Advertisement

Editorial Commentary: Expansion of Hip Arthroscopy in Sports Medicine Fellowship Training: The Good, Bad, and Ugly

      Abstract

      Orthopaedic sports medicine fellowship experience in hip arthroscopy is increasing rapidly (2.6-fold from 2011 to 2016), although the case numbers vary quite widely (64-fold) depending on the program. Orthopaedic providers are now able to refine diagnoses and refer or render indicated less-invasive hip treatment options, many of which yield outcomes equaling or surpassing those of open equivalents. Patients benefit. Our profession benefits. However, advanced hip arthroscopy procedures are technically challenging, and complications can be significant in inexperienced hands. For those who choose to perform hip arthroscopy after fellowship training, continuing hip arthroscopy education and skill development is essential.
      I congratulate Gordon, Flanigan, Malik, and Vasileff on their timely study entitled, “Orthopaedic Surgery Sports Medicine Fellows See Substantial Increase in Hip Arthroscopy Procedural Volume With High Variability from 2011 to 2016,”
      • Gordon A.M.
      • Flanigan D.C.
      • Malik Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      which is of personal professional interest to me. The key finding was a 2.6-fold increase in hip procedures (mean 25 increasing to 64 cases) but wide variation (64-fold difference between lower- and upper-10th-percentile exposure).
      The trend toward inclusion of hip arthroscopic procedures in sports medicine training translates into an increasing incidence of those surgeons performing hip labral repairs.
      • Westermann R.W.
      • Day M.A.
      • Duchman K.R.
      • Glass N.A.
      • Lynch T.S.
      • Rosneck J.T.
      Trends in hip arthroscopic labral repair: An American Board of Orthopaedic Surgery database study.
      Like most things, this can be good and bad. The good is that fellows are being exposed to not only the technical aspects of hip arthroscopy, but also, presumably, foundational clinical and imaging diagnostics. Rather than categorizing patients with groin or hip symptoms into buckets pretty much limited to bursitis, tendonitis, or arthritis and treated with nonsteroidal anti-inflammatory drugs, injections, and hip replacement, as in my training days, orthopaedic providers are now able to refine diagnoses and refer or render indicated less-invasive options, many of which yield outcomes equaling or surpassing those of open equivalents. Patients benefit. Our profession benefits.
      But the bad, in my humble opinion, is that an introductory “taste” of hip arthroscopy, which comes in many flavors (largely based on the experience, expertise, and training of the teachers in a given sports medicine fellowship program), and a challenging learning curve
      • Mehta N.
      • Chamberlin P.
      • Marx R.G.
      • et al.
      Defining the learning curve for hip arthroscopy: A threshold analysis of the volume-outcomes relationship.
      may result in well-intentioned but inexperienced surgeons performing difficult surgeries on often young, active patients. Scenarios may occur such as scuffed articular cartilage, debrided irreparable labrums (“we didn't learn labral reconstructions in fellowship”), and traction-related complications from excessive time and force, let alone suboptimal outcomes and reoperations from incomplete resection of cam or pincer femoroacetabular impingement or, perhaps worse, overzealous osteoplasties with resultant femoral neck fractures or iatrogenic dysplasia, even hip dislocation.
      • Matsuda D.K.
      Acute iatrogenic dislocation following hip impingement arthroscopic surgery.
      I believe sports medicine fellows trained in arthroscopic techniques are positioned for potential success should they choose to add hip arthroscopy to their practice. But it behooves the young surgeon, her patients, and our profession to encourage continued learning in the form of fellowships (both dedicated hip fellowships and better uniformity of hip experience during general sports medicine ones), mentorships, and courses focused on the indications and techniques of safe and efficacious hip arthroscopy along with related procedures beyond the central compartment (e.g., core muscle injury, trochanteric pain syndrome including abductor tendon repairs, proximal hamstring repairs).
      In sum, regarding the expansion of hip arthroscopy training in sports medicine fellowships, I believe the good outweighs the bad. More patients stand to benefit from more accurate and timely diagnoses (beyond the 3 diagnostic buckets of yore). To those fellows that incorporate hip arthroscopy into their practice, may they build upon their introductory training, committing to further (and ongoing) education and skill development. And may they have the insight and integrity to refer or seek mentorship so that the good outweighs the bad … and prevents the ugly.

      Supplementary Data

      References

        • Gordon A.M.
        • Flanigan D.C.
        • Malik Vasileff W.
        Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
        Arthroscopy. 2021; 37: 521-527
        • Westermann R.W.
        • Day M.A.
        • Duchman K.R.
        • Glass N.A.
        • Lynch T.S.
        • Rosneck J.T.
        Trends in hip arthroscopic labral repair: An American Board of Orthopaedic Surgery database study.
        Arthroscopy. 2019; 35: 1413-1419
        • Mehta N.
        • Chamberlin P.
        • Marx R.G.
        • et al.
        Defining the learning curve for hip arthroscopy: A threshold analysis of the volume-outcomes relationship.
        Am J Sports Med. 2018; 46: 1284-1293
        • Matsuda D.K.
        Acute iatrogenic dislocation following hip impingement arthroscopic surgery.
        Arthroscopy. 2009; 25: 400-404