On Patient Safety: Orthopaedic Surgeons Must Stop Performing Arthroscopic Partial Meniscectomy on Patients with Arthritic Knees

Despite well-known concerns over its efficacy [12, 13], arthroscopic partial meniscectomy (APM) continues to be one of the most commonly performed orthopaedic procedures in the United States [5]. How can that be? I believe that because of the relative infrequency of adverse events related to APM, the orthopaedic community and our referring physicians view APM as a “bread-and-butter” operation that is a generally safe (and quick) procedure. Additionally, as noted in a recent Clinical Faceoff on this very topic [9], it is easy for an individual surgeon to believe that the evidence does not apply to his or her patients or our results—our patients are somehow different. But two recent studies [1, 4] sound the alarm on the serious long-term risks of APM and compel us to curtail its use in patients with arthritic knees as doing so may, in fact, worsen their health.

The first of these studies found that patients who underwent APM and were followed for at least 15 years were 10 times more likely to proceed with a knee arthroplasty compared to the general population [1]. The length of this study’s follow-up, and its vast size (nearly 1 million patients) were compelling, as were a number of its other findings, such as the authors’ observation that patients with a history of APM in only one knee, the risk of knee arthroplasty was three times greater than in their knee without a history of APM.

The findings of that enormous observational study [1] were substantially supported by a recent, large randomized trial that arrived at substantially the same conclusion [4]. Those authors found that patients treated with knee arthroscopy for meniscal tears in an arthritic joint were almost five times more likely to proceed to total knee replacement (while achieving no better pain relief) compared to those treated non-operatively [4]. Therefore, the most-obvious, and, indeed, quite alarming, conclusion from these studies is that the use of APM in patients with arthritic knees makes it more likely that they will undergo subsequent knee replacement.

While total knee replacement is an excellent option for many patients whose symptoms persist despite reasonable non-surgical treatments, the operation carries well-known life- and limb-threatening risks of its own [2]. It is wrong to use a procedure like APM that does not alleviate symptoms [3], but increases the chance that our patients will undergo even larger surgery later in the form of a knee replacement [1, 4].

Too many APMs are being done, and the evidence is clear that this is bad for our patients [1, 4, 11]. Surgeons must change this harmful practice pattern, and we can do this in several ways. First, we must acknowledge and accept the available, high-quality evidence: This operation doesn’t help our patients who have visible arthrosis, and now we see that it harms them. The phenomena of transfer bias (insufficiently long and complete follow-up) and assessment bias make it difficult for individual surgeons to judge their own results when it comes to treatments like APM [7], and we should understand that we often are easy graders of our own work [8]. Many surgeons who perform APM follow their patients for a couple of months; they may fail to connect a subsequent arthroplasty to the earlier arthroscopy. Indeed, they may not even know the arthroplasty happened.

At this point, there is more-than-ample evidence that APM has little or no role in patients with visible arthrosis, and there is some evidence that it lacks efficacy for degenerative meniscus tears in patients with little or no arthritis [6]. It seems to me that in those patients, as well, it likely carries the same risks as it does when performed in arthritic knees.

Second, we should educate our patients, referring doctors, and fellow orthopaedic surgeons about the safety concerns of this procedure. Although APM may seem quick and easy, it is by no means innocuous—we now know that its use in patients with degenerative meniscus tears in patients with arthritis (and perhaps even those without arthritis) causes more of them to have knee replacements than might otherwise undergo that major procedure [1, 4].

Third, we should push the American Academy of Orthopaedic Surgeons (AAOS) to help end the use of this procedure for these indications. Already, based primarily upon efficacy considerations, experts in our field have already called upon the AAOS to re-evaluate its appropriateness in patients with osteoarthritis of the knee [7, 14]. No action has yet been taken. However, in light of these new safety data [1, 4], it is essential that our Academy take several steps. The AAOS should update its appropriate use criteria and clinical practice guidelines to recommend against APM in patients with osteoarthritis. We should go a step further and amend the AAOS Choosing Wisely list to include APM. Its inclusion on this list (with supplemental information on its safety risks and ineffectiveness) could be useful in tamping down patient expectations that a simple procedure can effectively and safely treat their arthritis and help direct conversations to therapies—such as joint replacement or physical therapy—in which the expected benefits outweigh the risks. Both of these steps would be meaningful actions our academy can take to improve our patients’ safety.

The most-effective step our academy could take would be presenting the data on APM to insurers and the Centers for Medicare and Medicaid Services (CMS) to align insurance coverage of this procedure with safety and effectiveness data. The AAOS was a party to CMS’ decision to no longer cover arthroscopic débridement/lavage for osteoarthritis [10] and the AAOS should push for similar action now. In my experience, whether the issue is simultaneous surgery, surprise medical billing, or out-patient joint replacement, leaders of our Academy almost always suggest that physicians are best suited to offer effective solutions to the problem in question. We should do so now regarding the use of APM in patients with degenerative knee pathology.