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Recently, the New York Times asked why ‘useless’ surgery is still popular.1 In this editorial we outline three factors that likely promote continuing use of arthroscopic partial meniscectomy, for more than 350 000 middle-aged and older Americans (>35 years) annually. These operations occur despite there being no scientific evidence for a benefit over placebo and despite clinical guidelines increasingly recommending against arthroscopic partial meniscectomy. We close with a call to action recommending patients, clinicians, researchers and funders to act and stop supporting ‘useless’ medical treatments.
It sounds plausible! But so does ‘removing tonsils’…
A medical procedure is often accepted as effective if a logical story describes how symptoms arise and how the treatment provides a cure. The dogma that removing or trimming torn meniscal tissue is necessary to improve knee symptoms is outdated. Nine randomised studies provide strong evidence that knee arthroscopy provides no greater pain relief or other improvements when compared to placebo or added to exercise.2 Our recent randomised study compared exercise therapy of sufficient quality and quantity (1 hour, twice weekly supervised progressive neuromuscular and strength exercises for 12 weeks) to arthroscopic partial meniscectomy alone.3 Exercise therapy was superior to arthroscopic surgery for improving muscle strength3 and equally good at reducing mechanical symptoms (catching, locking, clicking, pain when twisting knee).4 The relationship between knee pain, mechanical symptoms and structural findings on MRI is not straightforward5 and surgery is not required to relieve mechanical or other symptoms.
Cognitive dissonance and confirmation bias
An orthopaedic surgeon posted a link to The New York Times article on ‘useless’ surgery1 on his Facebook page. To his surprise, none of his 700 Facebook-friends liked or shared the story. How can it be, he asked himself, that this story is perceived as uninteresting by surgeons? Cognitive dissonance may explain this, and contribute to the continued practice of ‘useless’ surgery. Cognitive dissonance is ‘the mental stress or discomfort experienced by an individual who is confronted with new information that conflicts with existing beliefs, ideas or values’. A related concept is confirmation bias, which refers to ‘how people read or access information that affirms their already-established opinions, rather than referring to material that contradicts them’. By resorting to selective reading and recognition, such as with the Facebook post questioning surgery, cognitive dissonance, that is, mental stress and discomfort can be reduced or avoided.
Reversal of medical procedures is difficult
Reversing the use of accepted medical procedures is notoriously difficult, even when subsequent high-quality evidence speaks against their use. Since the introduction of knee arthroscopy in the 1970s, arthroscopic partial meniscectomy has been increasingly performed. The procedure is described in textbooks and taught to orthopaedic residents worldwide. It is quick, and believed to require little, if any, rehabilitation. The complications are few, compared to other surgeries such as knee ligament reconstruction and knee replacement surgery. This history of knee arthroscopy, and its substantial financial incentives for the surgeon (and hospital in many cases), work against the reversal of ‘useless’ procedures despite there being consistent and strong evidence of their ‘uselessness’ since the first randomised trial in 2002.2
What can be done?
Patients and clinicians can engage in shared decision-making
Shared decision-making involves communication between the patient and clinician about treatment options based on the best available evidence. In 2012, the case for shared decision-making in orthopaedics was still considered to be ‘emerging’6 and the emphasis in orthopaedics is perhaps more on ‘informed choice’ than a ‘shared decision’.7 Surgeons, general practitioners, sport and exercise physicians and physiotherapists, all can improve their practice of shared decision-making, including the benefits and harms of different treatment options for knee pain.
Researchers can improve sharing and implementing their findings
Researchers can engage in developing evidence-based shared decision-making tools. Researchers can target patients directly by disseminating their findings through social media and lay press and engage in making evidence-based non-surgical treatments readily available for use in clinical practice, and importantly, evaluate their outcomes. Such implementation initiatives for patients with knee pain are emerging and have successfully been rolled out nationwide in Sweden (2008), Denmark (2013) and Norway (2015).8
Payers can halve their costs
It is time for third-party payers to ask themselves why ‘useless’ surgery is reimbursed in preference to effective supervised exercise therapy. In Sweden, an unexplained 20% increase in annual reimbursement costs and an audit revealing that half of hip, knee or shoulder procedures were unwarranted, which have led three major private health insurance companies to require preapproval by an ‘unbiased’ orthopaedic surgeon. The aim is to reduce financial incentives driving surgical rates.9
Finally, the public healthcare sector should encourage uptake of clinical guidelines by applying reimbursement policies that shift money from surgery to non-surgical treatments. Non-surgical treatments are recommended as first-line treatment for knee pain but increasingly also for hip, shoulder, back and neck problems.
Reduction of knee arthroscopy in favour of patient education, exercise therapy and weight loss for knee pain is just the first step towards a paradigm shift in evidence-based musculoskeletal care.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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