Intended for healthcare professionals

Editorials

Arthroscopic surgery for knee pain

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i3934 (Published 20 July 2016) Cite this as: BMJ 2016;354:i3934

Arthroscopic surgery for knee pain; where is the shared decision making?

Sir,

There seems to be a strong argument that there is significant overtreatment of knee pain with arthroscopy when alternative, less invasive and less expensive treatment options are equally effective. This is not only potentially harmful for patients, but also represents an inexcusable misuse of resources. Surely this is a situation that could be solved through the judicious application of shared decision making?

A brief search for patient decision aids in this area reveals the NHS/BMJ aid for knee arthritis which clearly states that arthroscopy probably won’t improve pain, increase mobility or stop disease progression [1]. Faced with this as a patient I think I would question why the option is even offered given that it also carries the risks associated with surgery. This begs the question; is shared decision making being practiced in these consultations? In 2012, the case for shared decision making in orthopedics was still considered to be “emerging” [2] and there is perhaps an emphasis on “informed choice” as opposed to “shared decision” [3].

The British Orthopaedic Association recently blamed GPs for the fact that too many patients are undergoing needless arthroscopy [4]. Their statement was inflammatory which unfortunately may have distracted from the very good point that easy access to MRI is likely to be leading to overdiagnosis of meniscal tears and subsequent overtreatment. Regardless, although patients may prefer a quick fix instead of weeks of hard work, no-one is forcing surgeons to perform arthroscopies that may not benefit patients.

This editorial and associated research highlights an exemplar for overdiagnosis and overtreatment. Shared decision making for the management of knee pain should begin in the GP surgery and continue through the patient’s treatment. Given the research findings, it would be difficult to see why patients who are adequately supported in the decision making process would be choosing surgery over physiotherapy.

1. BMJgroup, Shared Decision Making: Deciding what to do about osteoarthritis of the knee; online http://sdm.rightcare.nhs.uk/shared-decision-making-sheets/osteoarthritis... accesed 21.7.16
2. Youm, J., Chenok, K., Belkora, J., Chan, V. and Bozic, K.J., 2012. The emerging case for shared decision making in orthopaedics: J Bone Joint Surg Am, 94(20), pp.1907-1912.
3. Levinson, W., Hudak, P. and Tricco, A.C., 2013. A systematic review of surgeon–patient communication: Strengths and opportunities for improvement: Patient education and counseling,93(1), pp.3-17.
4. Proce, C., 2015. Orthopaedic groups apologise after claiming that ‘GPs not doing their job properly': Pulse online, http://www.pulsetoday.co.uk/clinical/more-clinical-areas/musculoskeletal... accessed 21.7.16

Competing interests: No competing interests

21 July 2016
Samuel J Finnikin
GP
Ley Hill Surgery