FEATURE
enough hip arthroscopy case volume to support the investment in the equipment needed to perform the procedure, Lynch says. “Hip arthroscopy does not come up very often,” he says. “Even though I am busy, for every 20 knee scopes, there may be one hip scope. I tell hip arthros- copy patients that they are going to be the only one at the dinner party who’s had a hip scope.” Lynch says ASCs will want a surgeon
or group of surgeons who are dedicated to bringing their hip arthroscopy patients to the ASC. “An ASC will probably need at least 3–5 patients a week to support a hip arthroscopy program. If you are do- ing roughly 7–8 a month, you are prob- ably going to be at the cusp of achieving a financial benefit for that program.”
Strict Patient Selection Criteria Performing successful hip arthroscopies begins with careful identification of the appropriate patients for the procedure, Lynch says. “Surgeons need to use prop- er decision-making in the preoperative setting. The worst surgeries are the ones that have the worst thought process; the best surgeries are the ones that have the best thought process.”
This thought process begins with
recognizing that hip arthroscopy has a very narrow indication, Lynch contin- ues. “The pain needs to be truly com- ing from the patient’s hip. The patient’s anatomy must also be receptive to the technical aspect of having a hip scope. The joint needs to move well and not be still. There needs to be the presence of anatomy such as a cartilage tear that is typically identified by an MRI (magnetic resonance imaging). There also needs to be an absence of too much arthritis. Any arthritis that is stiffing the hip is too much; any arthritis that allows the hip to move well, that is somebody I can help.” To choose which patients to bring
to the ASC, you would use some of the same criteria used for an ACL (anterior cruciate ligament) or a rotator cuff re- pair, Pro says. “You are looking for pa-
Just like adding any procedure, you need to justify its capital outlay if you want to pursue it. Hip arthroscopy is probably one of the most capital intensive, short of spine surgery, that an ASC could pursue.”
— Patrick Lynch Jr., MD Northwest Orthopaedic Specialists
tients who have failed conservative treat- ments but are otherwise in good health.” Webster says hip arthroscopy is a fair-
ly straightforward procedure compared to many of the procedures performed at his ASC. “We do massive rotator cuff repairs. We do ACL and medial collat- eral ligament (MCL) repairs on the same patient, on the same day. Those are way more complex and difficult procedures.” While the procedure is not complex
compared to other arthroscopies, Pro says surgeons need to be cognizant of how long the procedure takes. “Unlike a shoulder or a knee scope, for the hip you actually have to use a traction table. You want to try to keep the patient under two hours of traction. I personally strive for under 1:30. The longer they are in trac- tion, the more postoperative discomfort they are likely to have.” Some ASCs might find it surprising
to learn that hip arthroscopy is not just for older patients, Webster says. “One month, we had only three patients who
were covered by Medicare. The average age of our patients that month was 49, the median was 47.5. The youngest pa- tient was 23, and we also saw a patient who was 30.”
Across-the-Board Benefits The addition of a hip arthroscopy pro- gram doesn’t just benefit the ASC; pa- tients benefit significantly as well, Pro says. “The ASC setting gives the patients I take care of the best opportunity to have a good outcome. They are in a facil- ity where infection rates are lower. The ASC helps to minimize traction time by having staff who are familiar with how I do the procedure. I work with the same team every day, whereas at the hospital, there is a lot more variability in terms of what team is going to work with you.” This familiarity benefits surgeons
as well, Pro adds. “There are certainly some nuances to positioning and instru- mentation for hip arthroscopy that can make it a little bit more difficult. When you are trying to do the procedure at a facility where you do not operate very often, that adds another layer of com- plexity. A hospital’s staff may not be as well-versed as the staff in the ASC set- ting due to the fact that most arthroscop- ic procedures are done in the ASC set- ting. When I came to Lawrence Surgery Center, it took the staff only one or two hip arthroscopy cases with me to seem as well-versed on it as if they had been in on my cases hundreds of times.” Lynch appreciates the efficiency
of performing hip arthroscopy in the ASC. “I can get patients taken care of more rapidly. Instead of having to wait 6–7 weeks to have their surgery done in the hospital, they may only need to wait three weeks for the surgery cen- ter. ASCs allow patients to be seen and have their situation addressed around their busy schedules. In the ASC, we do the surgery in a way that is not only successful but shows the professional- ism people should expect when dealing with the health care industry.”
ASC FOCUS NOVEMBER/DECEMBER 2013 19
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