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
Patients who experience persistent hip pain after nonoperative treatments for partial or full-thickness gluteus medius tears have two surgical repair options: open or endoscopic. A two-year follow up study by Chandrasekaran et al. in the August 19, 2015 edition of The Journal of Bone & Joint Surgery found that endoscopic repair with correction of identified intra-articular pathology yielded substantial postprocedure functional improvements and pain reduction, along with high levels of overall patient satisfaction. In addition, 15 of the 26 patients who had preoperative gait deviations were found to have a completely normal gait at the two-year follow up. No postoperative complications or re-tears were reported.
The study followed 34 patients (predominantly women, mean age of 57 years) who had endoscopic repairs. Seventeen (50%) of the patients with full-thickness or near full-thickness tears were treated with a suture bridge technique, while the 17 with partial-thickness tears received a transtendinous repair. There was no significant difference in patient-reported outcome measures between the two surgical techniques.
The ability to address intra-articular pathology is touted as an advantage of the endoscopic approach, and in this study concomitant procedures included capsule release, labral debridement and repair, and acetabuloplasty.
Although the Chandrasekaran et al. study did not compare outcomes of endoscopic versus open repair, it did track the largest reported number of endoscopy patients for the longest reported duration.