Triangular Fibrocartilage Complex (TFCC) Injuries

      Triangular Fibrocartilage Complex (TFCC) Injuries
                                 

                                         Dr KS Dhillon

Introduction

The triangular fibrocartilage complex (TFCC) is actually a complex structure which suspends the distal radius and ulnar carpus from the distal ulna and provides a gliding surface distal to forearm bones for three dimensional movements at the wrist. Wrist pain is a common condition which is often described as "Back Pain" of the wrist. Injuries to the TFCC are not uncommon and abnormalities of the TFCC are common even in asymptomatic individuals. There is no consensus in literature regarding the best way to treat injuries of the of TFCC, although most hand surgeons would like to believe that surgical treatment gives the best clinical outcome.

Anatomy of triangular fibrocartilage complex

The TFCC is the primary stabilizer (80% of the stability) of the distal radioulnar joint (DRUJ) and consists of the following structures:

• Dorsal and volar radioulnar ligaments
• Ulnocarpal ligaments; volar ulno-lunate, ulno-triquetral and ulno-capitate ligaments.
• Triangular fibrocartilage (TFC) disk
• Meniscal homolog
• Tendon sheath of the extensor carpi ulnaris

The triangular fibrocartilage (TFC) is a bowtie shaped disk that separates the DRUJ from the carpal joint and lies at the end of the ulna. The central portion is relatively avascular with poor healing power and its peripheral parts (10% to 40%) which merge with the radioulnar ligament are relatively vascular. The meniscal homolog lies between the ulnar styloid and the triquetrum and it joins with the extensor carpi ulnaris tendon sheath and joint capsule to form a ligamentous stabilizer. The meniscal homolog,TFC, extensor carpi ulnaris tendon sheath, and the ulnocarpal ligaments do not significantly contribute to overall DRUJ stability (1).The main stabilizers of the DRUJ are the volar and dorsal radioulnar ligaments which have both deep and superficial components and these ligaments arise from the medial border of the distal radius.

Classification for TFCC abnormalities

Palmer classification (2) is commonly used to classify TFCC abnormalities. Palmer divides TFCC abnormalities into two main classes with several subtypes.

Palmer Class 1 traumatic injury
A. Central perforation
B. Ulnar avulsion with or without distal ulnar fracture
C. Distal avulsion
D. Radial avulsion with or without sigmoid notch fracture

Palmer Class 2 degenerative injury
A - TFCC wear
B - TFCC wear with lunate and/or ulnar chondromalacia
C - TFCC perforation with lunate and/or ulnar chondromalacia
D - TFCC perforation with lunate and/or ulnar chondromalacia and lunotriquetral (LT) ligament perforation
E - TFCC perforation with lunate and/or ulnar chondromalacia, LT ligament perforation, and ulnocarpal arthritis

Class I Lesions (traumatic)

Class IA lesions are traumatic tears or perforations of the TFC proper. These usually are located 2-3 mm medial to the radial aspect of the TFC and are about 1 -2-mm in length. Sometimes there can be a flap of redundant cartilage along the palmar aspect of the TFC. These lesion occur in avascular portion of the TFC, they cannot heal.

Class lB lesions are traumatic avulsions of the TFC from its ulnar foveal attachment. These tears can be associated with fractures of the ulna styloid. These tears can lead to radioulnar instability because of their association with injury to the palmar and dorsal radioulnar ligaments.
Class IB lesions occur in vascular zone and can thus heal.

Class IC lesions are traumatic avulsions of the peripheral volar attachments of the TFCC, specifically the ulnocarpal ligaments. These lesions can lead to ulnocarpal instability.

Class ID lesions are traumatic avulsions of the radial attachment of the TFC in the region of the sigmoid notch and they may be accompanied by distal radial and sigmoid notch fractures. These lesion heal poorly because of poor vascularity.

Class II Lesions (Degenerative)

In Class IIA lesions there is degenerative wear or thinning of the articular disk without perforation. This wear results from  chronic axial forces, commonly seen with ulna variance.

In Class IIB lesions more degeneration is seen with TFC thinning,  chondromalacia of the lunate, triquetrum, or the distal ulna. Although the TFC wear is more advanced but there is no perforation of the TFC.

In Class IIC lesions there  is further degeneration with oval central perforation of the TFC.

In Class lID lesions, besides TFC perforation and chondromalacia there is lunotriquetral ligament perforation with lunotriquetral instability.

In Class lIE lesions, besides the large central TFC perforations, chondromalacia, lunotriquetral ligament disruption, there is ulnocarpal and sometimes distal radioulnar arthritis.

Diagnosis of TFCC injury

TFCC injuries present with ulna side wrist pain often associated with a click. Turning a door key is usually painful. Examination shows a positive "fovea" sign where there is tenderness in the space between the ulnar styloid and flexor carpi ulnaris tendon and between the volar surface of the ulnar head and the pisiform bone. The positive “fovea” sign apparently has a 95% sensitivity and 87% specificity for foveal disruptions of TFCC or ulnotriquetral ligament injuries.
Besides the fovea sign there are several other clinical test for the diagnosis of TFCC tears [3]. These include :

•  Screwdriver test – ulnar sided pain or click with passive maximum ulnar deviation and active forearm rotation against resistance or clench and ulnar deviate while passively rotating or grinding the wrist. 
• GRIT test – pain limited grip strength in supination versus pronation. The grip strength is measured in 3 forearm positions (neutral, full supination, and pronation). The supination and pronation values are calculated as a ratio relative to neutral grip. A ratio of more than 1 is equal to a high potential for ulnar impaction and for TFC tear.  
• Ulnocarpal stress test (TFC grind test) – ulnar sided wrist pain with rotation from supination to pronation while an axial load is applied, the forearm is in vertical position, and the wrist is in maximum ulnar deviation
• TFC shear test (pisiform boost test, ulno-menisco-triquetral dorsal glide test) – pain when pisiform is pushed dorsally by thumb while index and middle fingers translate ulnar head volarly
• Press test – ulnocarpal pain when seated patient lifts body weight off chair using affected wrist 
• Ulnocarpal meniscoid test (waiter’s test) – bringing wrist passively from extension to ulnar deviation and then flexing and applying axial load eliciting pain with supination

Prosser et al [4] studied the diagnostic value of provocative wrist tests and magnetic resonance imaging (MRI) in patients with suspected ligamentous injuries of wrist. They found that provocative wrist tests are only mildly useful for diagnosing wrist injuries and a MRI only slightly improves the diagnostic accuracy as compared to provocative test and is only mild to moderately useful in diagnosing wrist injuries.

Andersson  et al [5] in 2015 did a systematic review of the literature to study the efficacy of magnetic resonance imaging and clinical tests in diagnosis of wrist ligament  injuries. A minimum negative predictive value (NPV) of 95% was considered as clinically relevant cutoff value. A NPV is defined as the probability of an intact wrist ligament given a negative investigation. The NPV of MRI for TFCC tears was between 37% to 90% and the NPV of clinical tests was only 55%. They concluded that a negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the TFCC and clinical provocation wrist tests are of limited diagnostic value.

Prevalence of TFCC abnormalities on MRI of the wrist

Iordache et al [6] in 2012 studied the prevalence of TFCC abnormalities on MRI scans of asymptomatic wrists. They carried out MRI scans of the wrist in 103 asymptomatic volunteers. There was abnormalities of the TFCC in 39 wrists (37.86%). There was a complete tear of the TFCC in 23 wrists (22.5%). MRI abnormalities were seen in all wrists of subjects older than 60 years. The incidence of MRI abnormalities increased with age.

The authors concluded that the ‘prevalence of incidental TFCC findings in MRI scans of asymptomatic subjects is high’. Hence the presence of abnormalities on MRI of the wrist may be of questionable clinical meaning especially in those above the age of 50 years.
Chan et al [7] in 2014 did a systematic review and pooled analysis to see if  the prevalence of TFCC abnormalities regardless of symptoms increases with age. They found that the prevalence TFCC abnormalities increased from 27% in patients younger than 30 years to 49% in patients 70 years and older. In asymptomatic individuals the TFCC abnormalities increased from 15% to 49% in the same age groups. For symptomatic patients the prevalence ranged from 39% to 70% in patients between 50 and 69 years of age.

The authors concluded that since these abnormalities are so common they may be incidental findings. There is a need to find a reliable method to determine if these finding are the cause to the patients symptoms and we also need evidence to show that treatment improves symptoms better than placebo.

Treatment of TFCC injuries

Conservative or nonsurgical treatment for acute class I and class II TFCC injuries include temporary splinting of the wrist and forearm for 4 to 6 weeks, use of oral nonsteroidal anti-inflammatory medication (NSAIDs) , corticosteroid injections, and physical therapy. Surgical strategies include debridement, acute repair, and subacute repair.

Failure of conservative treatment may make surgery necessary. There are many surgical options available, depending on the type of lesion, including arthroscopic or open repairs of the ligaments and the disc, arthroscopic debridement,ulnar shortening, partial resection of the ulnar head (Wafer) or salvage procedures such as Darrach’s and Sauve‐Kapandji procedure.

Saito et al [8] in 2017 did a systematic review of the literature to study the outcomes of arthroscopic débridement for triangular fibrocartilage complex tears. They found 1723 studies of which there 18 studies which met the authors criteria. In 6 studies there was an increase in wrist flexion extension after the surgery and in 10 studies there was an increase in grip strength. In 6 studies the Disabilities of the Arm, Shoulder, and Hand scores improved and in 7 studies there was an improvement in pain visual analogue scale scores. Eighty-seven percent of patients returned to their original work.
The authors concluded that simple débridement can be performed with suitable satisfactory outcomes and few complication, though some patients may need further surgical procedures.

The authors of this article came under fierce criticism from fellow colleagues [8]. Henry and Ring [8] suspected that the data going into the above review was flawed. Of the 1723 studies found in literature on this topic, how is it that only 18 articles (1%) pertained strictly to arthroscopic triangular fibrocartilage complex débridement? It is very unusual to have only 18 studies in literature when wrist arthroscopy has been around for about 30 years and arthroscopic debridement is one of the most common wrist procedure carried out by arthroscopy. Could there be other relevant data hidden among those other 1705 publications? Henry and Ring believe that there is positive reporting bias in above review. We should be aware of  natural bias toward reporting positive outcomes and against reporting negative outcomes when we interpret the outcome of the review.

The major weakness of the review is that all 18 studies are uncontrolled case series (level IV evidence). Placebo effect of surgery can color the perception of the surgeons and the patients alike. We must resist drawing conclusions from uncontrolled level IV evidence data. What we need is studies like the one's done by Moseley et al [10] and Kirkley et al [11] who showed the futility of doing arthroscopic joint debridement for osteoarthritis (OA) of the knee. These two studies which included sham surgery provide level I evidence that joint debridement for OA is of no benefit to the patient.

We must avoid mistaking association for causation since TFCC abnormalities are common and often asymptomatic and hence we should not misinterpret the impact of therapeutic interventions [9].
Until sham-controlled trials are conducted, the value of arthroscopic debridement of the TFCC will remain unproven and potentially of no value.

Long-term follow-up studies to assess the durability of TFCC repairs and to see if the short term results of repairs deteriorate over time are needed.  The natural history of TFCC tears have to be studied and studies documenting the long term outcome of conservative treatment are also needed.

Conclusion

The anatomy of the TFCC has been well studied and elucidated and so has been the function of the TFCC. The diagnostic value of provocative wrist tests remains suspect and is of relatively low in diagnosis of TFCC injuries. The value of MRI in diagnosis is slightly better. Abnormalities of the TFCC are common and the incidence increases with age. Such abnormalities are often present in individuals who are asymptomatic. Although several surgical options are available in patients where conservative treatment has failed, the value these surgical options are suspect, since only uncontrolled level IV evidence data is available to support the use of these surgical options. In the absence of good data to support surgical intervention, conservative treatment should remain as the gold standard as is the case with treatment of osteoarthritis of knee in patient who are not suitable for a knee replacement.

References

1. Judy H. Squires, Eric England, Kaushal Mehta and Robert D. Wissman. The Role of Imaging in Diagnosing Diseases of the Distal Radioulnar Joint, Triangular Fibrocartilage Complex, and Distal Ulna. American Journal of Roentgenology. 2014;203: 146-153.
2. Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg [Am] 1989; 14:594-605.
3. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011 Aug;27(3):263-72. doi: 10.1016/j.hcl.2011.05.014.
4. Prosser R, Harvey L, LaStayo RP, Hargreaves I, Scougall P, Herbert RD. Provocative wrist tests and MRI are of limited diagnostic value for suspected wrist ligament injuries: a cross-sectional study. Journal of Physiotherapy 2011; 57(4): 247 - 253.
5. Andersson JK, Andernord D, Karlsson J, Fridén J. Efficacy of Magnetic Resonance Imaging and Clinical Tests in Diagnostics of Wrist Ligament Injuries: A Systematic Review. Arthroscopy. 2015 Oct;31(10):2014-20.e2. doi: 10.1016/j.arthro.2015.04.090.
6. Iordache SD, Rowan R, Garvin GJ, Osman S, Grewal R, Faber KJ. Prevalence of triangular fibrocartilage complex abnormalities on MRI scans of asymptomatic wrists. J Hand Surg Am. 2012 Jan; 37(1):98-103.
7. Chan JJ, Teunis T, Ring D. Prevalence of triangular fibrocartilage complex abnormalities regardless of symptoms rise with age: systematic review and pooled analysis. Clin Orthop Relat Res. 2014 Dec;472(12):3987-94.
8. Saito T, Malay S, Chung KC. A Systematic Review of Outcomes after Arthroscopic Débridement for Triangular Fibrocartilage Complex Tear. Plast Reconstr Surg. 2017 Nov;140(5):697e-708e. 
9. Henry SL, Ring DC. Discussion: A Systematic Review of Outcomes after Arthroscopic Débridement for Triangular Fibrocartilage Complex Tear. Plast Reconstr Surg. 2017 Nov;140(5):709e-710e.
10. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88.
11. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D'Ascanio LM, Pope JE, Fowler PJ. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359((11)):1097–107.

Epidemic of low value medical care and wastage of medical resources.

      Epidemic of low-value medical care and wastage of medical resources. 

                                                   DR KS Dhillon

What is unnecessary/ Low-value medical care?

Some investigators use the term unnecessary medical care but the majority prefer to use a milder term known as low-value medical care. Low-value medical care is defined as a service with little or no benefit or a service where the risk of harm outweighs any potential benefit. The risk is sometimes directly from the service and sometimes indirectly where the service will lead to extra tests and procedures which will provide little or no benefit to the patient but it may contain risks. Low-value medical care also increases health care spending without providing benefit to the patients.

What is wastage?

Wastage can be defined as an irrational, uncontrolled, and inconsequent use of valuable resources. The use of valuable resources should have a clear objective, purpose, and need, failing which the resources would be wasted. Inefficiency occurs when more resources than necessary are used to obtain a result and wastage occurs when resources are carelessly squandered by using resources for unproductive and wrong purposes.

The extent of the wastages

There is no literature available in Malaysia, on wastages of medical resources. However, in the USA, experts have estimated that the U.S. healthcare system wastes about $765 billion annually and this constitutes about a quarter of all the money that is spent on health care. A report by the National Academy of Medicine USA in 2012 estimated that $210 billion goes to ‘unnecessary or needlessly expensive care’ or to ‘interventions that do not benefit patients’ [1].

Healthcare budget

The healthcare allocations in Malaysia are given to the Ministry of Health and for 2018 the health ministry’s allocation was RM26.58 billion, a 9.5% or 1.7 billion increase compared to what it received in the 2017 budget [2]. This constitutes about 9.5% of the total allocation for the country of Rm 280.25 billion. Of the Rm 26.58 billion allocations for health care about RM4.1 billion (15%) goes to ‘medicines, drugs, medical aids and other consumables’[2]. The Malaysian government healthcare spending stands at about 4% of the nation's GDP (Gross Domestic Product).
The spending on health care, in 10 of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) ranged from 17.8% of GDP to 9.6% of the GDP in 2016. The spending was highest in the US at 17.8% while in other countries it varied between 9.6% (Australia) to 12.4% (Switzerland)[3].
It is generally agreed that a government should spend about 5% of its GDP for the nation to progress to universal health care [4]. There is a range of studies which suggests that to achieve universal health care, public health expenditure should be between 6% to 7% of GDP [5].
 A recent report by WHO did data envelopment analysis (DEA) which assesses and compares the performance of a nation on certain agreed indicators for service coverage and financial protection, relative to a country’s level of public spending on healthcare in per capita terms [6].
They studied the latest validated and published data (2012 or most recent) from 83 low and middle-income countries.
The DEA model identifies the best performing countries who have achieved greater performance relative to the level of sending as compared to their peers. The best performing countries are given a score of 100%. A score of 100%, however, does not imply that they have achieved or are even close to achieving UHC. It simply means that they have outperformed countries with similar levels of public spending on health care.
The six best ‘performer countries’ identified were Myanmar, Cambodia, Malawi, Rwanda, Thailand, and Cuba. Among the 27 upper middle countries studied Malaysia came in at 24 out of 27. Thailand and Cuba came at number 1 with a score of 100%. It, however, remains unclear why low-spending countries with similar levels of public spending have significant variations in performance. Inefficiency and wastages could be partly responsible for these variations.
At the hospital level, wastages are not uncommon and they come in the form of low-value care.

The epidemic of low-value care

Some investigators use the term unnecessary medical care but the majority prefer to use the term low-value medical care. Low-value medical care is defined as a service with little or no benefit or a service where the risk of harm outweighs any potential benefit. The risk is sometimes directly from the service and sometimes indirectly where the service will lead to extra tests and procedures which will provide little or no benefit to the patient but it may contain risks. Low-value medical care also increases health care spending without providing benefit to the patients. In recent years several investigators have studied low-value medical care.
Schwartz et al [7] studied a random 5% of the 2008–2009 Medicare beneficiaries claims data to analyze the extent of low-value medical services provided to Medicare patients. They found that in 2009, Medicare spent at least $1.9 billion on 26 types of tests and procedures which offered few or no health benefits to patients. They analyzed the data of 1.3 million Medicare patients and found that at least one in four patients received one of these ‘low value’ services.
When a narrower definition of low-value services was used, 25 percent of patients received at least one of the 26 wasteful services costing  $1.9 billion. On the other hand when a wider definition was used 42 percent of patients received at least one of the 26 wasteful services costing $8.4 billion.
Among the hundreds of health care services know to provide little or no benefits to patients only 26 procedures were analyzed in this study. In this study six service categories were analyzed which included ‘low-value cancer screening; low-value diagnostic and preventive testing; low-value preoperative testing; low-value imaging; low-value cardiovascular testing and procedures; and other low-value surgical procedures’ [7]. The list of 26 types of tests and procedures which offered few or no health benefits to patients that were analyzed included:

1.Cancer screening for patients with chronic kidney disease (CKD) receiving dialysis
2.Cervical cancer screening for women over age 65
3.Colorectal cancer screening for adults older than age 85 years
4.Prostate-specific antigen (PSA) testing for men over age 75
5.Bone mineral density testing at frequent intervals
6.Homocysteine testing for cardiovascular disease
7.Hypercoagulability testing for patients with deep vein thrombosis
8.Parathyroid hormone (PTH) measurement for patients  with stage 1-3 CKD (chronic kidney disease)
9.Preoperative chest radiography
10.Preoperative echocardiography
11.Preoperative pulmonary function testing (PFT)
12.Preoperative stress testing
13.Computed tomography (CT) of the sinuses for uncomplicated acute rhinosinusitis
14.Head imaging in the evaluation of syncope
15.Head imaging for uncomplicated headache
16.Electroencephalogram for headaches
17.Back imaging for patients with non-specific low back pain
18.Screening for carotid artery disease in asymptomatic adults
19.Screening for carotid artery disease for syncope
20.Stress testing for stable coronary disease
21.Percutaneous coronary intervention with balloon angioplasty or stent placement  for stable coronary disease
22.Renal artery angioplasty or stenting
23.Carotid endarterectomy in asymptomatic patients
24.Inferior vena cava filters for the prevention of pulmonary embolism
25.Vertebroplasty or kyphoplasty for osteoporotic vertebral fractures
26.Arthroscopic surgery for knee osteoarthritis

Their findings appear to be consistent with the believe that wasteful practices are pervasive in the US healthcare system. The authors believed that this was just the tip of the iceberg and that such practices were much more common. They were also surprised that these wasteful services were so prevalent in the United States [8].
Although similar studies have not been done in Malaysia anecdotal evidence suggests that the practice here in Malaysia is very similar to that in the US.
Elshaug et al [9]  reviewed a total of 5209 articles from the literature and they identified 156 potentially ineffective and/or unsafe medical services which are being provided to patients. The authors believe that low-value services have to be identified and low-value care has to be reduced so that the limited resources can be diverted to ‘more beneficial or cost-effective services, thus maximizing health gain’ [9].
Chassin et al [10] randomly sampled Medicare beneficiaries who had coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy in 1981 to study the appropriateness of the use of these procedures. They did a detailed review of the medical records and found significant levels of inappropriate use of these procedures. Inappropriate care was seen in 17% of cases of coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy.
There is no doubt that large amounts of money can be saved if these wasteful practices can be abandoned in the Malaysian government hospitals and the money thus saved can be diverted for use elsewhere in the healthcare system.
In the private health care system (excluding charity hospitals) in Malaysia, wastages is more difficult to stop because wastages bring in more income for companies managing the hospitals.

Patient safety, unnecessary surgery, and wastages

“There are many forces coming together to harm or even to kill the patients---their physician should not be one of them”
                                                       Arnold S. Relman, MD (1923-2014)
                                                       Editor Emeritus
                                                       The New England Journal of medicine
Medical errors and surgical complications remains a major problem in medicine due to ‘lack of physician-driven initiatives aimed at recognizing, preventing and mitigating’ these problems [11]. It is disheartening to know that it is ‘significantly safer to board a commercial airplane, a spacecraft, or a nuclear submarine than to be admitted to a U.S. hospital’ [11]. Medical errors rank as the 3rd leading cause of death, after heart disease and cancer, in the United States [12].
A medical error has been defined as an unintended act of either omission or commission, an act which does not achieve its intended outcome, an error of execution, an error of planning or a deviation from a process of care which would prevent harm to the patient [12]. One of the easiest ways to reduce errors, complications, and death would be by avoiding unnecessary surgery. Avoiding unnecessary surgery will also reduce cost and wastage.
Unnecessary surgery has been defined as surgery which is not indicated or needed and is not in the patients best interest. The scientific community has been aware of unnecessary surgery since the 1950s when Dr. Paul Hawley, the Director of the American College of Surgeons (ACS), said that “the public would be shocked if it knew the amount of unnecessary surgery performed (…)” [13].
Due to space constraints, only some examples of unnecessary surgery in orthopedics are analyzed and listed below.

Spine surgery

Gamache [14] in 2012 reviewed over a 14-month period, 155 patients who presented to his clinic for a second opinion and found that 69 (44.5%) of the patients did not need the spine surgery that was recommended to them by other spine surgeons.
Epstein NC [15] reviewed 437 patients with cervical or lumbar complaints who presented to the neurosurgical services over a 20-month period. Two hundred and fifty-four (58.1%) patients come for first opinions and 183 (41.9%) patients come in for second opinions. The author found that in 111 (60.7%) patients the surgery recommended by the previous surgeon was  “unnecessary”, in 61 (33.3%) patients “wrong” surgery was advised and only in 11 (6%) of the patients the “right” operation was advised. A “wrong” operation included operations that were overly extensive (multiple levels), or the approach (anterior or posterior approach) to the spine was wrong.
Arts et al. [16] in a study involving 82 patients who underwent additional spinal fusions for failed back surgery found that 65% of the patients had unsuccessful outcomes, which the authors classified as “unnecessary” spinal operations.
There have been several clinical trials which showed that spinal fusion for back pain is no better than conservative treatment [17,18]. Despite such evidence, the spinal fusion rates in the USA continue to dramatically increase [19].
Besides the spine, the other example where increasing rates of unnecessary surgeries are carried out is the knee.

Knee surgery

Arthroscopic partial meniscectomy

Arthroscopic partial meniscectomy is probably the most commonly performed surgical procedure in the world [20]. In the United States, more than 700,000 arthroscopic partial meniscectomies are carried out every year despite very good evidence (level 1) that arthroscopic partial meniscectomy in patients with degenerative meniscal tears is no better than sham surgery [21].

Arthroscopic debridement of the knee

Arthroscopic debridement of the knee joint for osteoarthritis is another operation that is commonly performed despite the presence of high level (level 1) clinical evidence that it provides no benefit to the patient [22,23].

Knee replacement

Riddle et al [24] studied the appropriateness of knee replacement in 205 patients. They found that the knee replacement was an appropriate procedure in 44% of the patients. It was inappropriate in 34.3% of the patients and in 21.7% of the patients, the appropriateness was inconclusive. The study showed that about a third of the patient had an inappropriate or unnecessary knee replacement.

Shoulder surgery

Arthroscopic subacromial decompression of the shoulder for subacromial shoulder pain is a commonly performed operation. In England, the number of patients undergoing subacromial decompression increased 7 times from 2,523 in 2000 to 21,355 in 2010 [25]. In the past, there have been controversial reports of the effectiveness of this surgical procedure and its value in the treatment of subacromial pain was uncertain. However in 2017 Beard et al published the outcome of a multicentre placebo-controlled trial which evaluated the effectiveness of arthroscopic subacromial decompression for subacromial shoulder pain [26]. They divided the patients into three groups, one group had arthroscopic decompression, the other only arthroscopy without decompression and the third group had no treatment. They found that the two surgical groups had a slightly better outcome as compared to no treatment group but the difference was of no clinical importance. The slightly better outcome was probably due to the placebo effect because the arthroscopy group had no surgical treatment.
The authors questioned the value of this operation and were of the opinion that this information must be shared with the patients who present with subacromial pain.
Even for the treatment of traumatic tears of the rotator cuff, there is no good evidence that surgery is better than conservative treatment. Recently there have been two prospective randomized studies which compared surgical and conservative treatments for rotator cuff tears and they found that there was no clinically significant difference in outcome between the two groups [27,28].

Removal of orthopedic implants

Implant removal after fracture union is one of the most common elective orthopedic procedure. A Finnish study showed that implant removal constituted about 30% of all planned orthopedic operations and 15% of all operations performed in their department [29].
A review of the literature shows that deep-seated stable implants are usually asymptomatic and most authors recommend that they should be left in situ even in children. Removal of implants is not as innocuous as is often believed. Besides anesthesia-related complications, there are surgery-related complications in 3% to over 40% of the patients. Implant removal is also associated with increased cost and time off work. In patients who complain of pain around the site of the implant, the actual cause of the pain is often not known and it could be due to the effect of the injury rather than the implant itself. In symptomatic patients removal of implants resolve the symptoms in only about 50 % of the patients [30].
There is no scientific evidence to support a routine removal of deep-seated orthopedic implants after fracture union though it is a common practice in many hospitals. Essentially, routine removal of asymptomatic deep-seated implants after fracture union can be classed as another example of unnecessary surgery which is quite rampant.
There are many other examples of unwarranted procedures, in other disciplines as well, which are frequently carried out such as tonsillectomy, appendectomy, CABG, hemorrhoidectomy, herniorrhaphy, prostatectomy, carotid endarterectomy, hysterectomy and cholecystectomy [31].

Why do surgeons continue to perform unnecessary surgery?

The often asked question is, how can a procedure which is contraindicated by research be so commonly carried out? Stahel et al [32] have framed the question very well when they asked: “Why would a reasonable surgeon consider performing unneeded surgical procedures?” They have come up with two answers from the surgeon’s perspective.
1. Surgeons perform surgery because they have been trained
to do so and that they have always been doing it that way and do not know any better. In German phycology, it is known as “Funktionslust” [33].
2. The other reason is that the surgeons are ‘incentivized to perform surgical procedures, either for financial gain, renown, or both’ [32].
It is obvious that it would be difficult to get people to do the right thing when they’re paid to do the wrong thing. Doctors are in a powerful position because of information asymmetry. Doctors know much more about medical treatment than patients do, hence doctors can recommend care which is of little or no value to enhance their incomes, partly out of habit and partly because doctors incorrectly believe in it. Unfortunately, many doctors have stopped being doctors and have become businessmen.
Besides the financial aspects, “availability heuristic,” also play a role. This term was coined by Nobel laureate psychologists Amos Tversky and Daniel Kahneman. It simply means that it is human instinct to base an important decision on an example which is dramatic and easy to recall even if that example is irrelevant or incredibly rare.

There is an avalanche of unnecessary medical care which is harming patients physically as well as financially. It also drains a large portion of the country’s healthcare budget.
Is there something that can be done about it?

Second Surgical Opinion Programs (SSOP)

Second surgical opinion programs were first introduced in the USA in 1974 specifically to reduce the rate of unnecessary surgery. Medicare and Medicaid programs strongly recommended the use of SSOP. By 1984 private health insurers also began to offer second opinion programs.
However, over the years enthusiasm for SSOPs cooled as more and more payers found that saving from this programs was not relevant and in some cases, it cost more than the savings [31].
 After the failure of SSOP to reduce the rate of unnecessary surgery, many believed that the introduction of practice guidelines may be of value.

Practice Guidelines

There is a lot of high-level scientific evidence available in the literature to guide appropriate treatment of patients. The challenge is to get doctors to assess this information and effectively use the information. The development of medical practice guidelines was an attempt to overcome this challenge. Now there are excellent practice guidelines easily available online from various professional specialty societies. The challenge now is to get doctors to treat their patients based on the best evidence available in these guidelines.
To date, however, there is no evidence that these guidelines have been effective in reducing the numbers of unnecessary surgeries.

Review of health care benefits

Another way to reduce unnecessary low-value medical care would be for the health insurers to stop paying for services which have been found to be of no value to the patients. The Australian government is taking steps in this direction by reviewing the Medicare Benefits Schedule to remove ineffective medical services from the schedule so that taxpayers do not have to pay for these services. The money thus saved can be more effectively used to fund more effective care.

Choosing Wisely

Choosing Wisely is an initiative of the ABIM Foundation which by advancing medical professionalism hopes to improve health care. Choosing wisely is one of ABIM Foundation’s most famous initiative. They help to promote conversation between patients and their doctors so that the patient can choose and get medical care which is supported by evidence, free from harm and is truly necessary. The various American specialist societies have provided recommendations, for the patients and the doctors, about what should not be done in the management of various medical conditions [34].
This initiative is relatively new and only time will tell if it is effective in reducing low-value medical care.

Tackling waste and inefficiencies in the ministry of health in Malaysia.

The above initiatives in US and Australia are for medical care of the citizens in private medical centers which the government pays for through Medicare. It is difficult for the government to control medical care in private hospitals.
In Malaysia, on the other hand, the government hospitals are run by the government and its employees, hence it should be relatively easy to control waste.
The Malaysian Health expenditure report 2013 shows that the public Malaysian healthcare expenditure has increased almost fivefold in 15 years from RM4,317 million in 1997 to RM19,797 million in 2011[35]. The government expenditure on health care as % of total expenditure on health care was 59.0% in the year 2000 and reduced to 55.5% in 2010 while the private expenditure on health as % of total expenditure on health care increased from 41.0% in the year 2000 to  44.5% in 2013 [35].
Pharmaceuticals constitute a large proportion of total health care expenditure in Malaysia as in many other low and middle-income countries. In Malaysia, ‘medicines expenditure has been increasing from MYR 1.61 billion in 2010, 1.76 billion in 2011, 1.98 billion in 2012 and 2.2 billion in 2013’ [36]. In 2012 medicine expenditure accounted for about 11.4% of the operating budget of the Ministry of Health Malaysia [36].
A World Health Organization/Health Action International (WHO/HAI) study in 2007 showed that medicine prices in our private healthcare sector were among the highest in the region. This is partly due to a free market economy where manufacturers, distributors, retailers and other private entities set prices of medications without government control [36].
These high prices not only makes it more difficult for patients to afford these medications but it also leads to wastage of healthcare resources.
In OECD (Organisation for Economic Co-operation and Development) countries, pharmaceuticals constitute a major source of operational wastefulness. The pharmaceutical spending in OECD countries comprises between 6.7 and 30.2% of national healthcare budgets. Bulk purchasing and replacing originator with cheaper generic drugs would be a good way to tackle waste of the healthcare budget [37]. This would hold true for Malaysia too, especially for the Ministry of Health. Switching from originator drugs to generic drugs, which have equal efficacy, can provide extensive price saving possibilities. This, however, requires a change in behavior amongst the doctors, pharmacists and the hospital authorities, over whom the pharmaceutical industry has great influence and traction. The pharmaceutical industry influences the prescribing behavior of the doctors to very large extent [38].
In Greece, the public hospitals have to reach a 50% share of generics in the total volume of drugs administered while in Japan pharmacists are given bonuses when more generics are used. In Greece and Ireland, the people pay for the difference between the cost of the originator and the generic drugs. People can also be persuaded to use generics if the reimbursement for generic drugs is higher than for the originator drugs [37].
There can be huge savings when there is a shift from expensive biologic medicines used in therapies for cancer and rheumatoid arthritis to cheaper biosimilar alternatives. The US and five European countries could save more than €50 billion (US$54.5 billion) by the end of 2020, according to estimates from the IMS Institute for Healthcare if they switch and replace eight key biologics with biosimilars drugs [37].
In the 1960’s, 70’s and 80’ the university hospital, University of Malaya Kuala Lumpur had an effective system of preventing pharmaceutical wastages. There was a drug committee consisting of several senior consultants and the pharmacist, which controlled what drugs should be bought and stocked in the hospital pharmacy. The lower ranking doctors such as medical and house officers could only sign off commonly used widely available drugs which were relatively cheap. Many of these drugs were generics. Prescriptions for any new expensive drugs had to be signed by a senior consultant who always asked for the reasons why the drug needs to be used.
Now I gather that there are no such checks and balance in the university and the government hospitals.
The other factors that contribute to wastages are the system of governance. The “giving and taking of bribes and the abuse of power for personal gain is widespread” in the healthcare industry. Furthermore, there are losses to fraud and error which has been estimated in 2015 to be about 6% of related health expenditure on average in OECD countries [37].
The other area of medical care that needs to be revamped to reduce wastages is the elimination of unnecessary investigations, procedures, and surgery.
Though reducing low-value care is a core component of healthcare reforms in many Western countries there appear to be no such reforms in Malaysia.
In our Malaysian private healthcare sector attempts at reducing wastage due to unnecessary care is unlikely to succeed anywhere in the near future because efforts to reduce overuse of healthcare services run counter to the dominant financial incentives in a fee-for-service system. Here more wastage translates to more revenue for all in the system including the doctors. Low-value care cannot be eliminated without the cooperation of the doctors.
In the public sector, it is much easier to control wastage due to unnecessary investigations, procedures, and surgery. The individual department heads in the university and ministry of health hospitals can have almost absolute control over the type and nature of investigations, procedures and surgery carried out in their department. Academy activities can be held on a monthly basis to update the staff on what is new and what the consensus is in the management of various medical disorders. Such academic activities were common at the University of Malaya hospital in the 1960s, 70s, and 80s. The department heads had sufficient control over the types of investigations, procedures and surgery carried out in their department.
Undoubtedly the efforts to reduce overuse has to be physician-led and increasing the visibility of low-value care, its harms and costs will go a long way to help reduce wastages due low-value health care. Disinvestment in low-value care should be made a priority.

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