Arthroscopic knee surgery for degenerative meniscal tears is one procedure that should be used less frequently, according to surgeons.
In many cases, the procedure can be avoided with nonsurgical methods such as physical therapy, but patients believe that surgery is the best course of action to address a tear.
Three surgeons spoke with Becker’s to discuss what procedures in orthopedics and sports medicine are being used more often than they need to be.
Ask Orthopedic Surgeons is a weekly series of questions posed to orthopedic surgeons and leaders around the country about clinical, business and policy issues affecting orthopedic care. Becker’s invites all orthopedic surgeons and specialists to respond.
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Please send responses to Cameron Cortigiano at ccortigiano@beckershealthcare.com by 5 p.m. Central time July 29.
Note: Responses were lightly edited for clarity and length.
Question: What is the most overused procedure in orthopedics right now, and why does it persist?
Armin Arshi, MD. Orthopedic Surgeon at DISC Newport Beach (Calif.): In the realm of sports medicine and degenerative joint care, partial medial meniscectomy for degenerative meniscal tears in older patients remains significantly overused. Large-scale trials have repeatedly demonstrated that for middle-aged or older patients with stable degenerative tears and underlying osteoarthritis, physical therapy often yields outcomes equivalent to surgery. This persists due to the psychological impetus to “fix” a tear once identified on MRI, combined with the temporary relief provided by arthroscopic washout. However, I do believe there is still a role for arthroscopy in older patients with meniscus tears, but it must be specifically discussed so the patient fully understands what the surgery can and cannot help with. The key is transparency: Surgeons must clearly communicate what arthroscopy can realistically improve, such as mechanical catching or locking, versus what it cannot, such as pain from global arthritic wear. When patients fully understand these distinctions, the procedure shifts from an overused default to a targeted, effective tool.
David Gazzaniga, MD. Orthopedic Sports Medicine Surgeon and Division Chief of Sports Medicine at Hoag Orthopedic Institute (Newport Beach, Calif.): The most overused orthopedic procedure is arthroscopy for a degenerative meniscus tear. A recent study out of Finland has proven this to be true. The published 10-year data shows that people who had part of their meniscus removed (meniscectomy) because of symptoms from a degenerative meniscus tear were more likely to have a knee replacement or some other arthritis type of surgery 2.75 times more often than those who had a sham or fake surgery.
It’s still persisting today because of patient education. A patient may request an MRI, which shows the meniscus tear and then they demand surgery because they want to get rid of their pain. It takes more time to explain to them that they probably don’t need surgery, and it actually may be harmful to them, than it is to just say, “OK, let’s do it” in an office visit where you have limited time. This is the sort of thing that happens.
Also, and this is somewhat cynical, there’s more money in doing the surgery than there is in not doing the surgery. I really don’t want to go down that path. If you’re a patient, ask your surgeon about the study.. If you’re seeing a doctor who does a lot of meniscectomies, then believe it or not you should probably look for a second opinion. I do more meniscus repairs than I do meniscectomies by far.
Elizabeth Matzkin, MD. Orthopedic Surgeon and Chief of Women’s Sports Medicine of Brigham and Women’s Hospital (Boston): I am not sure there is a single procedure that is “overused,” but we could perhaps be better at trialing nonoperative management. I think in the U.S., we are “quicker” to operate than in other countries and cultures.
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