On Patient Safety: Orthopaedic Surgeons Must Stop Performing Arthroscopic Partial Meniscectomy on Patients with Arthritic Knees.

Abstract

Despite well-known concerns over its efficacy [12, 13], arthroscopic partial meniscectomy (APM) continues to be one of the most commonly performed orthopaedic procedures in the United States [5]. How can that be? I believe that because of the relative infrequency of adverse events related to APM, the orthopaedic community and our referring physicians view APM as a “bread-and-butter” operation that is a generally safe (and quick) procedure. Additionally, as noted in a recent Clinical Faceoff on this very topic [9], it is easy for an individual surgeon to believe that the evidence does not apply to his or her patients or our results—our patients are somehow different. But two recent studies [1, 4] sound the alarm on the serious longterm risks of APM and compel us to curtail its use in patients with arthritic knees as doing so may, in fact, worsen their health. The first of these studies found that patients who underwent APM and were followed for at least 15 years were 10 times more likely to proceed with a knee arthroplasty compared to the general population [1]. The length of this study’s follow-up, and its vast size (nearly 1 million patients) were compelling, as were a number of its other findings, such as the authors’ observation that patients with a history of APM in only one knee, the risk of knee arthroplasty was three times greater than in their knee without a history of APM. The findings of that enormous observational study [1] were substantially supported by a recent, large randomized trial that arrived at substantially the same conclusion [4]. Those authors found that patients treated with knee arthroscopy for meniscal tears in an arthritic joint were almost five times more likely to proceed to total knee replacement (while achieving no better pain relief) compared to those treated non-operatively [4]. Therefore, the most-obvious, and, indeed, quite alarming, conclusion from these studies is that the use of APM in patients with arthritic knees makes it more likely that they will undergo subsequent knee replacement. While total knee replacement is an excellent option for many patients whose symptoms persist despite reasonable non-surgical treatments, the operation carries well-known lifeand limb-threatening risks of its own [2]. It is wrong to use a procedure like APM that does not alleviate symptoms [3], but increases the chance that our patients will undergo even larger surgery later in the form of a knee replacement [1, 4]. Too many APMs are being done, and the evidence is clear that this is bad for our patients [1, 4, 11]. Surgeons must change this harmful practice A note from the Editor-in-Chief: We are pleased to present our next installment of “On Patient Safety.” Dr. Rickert is on the clinical faculty at Indiana University School of Medicine and serves as President of The Society for Patient Centered Orthopedics. The goal of this quarterly column is to explore the relationships among patient safety, value, and clinical efficacy by engaging with diverse perspectives, including those of orthopaedic surgeons, patients, consumer and patient advocates, and medical insurers. We welcome reader feedback on all of our columns and articles; please send your comments to eic@ clinorthop.org. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. J. Rickert MD (✉), IU Health Southern Indiana Physicians, 583 S Clarizz Blvd., Bloomington, IN, 47401 USA, Email: jrickert1@iuhealth.org