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Letter to Editor: Editorial: Appropriate Use? Guidelines on Arthroscopic Surgery for Degenerative Meniscus Tears Need Updating

Rickert, James MD1,a; Boniface, Tom MD2; Burney, Dwight W. III MD3; Grogan, Tom MD4; Levin, Paul E. MD5; Piasio, Mark MD, MBA6; Rutherford, Rob MD7; Page, Alexandra E. MD8

Clinical Orthopaedics and Related Research®: September 2017 - Volume 475 - Issue 9 - p 2346–2347
doi: 10.1007/s11999-017-5428-0
Letter to the Editor

1The Society for Patient Centered Orthopedics, Bloomington, IN, USA

2North East Ohio Medical University, Rootstown, OH, USA

3Albuquerque, NM, USA

4Private Practice, Los Angeles, CA, USA

5Department of Orthopaedic Surgery, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA

6Medical Management, UPMC Health Plan, Pittsburgh, PA, USA

7Coeur d'Alene, ID, USA

8Musculoskeletal Health Care Solutions, La Jolla, CA, USA


Received June 13, 2017/Accepted June 20, 2017; previously published online June 27, 2017

(RE: Leopold SS. Editorial: Appropriate use? Guidelines on arthroscopic surgery for degenerative meniscus tears need updating. Clin Orthop Relat Res. 2017;475:1283-1286).

The author certifies that neither they, nor any members of their immediate families, 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.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

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®.

To the Editor,

We at the Society for Patient Centered Orthopedics appreciate Dr. Leopold's call for the American Academy of Orthopaedic Surgeons (AAOS) to update their appropriate-use criteria regarding partial meniscectomy in patients with osteoarthritis of the knee [4]. The clinical evidence he documents makes a highly compelling case. We also agree with Dr. Zywiel and his colleagues [7] that physicians are best suited to lead efforts to improve medical effectiveness by developing and implementing evidence-based guidelines. Absent such physician leadership, insurers and other payers will inevitably follow a blunt instrument approach that includes both effective and ineffective surgical procedures. This will lead to increased frustration for both patients and their surgeons.

As a small orthopaedic society, we have been engaged with insurers, such as Blue Shield of California, in developing patient-centered, evidence-based preauthorization and evaluation programs to help maximize the effectiveness of orthopaedic care. This includes a focus on shared decision making and the development of evidence-based decision aids to help patients better understand the risks and benefits of proposed procedures. We hope the AAOS will become an even bigger player in this space and make such efforts a core component of our quality programming.

We believe that the list of low-value interventions is long and includes such procedures as open reduction and internal fixation of adolescent clavicle fractures, vertebroplasty, and repair of degenerative rotator cuff tears in elderly individuals. For these interventions, there is either scant evidence of their need and effectiveness or good evidence for low-value [1-3, 5, 6]. We urge the AAOS to call attention to these low-value orthopedic procedures through public forums such as the Choosing Wisely campaign

A sharp focus on higher-value care will undeniably lead to changes in current practice patterns and will not be universally accepted; however, it will undoubtedly lead to both higher-quality care delivered to our patients and higher levels of physician satisfaction over time. These efforts deserve no less attention and resources than does our work developing new, effective treatment options. Both lead to better value for our patients.

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1. Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P, Wriedt C, Graves S, Staples MP, Murphy B. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009;361:557-568 10.1056/NEJMoa0900429.
2. Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson DJ, Diamond TH, Edwards R, Gray LA, Stout L, Owen S, Hollingworth W, Ghdoke B, Annesley-Williams DJ, Ralston SH, Jarvik JG. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med. 2009;361:569-579 10.1056/NEJMoa09005632930487.
3. Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Äärimaa V. Treatment of nontraumatic rotator cuff tears: A randomized controlled trial with two years of clinical and imaging follow-up. J Bone Joint Surg Am. 2015;97:1729-1737 10.2106/JBJS.N.01051.
4. Leopold SS. Editorial: Appropriate use? Guidelines on arthroscopic surgery for degenerative meniscus tears need updating. Clin Orthop Relat Res. 2017;475:1283-1286 10.1007/s11999-017-5296-7.
5. Moosmayer S, Lund G, Seljom US, Haldorsen B, Svege IC, Hennig T, Pripp AH, Smith HJ. Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: A randomized controlled study in 103 cases with a five-year follow-up. J Bone Joint Surg Am. 2014;96:1504-1514 10.2106/JBJS.M.01393.
6. Schulz J, Moor M, Roocroft J, Bastrom TP. Pennock AT Functional and radiographic outcomes of nonoperative treatment of displaced adolescent clavicle fracture. J Bone Joint Surg Am. 2013;95:1159-1165 10.2106/JBJS.L.01390.
7. Zywiel MG, Liu TC, Bozic KJ. Value-based healthcare: The challenge of identifying and addressing low-value interventions. Clin Orthop Relat Res. 2017;475:1305-1308 10.1007/s11999-017-5298-5.
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