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Hip Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Open AccessPublished:May 17, 2022DOI:https://doi.org/10.1016/j.asmr.2022.04.016

      Purpose

      The purpose of this study was to evaluate case volume and variability of hip arthroscopy exposure among graduating orthopaedic residents.

      Methods

      The Accreditation Council for Graduate Medical Education (ACGME) surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents were assessed. Arthroscopy procedures of the pelvis/hip were identified. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

      Results

      There was no change in the number of hip arthroscopy procedures between 2016 and 2020 [average: 8.4 ± 10 (range: 0 to 87) vs. 9.8 ± 12 (range: 0 to 101)] (P = .995). There was a wide variability in case volume among residents. The 90th percentile of residents performed 24 cases in 2020, compared to 2 cases in the 30th percentile and 0 cases amongst the 10th percentile of residents.

      Conclusions

      Despite the growing popularity of hip arthroscopy, resident exposure to this highly technical procedure remains limited, with about one-third of residents performing 2 or less cases by graduation.

      Clinical Relevance

      Understanding case volume and variability is important for orthopaedic surgery programs to ensure that graduating residents are gaining adequate exposure.

      Introduction

      Substantial changes in orthopaedic surgery residency education have occurred in the last decade. In 2013, the Accreditation Council for Graduate Medical Education (ACGME) implemented a new accreditation system for graduate medical education in the United States.
      • Kirk L.M.
      The next accreditation system.
      Seven specialties, including orthopaedic surgery, have since adopted the Next Accreditation System (NAS).
      • Marsh J.L.
      • Potts 3rd, J.R.
      • Levine W.N.
      Challenges in resident education: Is the Next Accreditation System (NAS) the answer?: AOA critical issues.
      Although the traditional accreditation process focused on the details of process and administration, the NAS focuses more on continuous monitoring of measurable and meaningful outcomes of resident training.
      • Kirk L.M.
      The next accreditation system.
      ,
      • Marsh J.L.
      • Potts 3rd, J.R.
      • Levine W.N.
      Challenges in resident education: Is the Next Accreditation System (NAS) the answer?: AOA critical issues.
      Procedural experience is among the most heavily weighted factors used by the ACGME to define program performance.
      • Marsh J.L.
      • Potts 3rd, J.R.
      • Levine W.N.
      Challenges in resident education: Is the Next Accreditation System (NAS) the answer?: AOA critical issues.
      As such, resident case logs have become a critical element of the NAS data analysis
      • Marsh J.L.
      • Potts 3rd, J.R.
      • Levine W.N.
      Challenges in resident education: Is the Next Accreditation System (NAS) the answer?: AOA critical issues.
      and are frequently monitored to ensure adequate procedural volume and case variety among residents for their given year of training.
      • Gordon A.M.
      • Flanigan D.C.
      • Malik A.T.
      • Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      Previous studies have assessed case volume and variability of various orthopaedic procedures.
      • Carender C.N.
      • Shamrock A.G.
      • An Q.
      • Karam M.D.
      Variability in experience performing lower extremity amputations between surgical residents: An examination of ACGME case logs.
      • DeFroda S.F.
      • Gil J.A.
      • Blankenhorn B.D.
      • Daniels A.H.
      Variability in foot and ankle case volume in orthopaedic residency training.
      • Blood T.D.
      • Gil J.A.
      • Born C.T.
      • Daniels A.H.
      Variability in trauma case volume in orthopaedic surgery residents.
      • Gil J.A.
      • Waryasz G.R.
      • Owens B.D.
      • Daniels A.H.
      Variability of arthroscopy case volume in orthopaedic surgery residency.
      • Hinds R.M.
      • Klifto C.S.
      • Guss M.S.
      • Capo J.T.
      Microsurgery case volume during orthopaedic surgery residency: A 7-year assessment.
      • Hinds R.M.
      • Gottschalk M.B.
      • Capo J.T.
      National trends in carpal tunnel release and hand fracture procedures performed during orthopaedic residency: An analysis of ACGME case logs.
      • Hinds R.M.
      • Rapp T.B.
      • Capo J.T.
      Orthopaedic oncology caseload among orthopaedic surgery residents.
      However, continued analyses are critical for implementing standardized training expectations that reflect changes in the orthopaedic landscape and reduce discrepancy in resident education.
      • Shiu B.
      • Petkovic D.
      • Levine W.N.
      • Ahmad C.S.
      Maximizing surgical skills during fellowship training.
      Hip arthroscopy is one of the fastest growing areas of orthopaedic surgery.
      • Bozic K.J.
      • Chan V.
      • Valone 3rd, F.H.
      • Feeley B.T.
      • Vail T.P.
      Trends in hip arthroscopy utilization in the United States.
      ,
      • Bonazza N.A.
      • Homcha B.
      • Liu G.
      • Leslie D.L.
      • Dhawan A.
      Surgical trends in arthroscopic hip surgery using a large national database.
      However, there is a lack of a formal hip arthroscopy curriculum at both the resident and fellowship level.
      • Peters C.L.
      • Beaule P.E.
      • Beck M.
      • Tannast M.
      • Jiranek W.
      • Sierra R.J.
      Report of breakout session: Strategies to improve hip preservation training.
      This raises concern that early-career arthroscopists may struggle with performance
      • Duchman K.R.
      • Westermann R.W.
      • Glass N.A.
      • Bedard N.A.
      • Mather 3rd, R.C.
      • Amendola A.
      Who is performing hip arthroscopy?: An analysis of the American Board of Orthopaedic Surgery Part-II database.
      given the technical demands of hip arthroscopy and its prolonged learning curve.
      • Hoppe D.J.
      • de Sa D.
      • Simunovic N.
      • et al.
      The learning curve for hip arthroscopy: A systematic review.
      • Park M.S.
      • Yoon S.J.
      • Kim Y.J.
      • Chung W.C.
      Hip arthroscopy for femoroacetabular impingement: The changing nature and severity of associated complications over time.
      • Lee Y.K.
      • Ha Y.C.
      • Hwang D.S.
      • Koo K.H.
      Learning curve of basic hip arthroscopy technique: CUSUM analysis.
      • Konan S.
      • Rhee S.J.
      • Haddad F.S.
      Hip arthroscopy: analysis of a single surgeon's learning experience.
      Despite the growing popularity of hip arthroscopy,
      • Bozic K.J.
      • Chan V.
      • Valone 3rd, F.H.
      • Feeley B.T.
      • Vail T.P.
      Trends in hip arthroscopy utilization in the United States.
      little is known about resident exposure to this technically demanding procedure. The purpose of this study was to evaluate case volume and variability of hip arthroscopy exposure among graduating orthopaedic residents. We hypothesize that case volume has remained low over the past 5 years and that wide variability in case volume is present among residents.

      Methods

      The ACGME case log reports for graduating orthopaedic surgery residents were reviewed from 2016 to 2020. The ACGME presents national averages of several procedures within particular anatomic categories using Current Procedural Terminology (CPT) codes. Procedures include incision, excision, intro or removal, repair/revision/reconstruction, trauma, fracture/dislocation, manipulation, arthrodesis, amputation, and arthroscopy. Anatomic categories include shoulder, humerus/elbow, forearm/wrist, hand/fingers, pelvis/hip, femur/knee, leg/ankle, and foot/toes. In this study, we assessed the mean number of total (adult and pediatric) arthroscopy cases performed per resident listed under the “pelvis/hip” ACGME case category from 2016 to 2020 to determine a percent change in volume. The CPT codes and definitions for each arthroscopy procedure within the “pelvis/hip” ACGME case category are provided in Table 1. In addition, the 10th, 30th, 50th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.
      Table 1CPT Codes with Description of Arthroscopy Procedures for the Hip/Pelvis
      29860Arthroscopy, hip, diagnostic; with or without synovial biopsy (separate procedure)
      29861Arthroscopy, hip, surgical; with removal of loose body or foreign body
      29862Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum
      29863Arthroscopy, hip, surgical; with synovectomy
      29914Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)
      29915Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)
      29916Arthroscopy, hip, surgical; with labral repair
      The mean case volumes reported per resident were compared using unpaired 2-tailed t tests. The level of statistical significance was designated as P < .05. Excel software, version 16.0 (Microsoft Corp., Redmond, WA) was used for data input and statistical tests.

      Results

      The total number of orthopaedic surgery residency programs was 153 (705 residents) in 2016, 156 (709 residents) in 2017, 154 (729 residents) in 2018, 154 (725 residents) in 2019, and 154 (724 residents) in 2020 (Table 2).
      Table 2The Demographics of Orthopaedic Surgery ACGME Case Log Respondents
      YearTotal Number of Residency ProgramsTotal Number of Residents
      2016153705
      2017156709
      2018154729
      2019154725
      2020154724
      The average number of total “pelvis/hip” procedures performed per resident was 216.1 ± 67 (median: 205; range: 80-487) in 2016, which increased to 248.9 ± 72 in 2020 (median: 241; range: 104-552), representing an 11.5% increase (P < .001) (Table 3). The average number of “pelvis/hip” arthroscopy procedures performed per resident in 2016 was 8.4 ± 10 (median: 5; range: 0-87), which increased to 9.8 ± 12 in 2020, representing a 16.7% increase (P = .995) (Table 3). Case volume for the total number of pelvis/hip procedures and the total number of arthroscopy procedures of the pelvis/hip performed per resident during the study period are depicted in Fig 1.
      Table 3Mean Number of Pelvis/Hip Arthroscopy Procedures per Graduating Orthopaedic Surgery Resident From 2016 to 2020
      Procedure (Area)20162017201820192020% ChangeP Value
      Mean ±SDMedian (Range)Mean ±SDMedian (Range)Mean ±SDMedian (Range)Mean ±SDMedian (Range)Mean ±SDMedian (Range)
      Arthroscopy (pelvis/hip)8.4±105 (0-87)9 ±115 (0-76)9.2±125 (0-109)9.8±146 (0-173)9.8 ±125 (0-101)16.7%.995
      Total (pelvis/hip)216.1±67205 (80-487)225.3±68216 (78-625)235.3±69225 (107-541)243.9±76230 (93-553)248.9±72241 (104-552)11.5%<.001
      Figure thumbnail gr1
      Fig 1Mean and median orthopaedic resident case volume for pelvis/hip arthroscopy and total pelvis/hip procedures.
      There was a low level of variability in the total number of pelvis/hip procedures and a wide level of variability in pelvis/hip arthroscopy case volume among residents over the study period (Fig 2). The average number of total pelvis/hip cases performed by the 10th percentile and 90th percentile of residents was 141 and 299 in 2016, representing a 2.12 fold difference, compared to 164 and 347 in 2020, which also represents a 2.12 fold-difference (Table 4).
      Figure thumbnail gr2
      Fig 2Mean case volume for pelvis/hip arthroscopy procedures in the 10th through 90th percentiles of orthopaedic residents.
      Table 4Fold-Difference in Pelvis/Hip Arthroscopy Procedures Between the 30th and 70th Percentiles of Graduating Orthopaedic Surgery Residents
      Procedure (Area)Year10th30th50th70th90th
      Arthroscopy (pelvis/hip)20160251022
      20170251023
      2018025923
      20190261123
      20200251224
      Total (pelvis/hip)2016141178205240299
      2017148186216251314
      2018157195225263331
      2019157200230272347
      2020164207241280347
      The average number of pelvis/hip arthroscopy cases performed by the 10th percentile and 90th percentile of residents was 0 and 22 in 2016, respectively, compared to 0 and 24 in 2020 (Table 4). Roughly 1 of every 10 residents failed to perform a single hip arthroscopy case each year of the study period, and about one-third performed 2 cases or less (Table 4).

      Discussion

      The most important finding of this study is that exposure to hip arthroscopy in graduating orthopaedic residents has remained low over the last 5 years, despite a significant increase in the total number of hip procedures performed per resident during this time. In addition, we found that about one third of graduating US orthopaedic residents performed 2 or fewer hip arthroscopy cases upon graduation.
      Case logging of hip arthroscopy procedures was introduced by the ACGME in 2012. Since then, one study has examined hip arthroscopy case volume among US graduating orthopaedic surgery residents.
      • Gil J.A.
      • Waryasz G.R.
      • Owens B.D.
      • Daniels A.H.
      Variability of arthroscopy case volume in orthopaedic surgery residency.
      In 2012, residents performed an average of 0.9 hip arthroscopy cases, compared to 6.2 cases in 2013, representing a 588.9% increase. However, as this study only examined the percent change in case volume over a 1-year period, longitudinal data were difficult to examine. Our study is unique in that it offers an updated analysis of these data over a 5-year span, which also coincides with the growing national popularity of this procedure. We found that residents performed an average of 8.4 hip arthroscopy cases in 2016, compared to 9.8 in 2020. However, this increase was not significant, which implies that resident exposure to hip arthroscopy has plateaued during this time. Furthermore, compared to the data presented by Gil et al.,
      • Gil J.A.
      • Waryasz G.R.
      • Owens B.D.
      • Daniels A.H.
      Variability of arthroscopy case volume in orthopaedic surgery residency.
      present-day hip arthroscopy case volume among orthopaedic surgery residents has only increased by roughly 3 cases per year in nearly a decade.
      Resident case volumes for hip arthroscopy do not seem to reflect the national rise in the incidence of this procedure. There has been a significant increase in the utilization of arthroscopic hip procedures over the last 2 decades.
      • Bozic K.J.
      • Chan V.
      • Valone 3rd, F.H.
      • Feeley B.T.
      • Vail T.P.
      Trends in hip arthroscopy utilization in the United States.
      ,
      • Colvin A.C.
      • Harrast J.
      • Harner C.
      Trends in hip arthroscopy.
      ,
      • Maradit Kremers H.
      • Schilz S.R.
      • Van Houten H.K.
      • et al.
      Trends in utilization and outcomes of hip arthroscopy in the United States between 2005 and 2013.
      Specifically, a 365% increase has occurred in the United States in recent years,
      • Montgomery S.R.
      • Ngo S.S.
      • Hobson T.
      • et al.
      Trends and demographics in hip arthroscopy in the United States.
      with a corresponding increase in the number of surgeons performing this procedure.
      • Degen R.M.
      • Bernard J.A.
      • Pan T.J.
      • et al.
      Hip arthroscopy utilization and associated complications: A population-based analysis.
      Hip arthroscopy has applications in several orthopaedic areas, including sports, hip and knee reconstruction, and pediatrics.
      • Duchman K.R.
      • Westermann R.W.
      • Glass N.A.
      • Bedard N.A.
      • Mather 3rd, R.C.
      • Amendola A.
      Who is performing hip arthroscopy?: An analysis of the American Board of Orthopaedic Surgery Part-II database.
      With improved surgical technique, expanding indications, and a growing understanding of prearthritic hip conditions,
      • Ayeni O.R.
      • Chan K.
      • Al-Asiri J.
      • et al.
      Sources and quality of literature addressing femoroacetabular impingement.
      such as intra-articular loose bodies, chondral injury, and femoroacetabular impingement (FAI) syndrome,
      • Griffin D.R.
      • Dickenson E.J.
      • O'Donnell J.
      • et al.
      The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): An international consensus statement.
      the demand for hip arthroscopy will likely increase.
      • Degen R.M.
      • Bernard J.A.
      • Pan T.J.
      • et al.
      Hip arthroscopy utilization and associated complications: A population-based analysis.
      As such, the importance of added exposure among orthopaedic surgery trainees is ever present.
      A possible explanation for low resident case volumes for hip arthroscopy lies in the complexity of the procedure. Given its technical demand, hip arthroscopy procedures are often assisted by fellows compared to residents.
      • Gordon A.M.
      • Flanigan D.C.
      • Malik A.T.
      • Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      Gordon et al.
      • Gordon A.M.
      • Flanigan D.C.
      • Malik A.T.
      • Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      studied case log data for hip arthroscopy among orthopaedic surgery sports medicine fellows and reported a 310% rise in case volume from 2011 to 2016. An even greater increase (>600%) was found among the number of candidates taking the American Board of Orthopaedic Surgery Part 2 examination.
      • Bozic K.J.
      • Chan V.
      • Valone 3rd, F.H.
      • Feeley B.T.
      • Vail T.P.
      Trends in hip arthroscopy utilization in the United States.
      These results indicate that early-career orthopaedic surgeons and sports medicine fellows are continuing to gain exposure to hip arthroscopy.
      • Gordon A.M.
      • Flanigan D.C.
      • Malik A.T.
      • Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      In addition, lack of resident exposure to hip arthroscopy may be a consequence of reduced access, as not every residency program has a hip arthroscopist on staff. Furthermore, even at institutions with faculty who have hip arthroscopy training, surgical volume is widely variable and may be as low as low as 1 to 2 cases per year.
      Although the ACGME has mandated case minimum requirements for knee and shoulder arthroscopy (30 and 20 cases, respectively),
      • Gordon A.M.
      • Flanigan D.C.
      • Malik A.T.
      • Vasileff W.
      Orthopaedic surgery sports medicine fellows see substantial increase in hip arthroscopy procedural volume with high variability from 2011 to 2016.
      no such guidelines have been implemented for hip arthroscopy. A recent systematic review on the learning curve associated with hip arthroscopy reported a wide spread of cutoff numbers to achieve procedural proficiency, ranging from 20 to more than 500 cases.
      • Go C.C.
      • Kyin C.
      • Maldonado D.R.
      • Domb B.G.
      Surgeon experience in hip arthroscopy affects surgical time, complication rate, and reoperation rate: A systematic review on the learning curve.
      While expertise in hip arthroscopy is unachievable in residency alone, early procedural exposure may equip residents with a better understanding of the key surgical steps in hip arthroscopy.
      • Wininger A.E.
      • Dabash S.
      • Ellis T.J.
      • Nho S.J.
      • Harris J.D.
      The key parts of hip arthroscopy for femoroacetabular impingement syndrome: Implications for the learning curve.
      Perhaps the implementation of an ACGME case minimum requirement may help to increase resident exposure to this increasingly popular procedure and better prepare trainees for fellowship and early practice.

      Limitations

      The present study is not without limitations. The ACGME case log data do not specify the types of procedures (or indications of said procedures) within the pelvis/hip category. Therefore, while overall case volume and variability for arthroscopic procedures of the pelvis/hip were provided, these findings are not applicable to specific CPT procedural codes. Next, the ACGME case log data accuracy may be influenced by bias due to underreporting or overreporting among residents.
      • Salazar D.
      • Schiff A.
      • Mitchell E.
      • Hopkinson W.
      Variability in Accreditation Council for Graduate Medical Education resident case log system practices among orthopaedic surgery residents.
      This may be particularly evident when logging arthroscopic procedures that are associated with a variety of CPT codes. Finally, the degree of resident participation within each case cannot be determined. Thus, resident case log data should not serve as a direct reflection of procedural proficiency.

      Conclusions

      Despite the growing popularity of hip arthroscopy, resident exposure to this highly technical procedure remains limited, with about a third of residents performing 2 or fewer cases upon graduation.

      Supplementary Data

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