates and the secondary aim of describing the fellowship training experiences of candidates performing hip arthroscopy. This study is an extension of work done by Colvin et al., who had used the same database2. The study by Duchman et al. demonstrated that utilization of hip arthroscopy by ABOS Part-II candidates has continued to rise at a significant rate: from 5.3% in 2006 to 10.3% in 2015. This increase was attributed to more candidates performing hip arthroscopy and less so to an increasing number of hip arthroscopy procedures being performed by individual candidates. Duchman et al. found that the procedure was most common among candidates who had received any sports medicine training, as they accounted for 74.5% of all candidates who performed the procedure. High-volume hip arthroscopists (candidates who performed ≥20 procedures) accounted for 6.5% of all candidates who performed hip arthroscopy, and the most common fellowship training among these high-volume candidates was also sports medicine. This information is important to educators as a call to create a hip-preservation curriculum for sports medicine trainees that is commensurate with improved clinical and radiographic outcomes. Careful patient selection with definition of proper indications is important to avoid the overuse of hip arthroscopy. A candidate’s training period is the most important time for learning such information. Gupta et al.3 and Harris et al.4 reviewed complications that can arise from hip arthroscopy, including neurapraxia, heterotopic ossification, iatrogenic cartilage scuffing, labral penetration, abdominal fluid extravasation, instrument breakage, and reoperations (revision hip arthroscopy for residual FAI or conversion to total hip arthroplasty). The rates of major and minor complications were 0.58% and 4.1%, respectively, and the reoperation rate was 6.3%. The learning curve for hip arthroscopy was directly related to the rates of reoperations and minor complications. The authors concluded that technique-related complications can be minimized by surgeon experience3,4. Avoiding these complications is important to enable patients to return to their normal life and sports activities. Defining the learning curve for hip arthroscopy is especially important as we know from the article by Duchman et al. that more and more sports-medicine-trained candidates are performing the procedure. Colvin et al. found that fellows are exposed to <20 hip arthroscopy cases in their fellowship training program2. The number of cases needed to achieve proficiency during the training period needs to be defined. The Accreditation Council for Graduate Medical Education (ACGME) has established minimum procedure volumes for shoulder and knee arthroscopy in residency programs but not for arthroscopy in other joints5. However, we are seeing a rise in hip arthroscopy elsewhere in the literature: Gil et al. found a 588.9% increase in hip arthroscopy procedures performed by residents during their training period5. Future Directions It would be helpful if we could evaluate outcomes (clinical scores, complications, revision hip arthroscopy procedures, and conversion procedures) of patients who were treated with hip arthroscopy by ABOS Part-II candidates. Outcomes could then be compared among candidates on the basis of the numbers of hip arthroscopy procedures that they performed during their fellowship training. This could help educators both outline a hip arthroscopy curriculum and set target goals for the numbers of cases that candidates need to perform to achieve proficiency. The numbers of hip arthroscopy procedures performed during the training period can be calculated on the basis of self-reporting and by incorporating the ACGME training case log database, which lists procedures logged during residency and fellowship. Combining the data from the ACGME training log with data from the ABOS Part-II database may provide greater clarity in defining the learning curve for early-career surgeons and creating a curriculum for hip arthroscopy in sports medicine programs.