Hip Arthroscopy: What and Who Account for Rising Utilization?

Hip arthroscopy for labral pathology and cam and pincer impingement has become increasingly established as an effective procedure in the hands of experienced surgeons. However, as with all technically complex orthopaedic procedures, success entails not only sound technique, but also appropriate patient selection, meticulous pre- and intraoperative setup, and appropriate use of intraoperative fluoroscopy. Thankfully, we have a community of leaders in arthroscopy who share and teach these details.

In the December 20, 2017 issue of The Journal, Duchman et al. use the ABOS Part-II exam database to analyze who among recent graduates of orthopaedic residencies is performing hip arthroscopies. Overall, between 2006 and 2015, the authors found that 643 of 6,987 ABOS candidates (9.2%) had performed ≥1 hip arthroscopy; nearly three-quarters of those reported sports-medicine fellowship training. More than two-thirds of candidates performing hip arthroscopy performed ≤5 such procedures; conversely, only 6.5% of those candidates performed 35% of all the hip arthroscopies identified in the database.

The concerning suggestion from these findings is that the increase in hip arthroscopy utilization comes from an increased number of individuals performing the surgery, rather than from an increase in procedure volume among individual surgeons. One question this study does not address is whether there has been an increase in the prevalence of hip pathology that warrants an increased utilization of this procedure. If not, an alternative explanation, which Wennberg et al. posit in the Dartmouth Atlas, is that procedure utilization expands in relationship to the distribution of provider resources and medical opinion in the local community.

I believe that hip arthroscopy is technically challenging and that the quality of the outcome is very likely related to the per-surgeon volume of procedures performed. This makes it incumbent upon all orthopaedists who offer this procedure to actively evaluate their outcomes with validated instruments so the practitioner and her/his patients can objectively understand and discuss what the results are likely to be.

In a commentary on this study, Rupesh Tarwala, MD calls for an outcomes analysis of patients who were treated with hip arthroscopy by ABOS Part-II candidates. I concur completely, and would more specifically ask that the cohort of surgeons evaluated in this study by Duchman et al. collect and report their 1- and 2-year outcomes to The Journal.

Marc Swiontkowski, MD
JBJS Editor-in-Chief