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Editorial: Chance Encounters, Overdiagnosis, and Overtreatment

Leopold, Seth S. MD1

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Clinical Orthopaedics and Related Research: July 2022 - Volume 480 - Issue 7 - p 1231-1233
doi: 10.1097/CORR.0000000000002258
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There is lots to like about the annual meeting of the American Academy of Orthopaedic Surgeons, but my best memories all involve getting introduced to someone I’ve not met before and discovering an exciting personal or professional synergy.

This year, my chance encounter was with Teppo Järvinen MD, PhD, Director of the Finnish Centre for Evidence-Based Orthopaedics (FICEBO). He has the energy of a true believer but the scientific chops of a world-beating clinician-scientist who manages to get the necessary funding, lay down the infrastructure, and put together fantastic research teams to ask [5] and answer [6] our specialty’s most pressing clinical questions. He does so with the highest-quality evidence; many of FICEBO’s projects are organized around that rarest of rare birds, the randomized surgical trial. I’ve been following his work for years, though I did not know about the larger program and teams that he’s built; my bad. If you’re not aware of FICEBO and the work that Dr. Järvinen's team does there, you ought to be. It’s good stuff.

But this chance encounter got me thinking that not all chance encounters in orthopaedic surgery end so happily. A patient gets an MRI of the shoulder looking for one thing and finds something else, say a superior labrum anterior posterior (SLAP) tear or some rotator cuff fraying. An unnecessary spinal radiograph leads to an unhelpful MRI, which discovers a bulging intervertebral disc. A family doctor finds a degenerative meniscus tear. Shoulder, back, and knee pain are part of life and part of aging; when they overlap with age-related MRI findings, which probably do not have anything to do with the presenting complaint, we get overdiagnosis.

Unfortunately, overdiagnosis leads to more than just unhelpful tests and unnecessary costs. The kissing cousin of overdiagnosis is overtreatment, and treating overdiagnosed conditions, sadly, occurs far too commonly in orthopaedic surgery. There is considerable high-quality evidence that many orthopaedic procedures, including our interventions for meniscal findings with or without early arthritis in middle adulthood or later [11], many SLAP tears [15], subacromial “impingement” [13], low back pain attributed to lumbosacral degenerative spondylosis [4], and a host of age-related or “degenerative” findings in the low back and elsewhere in the human body [9], are no more effective at relieving pain or improving function than are sham operations, placebo interventions of other kinds, cognitive interventions, or exercises.

What I find most intriguing about this is that when I talk with knee surgeons about spinal fusions for back pain, they tend to be pretty certain that the evidence in favor of fusion is lacking, and the evidence against it is strong. When I talk to spine surgeons about whether shoulder surgeons should quit doing subacromial decompressions and be a good deal more selective about tackling SLAP tears and problems of the proximal biceps tendon, those spine surgeons are sure the answer is yes.

And they’re correct. But when I suggest to knee surgeons that we’re doing too much arthroscopy for the wrong reasons [11], I get some fairly pointed comments back [7]. (In fairness, same goes, more or less, when asking my friends in spine surgery about fusions, shoulder surgeons about subacromial decompressions, and so on.) I’ll leave it to the reader to speculate as to why this might be.

The harms, though, are obvious: Every year, hundreds of thousands of patients undergo unnecessary, unhelpful, painful procedures that result in time away from family, friends, and work. A subset of those patients will experience serious and sometimes catastrophic complications. And all of them—along with our healthcare systems—bear the considerable associated costs. I won’t go deeper on any of that, since by now, it’s a tale too often told, and one that’s lost much of its charm in the retelling.

Instead, I’ll focus on several solutions:

  1. If you’re a surgeon, there’s a good chance that one or more procedures in your specialty has been brought into the bright light for inquisition. If randomized trials—particularly those that have used sham surgery as a control or no-risk nonsurgical interventions (like cognitive therapy [4] or exercises [10])—are at odds with your ideas about your procedure’s efficacy, perhaps ask yourself this: What would it take in terms of new evidence to cause you to change your beliefs [12]? If you can’t conceive of a real-world-practical trial design that could change your mind, then we’ve moved from the realm of science to the realm of faith. Our beliefs should be hypotheses we test, not treasures we guard.
  2. If you’re a leader of one of our societies, step up. About 10 years ago, the AAOS joined with the ABIM Foundation in a wonderful initiative called “Choosing Wisely,” which encouraged surgeons to speak with their patients in ways that will lead to the selection of diagnostics and interventions that are supported by evidence, that minimize harm, and that are necessary [1]. The Academy recommended (and last year, updated its list of) 10 things we probably should avoid doing. Great concept. Unfortunately, the list included things that surgeons haven’t done for decades (like “needle lavage” for osteoarthritis of the knee) or don’t get paid to do anyway (like supervised exercise therapy and splints after carpal tunnel release). The only “update” between the 2013 [3] and the 2021 lists [2] involved removing a recommendation against using glucosamine and chondroitin. None of the operations I’ve mentioned in this editorial, despite ample evidence against, made the list of procedures to avoid, or even to question. The key norms of a profession include public recognition for the strict adherence to shared ethical standards and the exercise of special knowledge and skills in the interest of others [14]. If we’re seen as providers who recommend, perform, and are compensated for procedures that are no better than sham surgery, we will—deservedly—lose that recognition. Our societies should not shy away from identifying ways we can improve. I hope that the next iteration of Choosing Wisely will do just that.
  3. Read this month’s guest “On Patient Safety” column [8] by Teppo Järvinen MD, PhD, the director of FICEBO. His group is doing some of the best work in the world on the problem of overdiagnosis and overtreatment, and his perspectives on the topic deserve our time and attention.
  4. If you’re a clinician-scientist with an interest in the topic of overdiagnosis and overtreatment, send your work to CORR. Email me when you do so ([email protected]), and I will give it expedited processing. There may be no more important topic in all of our specialty.

References

1. ABIM Foundation. Choosing wisely. Available at: https://abimfoundation.org/what-we-do/choosing-wisely. Accessed April 29, 2022.
2. American Academy of Orthopaedic Surgeons. Ten things physicians and patients should question. Available at https://www.choosingwisely.org/societies/american-academy-of-orthopaedic-surgeons/. Accessed April 29, 2022.
3. American Academy of Orthopaedic Surgeons. Ten things physicians and patients should question. Available at: https://www.choosingwisely.org/wp-content/uploads/2015/02/AAOS-Choosing-Wisely-List.pdf. Accessed April 29, 2022.
4. Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69:1643-1648.
5. FICEBO. Projects. Available at: https://www.ficebo.com/projects/. Accessed April 12, 2022.
6. FICEBO. Publications. Available at: https://www.ficebo.com/publications/. Accessed April 12, 2022.
7. Getelman M, Stone J, Tokish JT, Cole B, McIntyre L, Stiefel E. Letter to the editor: editorial: the new AAOS guidelines on knee arthroscopy for degenerative meniscus tears are a step in the wrong direction. Clin Orthop Relat Res. Published online April 26, 2022. DOI: 10.1097/CORR.0000000000002218.
8. Järvinen T. On patient safety: shoulder “impingement”—telling a SAD story about public trust. Clin Orthop Relat Res. 2022;480:1263-1266.
9. Jonas WB, Crawford C, Colloca L, et al. To what extent are surgery and invasive procedures effective beyond a placebo response? A systematic review with meta-analysis of randomised, sham controlled trials. BMJ Open. 2015;5:e009655.
10. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. 2016;354:i3740.
11. Leopold SS. Editorial: the new AAOS guidelines on knee arthroscopy for degenerative meniscus tears are a step in the wrong direction. Clin Orthop Relat Res. 2022;480:1-3.
12. Leopold SS. Reply to the letter to the editor: editorial: the new AAOS guidelines on knee arthroscopy for degenerative meniscus tears are a step in the wrong direction. Clin Orthop Relat Res. Published online April 26, 2022. DOI 10.1097/CORR.0000000000002228.
13. Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ. 2018;362:k2860.
14. Professional Standards Councils. What is a profession? Available at: https://psc.gov.au/what-is-a-profession. Accessed April 29, 2022.
15. Schrøder CP, Skare Ø, Reikerås O, Mowinckel P, Brox JI. Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. Br J Sports Med. 2017;51:1759-1766.
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