Arthroscopic Versus Open Elbow Debridements Among ABOS Part II Candidates: A Decline in Arthroscopic Volume yet Fewer Complications After Arthroscopic Procedures

Abstract

Background:

Loose body removal and debridement remain common indications for elbow arthroscopy.

Purpose:

To (1) identify trends in elbow arthroscopy versus open procedures for loose body removal and debridement among American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination candidates and (2) compare the use of elbow arthroscopy among candidates with different fellowship training backgrounds.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A search of the ABOS Part II Oral Examination case list database was performed for elbow arthroscopy and open debridement Current Procedural Terminology codes between 2011 and 2021. Cases were stratified according to fellowship training data found in the ABOS Part II case list database. Annual rates of elbow procedures, patient demographics, surgeon geographic location, and complications were collected. Statistically significance was determined using chi-square testing, Fisher exact test or 2-tailed t test (P < .05).

Results:

A total of 1443 procedures, 1147 (79.5%) arthroscopic and 296 (20.5%) open, were identified and included. A decrease in arthroscopic cases was observed while open cases remained steady. Arthroscopic cases were performed in a younger patient population (39 ± 18.5 vs 41.7 ± 17.3 years respectively; P = .02). The plurality of cases were performed by sports medicine fellowship–trained surgeons (n = 506; 35.1%), followed by hand and upper extremity fellowship–trained surgeons (n = 440; 30.5%) and shoulder and elbow fellowship–trained surgeons (n = 365; 25.3%). Sports medicine fellowship–trained surgeons performed the greatest proportion of arthroscopic cases (n = 482/506; 95.3%). In general, complication rates were lower following arthroscopic versus open procedures (surgical complications: 8.6% vs 27.7%, P < .001; readmissions: 0.7% vs 2.0%, P = .04; reoperations: 1.6% vs 3.7%, P = .02). Specifically, commonly associated complications including arthrofibrosis and nerve injury were also lower following arthroscopic procedures (stiffness/arthrofibrosis: 29.3% vs 34.1%, P < .001; nerve injuries: 1.7% vs 5.1%, P < .001).

Conclusion:

In this study of patients treated by ABOS Part II Oral Examination candidates, with the largest population of patients undergoing elbow arthroscopy to date, rates of elbow arthroscopy have decreased over the past decade, although surgeons with sports medicine, hand and upper extremity, and/or shoulder and elbow fellowship training demonstrate a proclivity toward arthroscopic rather than open procedures. Overall rates of complication were lower following arthroscopic approaches in this cohort of surgeons.

Indications for elbow arthroscopy are increasingly common, particularly in the management of intra-articular loose bodies and osteophytes.^1,2,9,15,25 Although previously associated with high complication rates including heterotopic ossification, transient nerve palsies, infection, and articular cartilage injuries, recent literature has demonstrated significant advances in the safety of elbow arthroscopy, especially with increased clinical and cadaveric studies describing safe portal placement.^7,11,16 Surgeon experience with elbow arthroscopy and associated techniques is considered important to preventing complications. ⁷

While elbow arthroscopy is known to have a steep learning curve, similar complication rates and better short-term functional outcomes have been observed when compared with open procedures.^5,14,24 Kim et al ¹³ report a significant decrease in operative time after 15 cases, while Keyt et al ¹² estimate a threshold of 19 cases to be “safe” and 42 to be “competent.” Prior studies have correlated exposure with other advanced arthroscopic techniques in fellowship training with increased use of aforementioned advanced arthroscopic techniques in early practice ²⁰ ; however, the prevalence of elbow arthroscopy in the practices of orthopaedic surgeons in their early careers remains unclear.

The purpose of this study is (1) to report the utilization of arthroscopic elbow debridement by American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination candidates between 2011 and 2021 compared with open elbow debridement procedures and (2) to assess the relationship between type of fellowship training and the prevalence of arthroscopic versus open procedures. We hypothesize that elbow arthroscopy usage will increase over the study period and surgeons with arthroscopy-oriented fellowship training will gravitate toward its usage over open techniques.

Methods

Study Design

A retrospective database analysis was performed including all patients who underwent arthroscopic or open debridement of the elbow as reported by ABOS Part II candidates. Original data were sourced from the deidentified ABOS Part II database, which serves as a repository of cases performed by ABOS Part II candidates. Candidates are required to submit detailed 6-month case lists with relevant clinical features for evaluation by the ABOS and, while case lists are reported by the candidates, the surgical cases are subject to verification performed by hospital systems as well as by the ABOS.

Database Search

Data were collected from the ABOS Part II case list database between 2011 and 2021. Elbow debridement cases were identified using Current Procedural Terminology (CPT) codes for elbow arthroscopy (29830, 29834, 29835, 29836, 29837, 29838) and open debridement (24006).

Data Collection

For each case, relevant CPT codes, patient demographics, surgeon location, and complications were collected in standardized fashion as recorded by the ABOS. For candidates with >1 reported subspecialty, candidates were categorized according to the subspecialty with the closest proximity to the elbow or to advanced arthroscopic procedures (shoulder and elbow, sports medicine, and hand and upper extremity, in that order).

Statistical Analysis

Cases were stratified by the subspecialty of the operative surgeon for comparative analyses. Statistical analyses were performed using 2-tailed t tests for continuous variables and chi-square analyses or Fisher exact tests for categorical variables. Chi-square tests for trend were used to compare trends in proportions among case volumes. Linear regression was performed to identify trends among case volumes. Statistical significance was defined as P < .05.

Results

Volume Trends

A total of 1443 cases were performed by 8108 ABOS Part II Oral Examination candidates. Of these, 79.5% (n = 1147) were performed arthroscopically and 20.5% (n = 296) open (Figure 1). There was an overall downward trend in the number of cases performed between 2011 and 2021, though 2015 had the greatest number of cases reported during this time (slope = −5.6; R² = 0.48). In comparing proportions of cases, there was a statistically significant trend in proportion of arthroscopic cases over time (X² = 9.49; df = 1; P = .002). While the number of open debridements remained stable, there was a downward trend among arthroscopic debridements overall (slope = 0.19, R² = 0.06; slope = −5.8, R² = 0.52, respectively) (Table 1; Figures 1 and 2).

Figure 1.

Trend in total number of elbow debridements per year.

Table 1.

Trend of ABOS Part II Candidates Performing Arthroscopic Debridement and Open Debridement of Elbow by Year ^a

Exam Year	ABOS Part II Candidates, n	Arthroscopic Cases, n	Cases Treated Arthroscopically, %	Open Cases, n	Cases Treated Open, %
2011	662	142	84.5	26	15.5
2012	722	114	83.2	23	16.8
2013	689	113	81.9	25	18.1
2014	770	106	79.7	27	20.3
2015	746	156	84.3	29	15.7
2016	729	94	75.8	30	24.2
2017	743	91	74.0	32	26.0
2018	752	83	77.6	24	22.4
2019	789	79	75.2	26	24.8
2020	767	102	79.1	27	20.9
2021	739	67	71.3	27	28.7
Total	8108	1147	79.5	296	20.5

^aThe denominator is the total number of cases performed that year. ABOS, American Board of Orthopaedic Surgeons.

Figure 2.

Trends in arthroscopic and open procedures case volume.

Patient Demographics

Arthroscopic debridements were performed on a significantly younger patient population as compared with open debridements (39 ± 18.5 vs 41.7 ± 17.3 years of age; P = .02). The majority of patients included in the study were male (n = 971; 67.3%). Mean patient follow-up was approximately 1.5 weeks shorter after arthroscopic versus open procedures (7.9 ± 6.1 vs 9.4 ± 6.1 weeks; P < .001).

Geographic Distribution

Table 2 presents the geographic distribution of cases performed throughout the study. Candidates from the Midwest performed the greatest proportion of the 1443 total cases (n = 302; 20.9%), while candidates from the Northwest performed the least proportion of total cases (n = 139; 9.6%). Significant differences were observed among rates of arthroscopic versus open procedures between geographic distributions (X² = 16.1; P < .001).

Table 2.

Arthroscopic and Open Elbow Debridements by Region ^a

	Midwest	South	Southwest	Northeast	Southeast	Northwest	Other
Arthroscopic	233 (77.2)	228 (81.4)	206 (77.4)	167 (75.6)	163 (79.9)	121 (87.1)	28 (90.3)
Open	69 (22.8)	52 (18.6)	60 (22.6)	54 (24.4)	41 (20.1)	18 (12.9)	3 (9.7)
Total	302	280	266	221	204	139	31

^aData are presented as n (%).

Fellowship Training

The greatest proportion of elbow debridements were performed by surgeons with fellowship training in sports medicine (n = 506/1443; 35.1%), followed by hand and upper extremity (n = 440/1443; 30.5%), and shoulder and elbow (n = 365/1443; 25.3%). Surgeons with sports medicine training performed the greatest proportion of elbow debridements arthroscopically (n = 482/506; 95.3%) followed by surgeons with shoulder and elbow training (n = 283/365; 77.5%). Surgeons with hand and upper extremity fellowship training performed the lowest proportion of arthroscopic procedures (n = 298/440; 67.7%) overall. Similarly, surgeons with sports medicine fellowship training demonstrated higher odds of performing arthroscopic rather than open elbow debridements as compared with their hand and upper extremity (odds ratio [OR], 9.6; P < .001) as well as shoulder and elbow (OR, 5.8; P < .001) fellowship trained counterparts (Table 3). Only 2% of elbow arthroscopy cases (n = 30) were performed by surgeons without fellowship training.

Table 3.

Rates and Ratios of Arthroscopic and Open Cases by Type of Fellowship Training ^a

	Hand and Upper Extremity	Shoulder and Elbow	Sports Medicine	Other
Arthroscopic	298 (67.7)	283 (77.5)	482 (95.3)	80 (60.6)
Open	142 (32.3)	82 (22.5)	24 (4.7)	52 (39.4)
Total	440	365	506	132
Ratio
Hand and upper extremity	–	0.6 (P = .002)	0.1 (P < .001)	–
Shoulder and elbow	1.6 (P = .002)	–	0.2 (P < .001)	–
Sports medicine	9.6 (P < .001)	5.8 (P < .001)	–	–

^aData is presented as n (%) or odds ratio with significance. Dashes in table cells indicate that no calculation was perfomed.

Complications

Overall complication rates are presented in Table 4 and specific complications in Table 5. Significantly lower rates of complication were observed among patients undergoing arthroscopic procedures, including surgical complication rates (P < .001), reoperation rates (P = .02), and readmission rates (P = .04). The 2 most common adverse events among both arthroscopic and open procedures were arthrofibrosis/stiffness and nerve injury or palsy. Significantly lower rates of arthrofibrosis/stiffness were observed following arthroscopic procedures (P < .001) and significantly fewer nerve injuries were observed following arthroscopic procedures (P < .001). Additionally, arthroscopic procedures exhibited decreased rates of hematoma/seroma formation and fracture (both with P < .001).

Table 4.

Comparison of Arthroscopic and Open Debridement Complications

	No. of Cases	Medical Complications	Surgical Complications	Reoperation	Readmission
Arthroscopic	1147	10 (0.9)	99 (8.6)	18 (1.6)	8 (0.7)
Open	296	4 (1.4)	82 (27.7)	11 (3.7)	6 (2.0)
P		.45	<.001	.02	.04

Table 5.

Comparison of Arthroscopic and Open Debridement Surgical Complications

	Total	Arthroscopic			Open
Type of Complication	n	n	Arthroscopic Complications, % (n = 99)	Overall Rate, % (n = 1147)	n	Open Complications, % (n = 82)	Overall Rate, % (n = 296)	P
Stiffness/arthrofibrosis	57	29	29.3	2.5	28	34.1	9.5	<.001
Nerve palsy/injury	34	19	19.2	1.7	15	18.3	5.1	<.001
Surgical unspecified	26	20	20.2	1.7	6	7.3	2.0	.74
Infection	19	13	13.1	1.1	6	7.3	2.0	.23
Pain	15	14	14.1	1.2	1	1.2	0.3	.18
Hematoma/seroma	9	2	2.0	0.2	7	8.5	2.4	<.001
Wound healing delay/fail	8	6	6.1	0.5	2	2.4	0.7	.75
Bone fracture	5	1	1.0	0.09	4	4.9	1.4	<.001
Skin ulcer/blister	3	0	0	0.00	3	3.7	1.0
Tendon/ligament injury	2	1	1.0	0.09	1	1.2	0.3	.30
Hemarthrosis/effusion	2	1	1.0	0.09	1	1.2	0.3	.30

Discussion

The major findings of our study demonstrated a decline in the volume of arthroscopic elbow debridements performed between 2011 and 2021 by ABOS Part II Oral Examination candidates (slope, –5.8; R² = 0.52). Arthroscopic procedures were performed on a significantly younger patient population than open procedures (39 ± 18.5 vs 41.7 ± 17.3 years of age; P = .02). Additionally, surgeons with sports medicine fellowship training performed the largest volume of arthroscopic debridements followed by surgeons with hand and upper extremity fellowship training and shoulder and elbow fellowship training. The most frequently observed complications included arthrofibrosis/stiffness and nerve injuries following both arthroscopic and open procedures, although complication rates were significantly lower after arthroscopic procedures (P < .001).

In general, elbow arthroscopy is considered to be a technically challenging procedure with a steep learning curve, partially because of the close proximity of portals to neurovascular structures.^2,3 Additionally, elbow arthroscopy comprises a small proportion of case volume for early career shoulder and elbow subspecialists ⁶ and exposure to elbow arthroscopy during training is variable and poorly distributed, with a mean of 1 to 3 cases annually.^8,21 Keyt et al ¹² previously established the case volume required for safety in elbow arthroscopy to be 19 cases with competence identified at 42 cases and proficiency at 93; in comparison, 30 cases is often cited as the threshold to differentiate between early and late hip arthroscopists’ experience while operative times for reverse total shoulder arthroplasty are noted to decrease after 18 cases.^8,19

In the present study, surgeons with fellowship training, specifically in sports medicine, hand and upper extremity, and shoulder and elbow, performed 91% of elbow arthroscopy cases, and only 2% were performed by surgeons who did not pursue fellowship training. Similarly, in their study specific to treatment of lateral epicondylitis, Wang et al ²³ found that only 7.8% of surgical cases were performed arthroscopically and also described the popularity of arthroscopic procedures among shoulder and elbow as well as sports medicine surgeons as compared with hand surgeons, although the authors recognize that different practices based on training and the need for concomitant procedures may confound results. With regard to training exposure, Ibitayo et al ¹⁰ report a mean of 2.5 arthroscopic humeral and elbow sports medicine cases logged in 5 years of residency versus 17.1 cases logged in 1 year of sports medicine fellowship from an analysis of Accreditation Council for Graduate Medical Education case logs. However, when compared with an analysis of case volumes of sports medicine fellows prior to and during the COVID-19 pandemic by Testa et al, ²² who report a mean of 2.5 cases in the 2019 academic year, 2.2 cases in the 2020 academic year, and 2.6 in the 2021 academic year, fellowship exposure appears to be highly variable. In this context, achieving the “proficiency” threshold for elbow arthroscopy of 93 cases requires a substantial number of cases that may be difficult to reach in many practices prior to the conclusion of a residency or fellowship program. Subsequently, the global decrease in arthroscopic cases may be explained in part by changes in training exposure or coding behavior, and the combination of lack of exposure, technical difficulty, and emerging data to supporting a steep learning curve offer a possible explanation for the overall decrease in general rates of elbow arthroscopy among ABOS Part II candidates over the past decade.

The present study demonstrates lower rates of adverse events following arthroscopic versus open elbow debridement. Rates of resultant complication remain consistent and even slightly lower than those reported in existing literature: in their systematic review and meta-analysis of 95 studies reporting on complication rates after elbow arthroscopy, Ahmed et al ¹ report an overall complication rate of 11.0% and reoperation rate of 4.1%, versus those in the present study of 8.6% versus 1.6%, respectively. Rates of postoperative stiffness, found to be the most common complication, were reported at 4.5% versus 2.5% in the present study, and rates of nerve injury noted at 3.4% versus 1.7% in the present study. ¹ In comparing open versus arthroscopic arthrolysis for osteoarthritic elbows, overall risk of wound complication was noted to be significantly higher after open procedures with an associated odds ratio of 7.7 ¹⁷ ; however, younger patients with fewer medical comorbidities that can affect outcomes may be more likely to undergo arthroscopic versus open procedures or receive steroid injections that may increase risk of postoperative infection,^4,17,18 which may bias existing data to favor arthroscopy. Regardless, the present study remains fairly consistent with existing literature and suggests fewer complications such as arthrofibrosis and nerve injuries as well as adverse events like surgical complications, readmission, and reoperation among patients indicated for arthroscopic rather than open elbow debridement.

Limitations

This study is not without limitations. As a retrospective review, there is inherent bias built into the study. The ABOS data set, while comprehensive, does not include data regarding comorbidities, functional outcomes, patient-reported outcome measures, or more specific patient demographic data, and age and comorbidity matching was not performed. Additionally, indications for surgery remain a difficult variable to elucidate given the structural dependence of the ABOS Part II database on CPT codes for each treatment and there was limited ability to standardize debridement procedures and specific structures debrided or performed intraoperatively outside of the CPT code allocation for each surgery, as International Classification of Diseases, Tenth Revision, data were not included in the data set. The absence of patient comorbidities and case complexity introduces a subsequent selection bias. The COVID-19 pandemic also lengthened the collection periods, which may have allowed for greater follow-up time and more case collection during a period with lower rates of elective surgery nationwide. Future studies will assess and compare specific pathologies, especially as the indications for elbow arthroscopy continue to expand. A comparison study with a national database or ABOS recertification data may also encourage greater generalizability to surgeons currently in the window for maintenance of certification.

Conclusion

In this study of patients treated by ABOS Part II Oral Examination candidates, with the largest population of patients undergoing elbow arthroscopy to date, rates of elbow arthroscopy have decreased over the past decade, although surgeons with sports medicine, hand and upper extremity, and/or shoulder and elbow fellowship training demonstrate a proclivity toward arthroscopic rather than open procedures. Overall rates of complications were lower following arthroscopic approaches in this cohort of surgeons.