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
In the May 20, 2015 edition of The Journal of Bone & Joint Surgery, Horst et al. document the increasing subspecialization of orthopaedic residency graduates taking the American Board of Orthopaedic Surgery (ABOS) Part II oral exams. The authors found that in 2013, 90% of applicants for the Part II exam were fellowship-trained. Among those fellowship-trained applicants, 81% of the procedures they performed in 2013 were in their field of fellowship training.
One possible interpretation of these findings is that the increasing complexity of interventional care in our field calls for additional subspecialized expertise in order to serve patients well. Another is that deficiencies during the five-year orthopaedic training scheme leave young surgeons feeling incompletely prepared for independent practice. This narrowing of scope certainly can occur with the highly super-specialized faculty practices in some training programs, where residents are often not exposed to the management of routine orthopaedic conditions.
To address what Horst et al. see as potential “gaps in coverage across the field of orthopaedic surgery,” the ABOS is embarking on a program to evaluate the orthopaedic curriculum nationwide to usher in a new era of competency-based education. In the meantime, it is worth considering that smaller U.S. communities of 5,000 to 10,000 citizens really need orthopaedic surgeons with a broad set of diagnostic and therapeutic skills. Younger surgeons who start practicing in larger urban settings also need the same broad skill set to fulfill their community responsibilities for urgent/emergent care—and to successfully care for patients with a broad range of musculoskeletal problems while they build a referral base in their area of subspecialization.
Both of those scenarios require that orthopaedic surgeons in training and those who train them rededicate themselves to producing clinicians with broad skills who can serve their communities while exercising their professional responsibilities and fulfilling their personal goals.
Marc Swiontkowski, MD