Surgeons’ predictions of benefit from meniscal surgery
Only 50% of surgeons’ predictions of outcomes after arthroscopic partial meniscectomy (APM) were correct. This value was higher for patients with the best outcomes (66%) than for patients with worse outcomes (34%). Moreover, the predictive ability was not different between experienced and non-experienced surgeons. Thus, surgeons are limited in their ability to predict outcomes in patients with non-obstructive meniscal tears. These are findings of a large study among orthopaedic surgeons in The Netherlands and Australia.
Despite the fact that meniscal tears are found on MRI in 60% of asymptomatic adults over 50 years with radiographic evidence of osteoarthritis, the decision to perform APM is among the most common in orthopaedics. Multiple randomised controlled trials failed to show the clinical benefit of surgery over conservative treatment or sham surgery; however, the number of APMs has not decreased accordingly.
Orthopaedic surgeons were presented 20 profiles of middle-aged patients with degenerative meniscus tears and asked to choose between APM or exercise therapy, estimate the how much they expected knee function to change for both treatments, and mention which factors led to their decision though an electronic survey. The primary outcome was the percentage of correct predictions.
The survey was sent to 1111 orthopaedic surgeons and residents active in The Netherlands and Australia. A total of 194 responses (17%) were received. Despite the fact that 89% of surgeons disagreed that APM is the preferable first treatment option, it was still chosen in 22% of cases. There was a greater likelihood of recommending surgery to patients who ended up being non-responders to surgical treatment.
The factors which more frequently led surgeons to suggest APM were locking complaints and traumatic etiology. However, the literature shows no added benefit of APM in patients with these factors, which, together with tradition, may explain why the number of procedures remains high in patients with degenerative tears.
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This is a very interesting study on various aspects. First, it reinforces the idea of no clear benefit of surgery over exercise in degenerative meniscus tears. Second, it shows that despite this being shown in the literature, it still has not resonated in daily clinical practice. Finally, it seems that despite claiming to know the latest evidence, surgeons still seem reluctant to acknowledge it. Thus, this is an article that definitely warrants a thorough read, even more so since it is free to access.
On a more personal note, I firmly believe these findings are in no way exclusive to orthopedic surgeons and/or degenerative conditions. I wonder how different the results would be if the authors asked physios which patients with a given condition would benefit from method/technique A, B or C? Deep down, this may be more due to human nature and resistance to change, even in light of improved information.
> Da: Van de Graaf et al., Br J Sports Med 54 (2020) 354-359. Tutti i diritti sono riservati a: The Author(s). Clicca qui per vedere il riassunto su Pubmed. Tradotto da .