Editor’s Spotlight/Take 5: Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study from Spain : Clinical Orthopaedics and Related Research®

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Editor's Spotlight/Take 5

Editor’s Spotlight/Take 5: Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study from Spain

Leopold, Seth S. MD1

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Clinical Orthopaedics and Related Research: November 22, 2022 - Volume - Issue - 10.1097/CORR.0000000000002493
doi: 10.1097/CORR.0000000000002493
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Readers who follow the editorial [15, 16, 19] and Editor’s Spotlight/Take 5 [17] pages here at Clinical Orthopaedics and Related Research® know that the topics of overdiagnosis, overtreatment, and ineffective surgery surface from time to time, and that the inappropriate use of arthroscopic partial meniscectomy for degenerative meniscus tears is something of a frequent flyer as well [14, 16]. This procedure gets more coverage because it is captured in an unhappy but important slice of the orthopaedic overtreatment Venn diagram: It’s among the most common operations that we perform, and compelling evidence suggests it’s no more effective than nonsurgical treatment [2, 3].

This means, by definition, that surgeons who perform arthroscopic surgery for degenerative meniscus tears with or without arthritis (and with or without so-called “mechanical symptoms” like roughness or catching) are harming patients.

We cannot ignore the evidence: At this point, about a dozen well-designed, randomized controlled trials confirm that fact [3, 9, 10, 12, 13, 26, 27, 28, 32], and I can find only one RCT [5]—a problematic study for reasons I’ve described before [14]—that suggests anything different. Evidence from two recent randomized trials has even questioned its use among younger patients, excluding those who present with locking [29, 31]. This puts the onus on those who think the operation helps to prove it. Calling on our “judgement and experience” [6] to wave away this mountain of evidence is self-deception in its worst form: We deceive ourselves [18] while hurting others.

It’s worth noting that arthroscopic partial meniscectomy in middle adulthood is only one of several widely used operations that fall into this category; similar arguments have been made about the relative inefficacy of arthroscopic subacromial decompression when compared with nonsurgical treatments [11], as well as spinal fusion versus cognitive intervention and exercises for degenerative disc disease [2]. That surgeons continue to perform these operations in such great numbers should cause us to feel some measure of professional shame.

And yet.

In this month’s CORR®, we learn that over the span of time when those randomized trials showing arthroscopic meniscectomy to be unhelpful were published, the standardized rate with which this procedure was performed in Spain increased by about one-third [20]. And, remarkably, the largest increases in the procedure’s usage occurred in older patients—those adults in middle adulthood and beyond—in whom the evidence most strongly suggests it should not be used. This trend may not be global [24], though this is far from clear [4, 20], and even in the summary report that found a general decline in the global usage of knee arthroscopy for these indications [24], the rate of that decrease is not as steep as it ought to be given how strong the evidence is regarding the ineffectiveness of this procedure.

The authors of this month’s Editor’s Spotlight study in CORR [20] come from several institutions in Valencia, Spain, that are charged with population-level healthcare issues. The paper itself, by Dr. Julio Doménech-Fernández and his team, is both well done and convincing.

Based on their study, along with the numerous RCTs that should more than nail the coffin shut on this operation, I wish that our professional societies would take a stronger stance in defense of our patients on this topic. Unfortunately, when one looks at our Academy’s clinical practice guidelines about arthroscopic meniscal surgery in patients with knee osteoarthritis [1] and public statements from individuals charged with leading another professional society [6], the opposite seems to be happening. If that were to change, such entities might surface the issue of orthopaedic overdiagnosis and overtreatment from the podium at meetings, in more thoughtful clinical practice guidelines, and in online patient-education materials.

But even were they to do so, I wonder whether it would work. It seems likely that modifying the financial incentives (or adding disincentives) may be the only way to curb our enthusiasm. It shouldn’t have to come to that.

I believe Dr. Doménech-Fernández's perspective on these issues will be worth your while. Join me in the Take 5 interview that follows to see why.

Take 5 Interview with Julio Doménech-Fernández MD, PhD, senior author of “Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study from Spain”

Seth S. Leopold MD:Congratulations on this well-executed, important study. How do the data showing increase in arthroscopic meniscectomy (especially among adults in middle adulthood and later) in Spain fit in with data from the rest of the world on this topic?

Julio Doménech-Fernández MD, PhD: Thank you. The evidence on the futility of meniscectomy in degenerative tears is beyond doubt. However, the translation of this new knowledge into clinical practice has varied across healthcare systems around the world, perhaps based on differing policies about continuing medical education or on the economic incentives in those healthcare systems. Arthroscopic meniscectomy rates have continued to increase in some countries while in others there has been a slight decrease or stabilization. Interestingly, in the places where there has been a reduction, it has been linked to information campaigns, restrictions imposed by health authorities, or changes in authorization protocols by insurance companies.

Julio Doménech-Fernández MD, PhD

In Spain, with a universal and free healthcare system, economic incentives have little weight because doctors are salaried. Therefore, Spanish doctors’ decisions depend more on how they acquire new knowledge and how they interpret it. It was surprising to see that in Spain, with a public health system with excellent health indicators, there is such a mismatch between evidence and clinical practice in this particular area. But neither our health authorities nor the Spanish or European scientific societies have campaigned to reverse this inappropriate surgical practice. Therefore, I believe the most powerful explanatory factor is the lack of diffusion of new knowledge or disbelief in the evidence on the part of Spanish surgeons.

Dr. Leopold:Why do you think the rate of arthroscopic meniscectomy increased the most in the group for whom there is the strongest evidence against its usage (older adults)? If the trends were similar in each group, I could sort of understand it, but I found that discovery—which seems almost perverse, given what we know—both troubling and confusing.

Dr. Doménech: There is no epidemic of meniscal tears, and there appears to be no great change in sporting or leisure activity. The increased availability of MRI may have triggered an increase in overdiagnosis in age groups where meniscal degeneration should be considered a normal age-related process. This would be a good example of inappropriate use of a diagnostic technique.

Since studies published in the early 2000s, arthroscopic lavage has been progressively abandoned as a treatment for knee osteoarthritis. It is possible that the increased availability of MRI has promoted the change of diagnosis from osteoarthritis to meniscal tear, allowing physicians to find a potentially treatable problem. Thus, in Finland [21] and in Canada [22], a reduction in the number of arthroscopic lavage procedures has been accompanied by an increase in meniscectomies. In Denmark, an increase in meniscectomies for degenerative tears was observed in parallel with an increase in MRI requests [7]. The number of MRIs per 10,000 inhabitants performed in 2018 in Spain is much higher than the average of the 26 countries of the European Union, ranking third behind Austria and France [23]. In this sense, we think that actions to try to reduce the number of unnecessary arthroscopies should also aim to reduce the number of unnecessary diagnostic studies. A study conducted in the Netherlands found that clinicians’ beliefs about the added value of MRI and arthroscopy, and their greater appreciation of their own clinical experience rather than existing evidence, hampered adherence to recommendations to reduce unnecessary MRIs and arthroscopic procedures [25].

On some occasions, the surgeon himself or herself knows the evidence but finds it difficult to apply. The mismatch between what the evidence tells us and what we do may generate a cognitive dissonance. By this, I mean that surgeons would like to believe what the evidence tells them, but this operation is something they have always done, and it generally goes well. So, we may be tempted to take cognitive shortcuts, such as thinking that the trials are not applicable in a particular patient or that the trials are flawed. The physician always wants to help the patient regardless of financial incentives, and not operating may feel like not helping; it may even feel negligent.

Medical reversal of a surgical practice is easier if there is an effective alternative. For example, metal-on-metal bearings in THA have been abandoned because of the complications they caused, but there are other, more effective bearings one can choose. In the case of meniscectomy for patients with degenerative tears, the alternative of conservative treatment has limited efficacy. It is difficult to explain to a patient with a meniscal tear that you are not going to operate. By the very nature of our work as surgeons, we tend to be very proactive in what we know we are technically good at doing. The patient usually seeks an immediate solution and pushes for it. We’ve all heard of Maslow’s hammer: If the only tool you have is a hammer, you tend to see every problem as a nail. This is a cognitive bias that implies an overreliance on a familiar tool. Adding to this is the perception that meniscectomy causes few complications; while true, it causes some, and they can be severe. This is important to consider if the operation itself is not effective.

Dr. Leopold:Do the roles that you and your authors have in Valencia and Zaragoza at the Institute for Health Research, the Foundation for the Promotion of Health and Biomedical Research, or the Spanish Network for Chronicity, Primary Care, and Health Promotion give you any sense for the usage in Spain of other procedures that are “coming under the microscope” lately? Subacromial decompression for “impingement,” spinal fusions for low back pain, and the like?

Dr. Doménech: The need for medical reversal, that is, to stop doing widespread but ineffective practices, affects almost all specialties. In a recent study [8] reviewing clinical trials in four leading journals, the authors found 396 commonly used medical practices that are of little value or cause harm. These should be targets for medical reversal.

In orthopaedic surgery, there are several procedures that should be abandoned or performed far less frequently considering the evidence that contradicts common practice. For example, vertebroplasty in osteoporotic fractures, osteosynthesis in distal radius fractures in older patients, surgery to treat fractures of the proximal humerus, and fusion with laminectomy for spinal stenosis all are performed too often. In our institution, Hospital Arnau de Vilanova in Valencia, Spain, the number of arthroscopic meniscectomies has been drastically reduced since 2014. We do not do vertebroplasties, and in patients having laminectomy for spinal stenosis, fusion is rarely performed. The number of osteosynthesis procedures and arthroplasties in patients with proximal humerus fractures has also been reduced. We have achieved this through various actions such as evidence-based protocols, reminders in clinical sessions, training in critical appraisal, evidence-based medicine skills and formative sessions with referring family physicians.

The first action to solve the problem of overuse of low-value interventions is to recognize the problem and to share information about it. On this point, CORR’s efforts are commendable, because elsewhere, the debate on medical reversal seems to have been sidelined. I hope that studies like ours [20] can alert healthcare system leaders to the need to take actions that promote change, and make surgeons reflect on their own practices.

Dr. Leopold:You mentioned a few suggestions to try to reverse the troubling trends you saw. I’d like to go through them one by one, as each is important. First, you talked about financial and regulatory strategies; what might be practical in countries whose healthcare systems are somewhat centralized, and how realistic are these kinds of strategies in countries—like the United States—where most surgeons are incentivized to operate?

Dr. Doménech: In general, all health systems have two strategies to reduce overutilization or low-value care: (1) attempt to reduce uncertainty (and ignorance), and (2) assume the presence of uncertainty and try to modify practice styles through restrictive measures. For the first, the measures directed at clinical decision-making include educative interventions to disseminate new knowledge, clinical pathways, decision-making aids for patients and physicians, and provide feedback on a clinician's performance compared with that of their colleagues or compared with evidence-based guidelines. Although these measures address the root of the problem—and they can be done both in public and private health systems—they take more time and have less effect than do more restrictive measures.

In terms of those measures, they differ depending on whether one is working in a public system, a universal healthcare system, or private practice. Regulatory measures may restrict access to specialists or use incentives to promote alternatives such as physical medicine and rehab, rheumatology, or physiotherapy. Financial measures are the most powerful disincentives but can have undesirable effects. For example, reducing compensation may lead paradoxically to increases in surgical volume to compensate. Cessation of funding for a procedure may lead to the choice of another company or another hospital setting, depending on the healthcare system.

Although restrictive measures or bans are more effective, personally I am more in favor of promoting change by convincing physicians and patients. Direct economic incentives may result in unexpected harmful effects, and they should be reserved for situations in which the evidence is incontestable. Restrictions and prohibitions are very effective but are badly perceived by physicians and patients and can have effects contrary to those desired.

Dr. Leopold:What other kinds of incentives might help?

Dr. Doménech: The evidence against arthroscopic knee surgery for the indications we’re discussing is so strong that the number of meniscectomies should be an indicator of quality in a hospital. It could be added alongside other usual performance indicators such as the number of infections, 30-day readmissions, or early hip fracture surgery. Quality indicators may result in changes to funding, but in a less direct way, and in a way less likely to have the unintended consequences I mentioned earlier.

We should push journal editors and organizers of specialty congresses to put medical reversal in the spotlight. One study indicated that trials that show a contradiction with common practice receive less attention in terms of the number of citations they receive [30]. In addition, trials that share negative results have more difficulty being published. This, too, is problematic, and it’s something that journal editors can address directly.

Finally, research is needed on how clinicians incorporate new evidence to make decisions and communicate with patients because human reasoning is not algorithmic, and decisions are influenced by heuristics, intuitions, emotions, and individuals’ values.


The author thanks Terence J. Gioe MD and Paul A. Manner MD for their thoughtful suggestions, which improved this essay.


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