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

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

“…As you point out [4], my views on the topic of the inappropriateness of arthroscopic meniscectomy in these clinical settings are widely available [10-14], so I will try to keep this brief, but I did feel some response was called for out of respect to you for writing such a thoughtful letter.…”

“…The letter-writers’ concluding suggestion that we should rely on surgeons’ “experience” when there is so much robust evidence from actual clinical trials is, as I’ve said before [14], a bad idea. Our “experience” in practice is colored by our perceptions, which, in this situation, are misleading for at least several reasons: (1) Most surgeons follow their patients after arthroscopic partial meniscectomy for a few months, maybe less, which is long enough for the immediate post-operative pain to resolve but not long enough to see whether the intervention provides any durable benefit; (2) dissatisfied patients tend to go elsewhere for follow-up (often from an arthroscopic surgeon to an arthroplasty surgeon, in this circumstance), and most surgeons who perform these arthroscopic procedures don’t know what proportion of their patients have had a reoperation or a knee replacement; (3) surgeons grade their own work, and surgeons, like many people, tend to grade themselves generously; and (4) the impact of confirmation bias is strong here, in that we expect our operations to work and we interpret what we see in light of that expectation.…”

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Dear Dr. Brown and colleagues, Thank you for taking the time to write in. Post-publication dialogue is important, and I'm grateful to you for engaging with me on this one.As you point out [4], my views on the topic of the inappropriateness of arthroscopic meniscectomy in these clinical settings are widely available [10][11][12][13][14], so I will try to keep this brief, but I did feel some response was called

…”

Editorial: Chance Encounters, Overdiagnosis, and Overtreatment

“…Instead, I’ll focus on several solutions: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.…”

On Patient Safety: Shoulder “Impingement”—Telling a SAD Story About Public Trust

“…In fairness, our experience does matter, and our motives are good; we want to help. But we have to remember that using our own surgical experiences as a data source suffers from exactly the same problems as do case series, or worse [15]. Two of these shortcomings are follow-up that is insufficiently long or complete (remember, the missing usually are not doing as well as the accounted for, and a lot of patients in a surgical practice do not follow-up as instructed) and the general lack of an objective outcomes tool (our own observations are not very rigorous in this regard).…”