Purpose The purpose of this study was to assess which factors were associated with the implementation of "Choosing Wisely" recommendations to refrain from routine MRI and arthroscopy use in degenerative knee disease. Methods Cross-sectional surveys were sent to 123 patients (response rate 95%) and 413 orthopaedic surgeons (response rate 62%) fulfilling the inclusion criteria. Univariate and multivariate logistic regression analyses were used to identify factors associated with implementation of "Choosing Wisely" recommendations. Results Factors reducing implementation of the MRI recommendation among patients included explanation of added value by an orthopaedic surgeon [OR 0.18 (95% CI 0.07-0.47)] and patient preference for MRI [OR 0.27 (95% CI 0.08-0.92)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own MRI experience than existing evidence [OR 0.41 (95% CI 0.19-0.88)] and higher estimated patients' knowledge to participate in shared decision-making [OR 0.38 (95% CI 0.17-0.88)]. Factors reducing implementation of the arthroscopy recommendation among patients were orthopaedic surgeons' preferences for an arthroscopy [OR 0.03 (95% CI 0.00-0.22)] and positive experiences with arthroscopy of friends/family [OR 0.03 (95% CI 0.00-0.39)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own arthroscopy experience than existing evidence [OR 0.17 (95% CI 0.07-0.46)] and belief in the added value [OR 0.28 (95% CI 0.10-0.81)]. Conclusions Implementation of "Choosing Wisely" recommendations in degenerative knee disease can be improved by strategies to change clinician beliefs about the added value of MRIs and arthroscopies, and by patient-directed strategies addressing patient preferences and underlying beliefs for added value of MRI and arthroscopies resulting from experiences of people in their environment. Level of evidence IV.

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