Musculoskeletal

Even experienced surgeons can’t pick who’ll benefit from knee surgery


As accurate as a coin toss – that’s an assessment of the ability of orthopaedic surgeons to predict which patients will benefit from an arthroscopic partial meniscectomy (APM) over non-surgical management of a non-obstructive meniscal tear.

An online survey of 194 orthopaedic surgeons in the Netherlands and Australia asked them to predict the outcome of 20 patient profiles representing participants in the ESCAPE trial. The 20 profiles comprised the most improved and least improved patients in both the surgical or exercise treatment group.

Overall, 50% of the 3,880 predictions were correct – with little difference between experienced knee surgeons and other surgeons (50.4% v 49.5%).

However the majority of surgeons (78.4%) indicated they would choose exercise therapy as the preferred treatment for the patients.

“Patient characteristics that direct surgeons towards APM include bucket handle tears (94% of surgeons), knee locking (82%), failed non-operative treatment (82%), traumatic aetiology (76%) and age <45 years (74%), while characteristics that direct surgeons towards exercise therapy include moderate to severe osteoarthritis (96%), degenerative aetiology (92%), no obstructive complaints (88%), age >45 years (87%) and obesity (79%),” the study authors said.

About half the respondents said evidence-based medicine was more important in their clinical decision-making than personal experience and most (77%) said they were completely up to date with the evidence for management of meniscal tears.

However the study’s authors said the evidence was against them.

“Surgeons’ criteria used for deciding that surgery is indicated in a sample of patients with degenerative meniscal tears resulted in a prediction as accurate as a coin toss. This was true regardless of a surgeon’s experience.”

“This suggests that non-surgical management is appropriate as the first-line therapy in these patients. We respectfully recommend that orthopaedic surgeons should rely more on the objective evidence from the literature when choosing treatment options.”

One of the co-authors on the study Professor Ian Harris, from the Whitlam Orthopaedic Research Centre in Sydney, told the limbic that rates of partial meniscetomy were declining in Australia but with some states doing better than others.

Rates in South Australia and WA were still much higher than in NSW.

And although surgeons said in the survey they would choose exercise as a first-line therapy, that may not be reflective of practice, he said.

“The main point is that they cannot pick who will benefit from surgery and who will not, yet that is what they claim, and that is what drives surgery.”

Partial meniscectomy for a degenerate meniscal tear was in the ARA’s ‘top five’ list of low value practices to avoid.

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