Hip Arthroscopy and The Innovation Cycle in the United Kingdom: Data, Drivers, and Global Context

Ajay Malviya, PhD, FRCS (T&O), MSc, MRCS Ed, MS (T&O), MBBS, UNITED KINGDOM Vikas Khanduja, MA(Cantab), MBBS, MSc, FRCS, FRCS(Orth), PhD, UNITED KINGDOM

ISAKOS eNewsletters   Current Perspective 2026   rating (1)

Introduction

Hip arthroscopy has experienced one of the most dramatic utilisation cycles in modern orthopaedics. Advances in imaging, instrumentation, and the understanding of femoroacetabular impingement syndrome (FAIS) led to rapid adoption in the early 2000s, with the number of procedures rising sharply across the globe, especially in the UK and USA. Early national analyses in the UK suggested that this growth would continue unchecked into the following decade.

However, contemporary national data now tell a different story. Administrative and registry sources consistently show that hip arthroscopy volumes in England have declined markedly since the mid‑2010s. Importantly, this reduction has occurred alongside improving quality of outcome data and increasing clarity around appropriate patient selection. Using the UK’s Non‑Arthroplasty Hip Registry (NAHR), updated Hospital Episode Statistics (HES) analyses, and earlier landmark HES work as its foundation, this article explores what the decline means, why it has occurred, and how it compares with international practice.

Rapid Expansion: the Early HES Era (2002–2013)

The first comprehensive national picture of hip arthroscopy utilisation in England emerged from analysis of HES data covering 2002–2013. Over that 11‑year period, the number of procedures increased by >700%, rising from just >500 cases annually to >4,000. The incidence increased from approximately 0.5 to >4 procedures per 100,000 population.

Several important features characterised this expansion. Patients were predominantly young and active, with a female predominance of around 60%. Regional variation was pronounced, with more than sixfold differences in incidence between some English regions, reflecting differing access to expertise, variable commissioning approaches, and uncertainty regarding indications.

Perhaps most striking were the projections derived from these early data. Extrapolation of observed trends suggested that hip arthroscopy volumes could increase by >1,000% again by the early 2020s. In retrospect, these projections serve as a useful marker of the optimism—and uncertainty—that surrounded hip preservation surgery during this formative period.

Reversal of the Trend: Contemporary HES data (2010–2023)

Updated national HES analyses covering 2010–2023 demonstrate a clear inflection point. After an initial rise in activity, hip arthroscopy volumes peaked in 2014/15 and subsequently declined steadily. From peak activity to 2022/23, annual procedure numbers fell by approximately two‑thirds. Overall, there was a reduction of around 30% across the 13‑year period (Fig. 1).

The COVID‑19 pandemic undoubtedly contributed to the sharp fall in elective activity from 2019 onwards, but procedure volumes have not returned to pre‑pandemic levels despite recovery of elective surgical capacity. This persistence strongly suggests that the decline reflects deeper structural and clinical changes rather than temporary disruption alone.

Demographic patterns have remained broadly consistent, with a continued female predominance and a modest reduction in mean patient age. Geographic variation persists, although to a lesser extent than reported in earlier work, with approximately fourfold differences between regions. These findings indicate that while access may be becoming more uniform, substantial variation in service provision remains.

Insights from the NAHR: Volumes, Outcomes, and Maturity

The NAHR provides a complementary and clinically richer perspective on these trends. Now in its tenth year, the registry includes >14,000 recorded patient pathways and represents the largest non‑arthroplasty hip registry worldwide.

The 2025 NAHR report confirms that volumes of hip preservation procedures, including arthroscopy, remain below pre‑pandemic levels, with only modest recent recovery. Importantly, however, the registry consistently demonstrates substantial improvements in patient‑reported outcome measures following surgery when patients are appropriately selected. A high proportion achieve clinically meaningful improvements in terms of pain, function, and quality of life at short‑ and medium‑term follow‑up.

The NAHR also highlights evolving practice patterns, with increasing emphasis on outcome measurement, closer scrutiny of revision and conversion to arthroplasty, and growing interest in data linkage with national administrative datasets. At the same time, the report notes falling numbers of contributing surgeons, underlining challenges associated with voluntary registry participation in a lower‑volume environment.

Taken together, NAHR data suggest that hip arthroscopy in the UK has entered a phase of consolidation, with fewer procedures overall but also with stronger outcome evidence and clearer definitions of value.

Why Has Hip Arthroscopy Declined?

The convergence of HES, NAHR and expert analysis points to a multifactorial explanation.

• Pandemic acceleration of existing trends. While COVID‑19 clearly reduced elective activity, the sustained nature of the decline suggests that it accelerated use rather than initiated a move toward more selective use.
• Maturation of evidence and refined indications. Randomised trials and large observational studies have clarified that the benefits of hip arthroscopy are greatest in younger patients with minimal degenerative change and clearly defined FAIS. As these data have been disseminated, thresholds for surgery have become more consistent and selective.
• System‑level pressures and commissioning. In a publicly funded healthcare system, procedures perceived as discretionary or resource‑intensive face particular scrutiny. Ongoing elective backlogs, workforce constraints, and variable commissioning policies are likely to have influenced referral thresholds and access.
• The surgical innovation lifecycle. Commentary from the British Orthopaedic Association, including recent discussion in the Journal of Trauma and Orthopaedics, has framed hip arthroscopy as a classic example of surgical innovation maturation: early enthusiasm and rapid diffusion, followed by critical appraisal and recalibration of practice. The observed decline aligns closely with this model.

UK and European context

Comparable national‑level data from other European countries are limited, but available registry and administrative studies suggest similar patterns of recalibration rather than continued exponential growth in several publicly funded systems. Scandinavian registry data, for example, demonstrate increasing selectivity and strong emphasis on outcome measurement, echoing the UK experience.

These similarities suggest that healthcare structure, commissioning mechanisms, and cultural attitudes toward evidence adoption play an important role in shaping procedural trends.

Comparison with the United States and Rest of the World

In contrast to the UK experience, administrative data from the United States demonstrate continued growth in hip arthroscopy volumes through the late 2010s and early 2020s. Studies have shown near‑doubling of procedure numbers over recent decades, with projections of further increases.

This divergence likely reflects fundamental differences in healthcare systems, reimbursement models, and patient expectations. It also highlights that the UK decline should not be interpreted as a global retreat from hip arthroscopy, but rather as a system‑specific recalibration driven by evidence and resource considerations.

Future Perspectives and Implications for Training and Service delivery

Lower national procedure volumes have consequences beyond utilisation statistics. Hip arthroscopy has a recognised learning curve, and declining exposure risks concentrating expertise within a small number of high‑volume centres. While such centralisation may improve outcomes, it also raises concerns regarding equitable access and training capacity.

From a training perspective, deliberate strategies—such as regional hubs, mentorship models and simulation—may be required to ensure that future surgeons achieve and maintain competence. From a service perspective, transparent monitoring of regional access and outcomes will be essential to avoid widening inequity.

For ISAKOS members, the UK experience offers an instructive case study. The challenge now is to ensure that declining volumes translate into higher‑value care, supported by robust data capture, equitable access, and sustainable training pathways—rather than unintended loss of expertise. In that sense, the story of hip arthroscopy in the UK is not one of decline, but of maturation.

Fig. 1. Annual numbers and trend of arthroscopic hip surgery between 2010 and 2023 in England.

References

1. Palmer AJ, Malak TT, Broomfield J, Holton J, Majkowski L, Thomas GE, et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013. BMJ Open Sport Exerc Med. 2016;2(1):e000082.
2. https://www.boa.ac.uk/resource/jto-june-2025.html
3. https://www.nahr.co.uk/annual-reports/
4. Kolhe S, Khanduja V, Malviya A. TEMPORAL TRENDS AND REGIONAL VARIATION OF HIP ARTHROSCOPY AND PELVIC OSTEOTOMY IN ENGLAND FROM 2010 TO 2023. Orthop Procs. 2024;106-B(SUPP_6):48-48. doi:10.1302/1358-992X.2024.6.048

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