Continuing Professional Development (CPD): Does it help improve the safety and quality of care provided for patients and the public?

Continuing Professional Development (CPD): Does it help improve the safety and quality of care provided for patients and the public? 

                                               Dr KS Dhillon

CPD and CME

How did the concept of continuing medical education (CME) come about? Through the 1960’s many believed that drug advertising was educational and many physicians relied on information provided by the pharmaceutical industry. Industry funders were choosing the subjects offered in the talks provided and the drug firms provided commercially biased prescribing information which led to inappropriate drug use. Policy makers decided to provide an alternative which saw the birth of the concept of CME in the USA [1]. In USA they started granting CME recognition awards to doctors in the 1960s.
The European Union of Medical Specialists (UEMS) first made the move from CME to CPD. UEMS defined the term CPD thus ‘(t)he term CPD acknowledges the wide-ranging competencies needed to practice high quality medicine, including medical, managerial, ethical, social and personal skills. CPD therefore incorporates the concept of CME, which generally is taken to refer only to expanding the knowledge and skill
base required by doctors’ [2].
The CPD subcommittee of Academy of Medical Royal Colleges (AoMRC) has put forth a succinct definition of CPD. They defined CPD as ‘a continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour, CPD should also support specific changes in practice’ [3].
This definition emphasizes two important aspects of CPD i.e gaining knowledge and improving patient care.
Although CPD and CME are frequently used interchangeably the current literature considers CME as an ingredient of CPD. Many countries are moving from skill and knowledge based CME system to a CPD system which promotes competencies in a wide range of areas resulting in high quality medical practice [4].

International perspective of CPD

Murgatroyd (4) in 2011 did a study to evaluate the international perspective of CPD programmes and requirements for doctors. The study involved 25 countries from around the world to form an overview of CPD. The countries studied were from Europe, North America, Africa, Australasia and Asia. Out of the 25 countries as of 2011, France had no CPD requirement, in 7 countries CPD was voluntary (including Malaysia) and in 17 countries (including Singapore) CPD requirements were compulsory. In Canada the yearly credit requirements were the highest at 80 credits and it was the lowest in Kenya at 5 points. In Singapore the requirement was 25 credits per year.
Regulatory bodies in countries where CPD is mandatory have developed standards and have guidelines on the use of CPD, although these standards and guidelines vary from country to country. Each country has its own minimum numbers of credit requirement per year to fulfill the regulatory body’s requirements. In majority of the countries it is between 40 to 50 points. There is no international, standardised system for obtaining CPD credits, though in most countries 1 credit point is given for 1 hour of CPD activity [4].
The CPD scheme is delivered by different bodies in different countries and these include accredited providers, universities, specialist societies, specialist boards, specialist colleges, professional societies and medical associations.
In countries with compulsory CPD requirement, failure to obtain the required credits would result in sanctions ranging from suspension from register, fine, reprimand, removal from register, removal of licence, retake examinations, licence loss /fees reduced and loss of status plus fees [4].

Effectiveness of continuing professional development

CPD is suppose to keep the doctor up to date in clinical knowledge and in practice so that he/she can provide high quality care to the patients. CPD is suppose to keep the doctor safe to practice and it is suppose to improve the quality of service provided. Hence CPD and high quality of care are supposed to be irretrievably intertwined. Having said that it is also known that new knowledge does not always translate into a change in behaviour [5].
Knowledge translation is an interesting concept. It ‘describes any activity or process that facilitates the transfer of high-quality evidence from research into effective changes in health policy, clinical practice, or products’ [5].
There is obviously a need to amalgamate elements of education, research and quality improvement in daily clinical practice to improve patient outcomes.
There are however obstacles to this knowledge translation. In orthopaedic surgery for example there is level I evidence that arthroscopic knee joint debridement and arthroscopic partial meniscectomy serves no purpose in the treatment of patients with knee OA and patients with partial tear of the meniscus respectively, yet these are the most common operations performed in clinical orthopaedic practice around the world. This is an example of an instance where validated evidence has failed to achieve widespread implementation. More research in knowledge translation is needed where the discrepancies between what is known and what is done can be determined.
Schostaka et al [3] studied the effectiveness of continuing professional development (CPD). They found that that the effectiveness of CPD is related to the impact it has on knowledge, skills, values, attitudes, behaviours and changes in practice it produces in the workplace. The quality of CPD will dictate the improvements which will occur in the quality of the professional practice which is required for delivery of service. Learning in the professional setting was found to be most useful. There is a definite need for an ‘in-dept identification of learning needs’ both within and external to the place of work [3].
There is some consensus that CPD is useful when it addresses the needs of the clinicians, the patients they serve and the organization where they work. However, the effectiveness of CPD programs which are very diverse and not uniform, remains uncertain. The assessment of outcome of CPD activities remains difficult.

CPD in Malaysia

In Malaysia CPD is and has been voluntary. However, on 1st July 2017, the
Medical (Amendment) Act  2012, which is the amendment to the Medical Act 1971, and the Medical Regulations 2017 which replaces the Medical Regulation 1974, came into force.
Section 28(2)(b) of the Medical Regulations 2017 makes it mandatory for  registered medical practitioners to obtain a stipulated number of CPD points to make them eligible for the Annual Practising Certificate (APC).
This requirement will take effect for submissions received on or after 1 January 2019. The present requirement for the APC is 20 CPD points which are accumulated in a year. The collection of CPD points for the application of APC for a CPD year will be from 1st July to 30th June.
The medical practitioner is expected to take responsibility for his/her own  learning and professional development. The medical practitioner is expected to identify his/her educational needs and plan the CPD activities to be undertaken.
The practitioner is ‘encouraged’ to undertake CPD activities that are relevant to his/her field of practice and which will support his/her professional development. There is however no compulsion to undertake CPD activities in one’s own medical field or speciality. The doctor is advised to attend CPD activities that have been approved by the CPD review committees [6].
The Malaysian Medical Council – Continuing Professional Development  (MMC-CPD) grading system scoring schedule 2018,  is divided into 9 categories from A1 to A9.

A1- Medical congress (Local/International) - Attendance for 3 full days allows participant to earn a maximum of 20 points. A full day is 5 to 8 hours. Points for 1 day is 8, two days is 16 and three or more days is 20 points. The speakers at the congress must be of international standing. The guidelines however does not state what is speaker of international standing. The congress should contain plenary lectures /symposia. Presentation of free communication /poster (sic), etc should be allowed at the congress.

A2--Scientific Meetings of Academy / Universities /Colleges / Association / Institutions. Maximum points per meeting is 20 points.
a. 1- 2 hours 2 points
b. 2-4 hours (½ day) 4 points
c. 5-8 hours (full day) 8 points
d. 2 Full days 16 points
e. 3 or more full days 20 points

A3--Workshops/Course/ study tour which includes hands-on & skills
courses.
a. Half day (2-4 hours) 4 points
b. Full day (5-8 hours) 6 points
c. Two full days 10 points
d. Three or more full days 15 points
e. Skills accredited courses by specific disciplines (e.g. ALS, PALS, NRP, MTLS) 20 points.
f. Study tour 5 points

A4--CME session/ other professional activities. This include topic seminar, forum, lectures, formal ward rounds (teaching rounds), clinic attendance, hospital clinical meeting, video presentation, medical video conferencing, morbidity and mortality reviews, epidemiological reviews.
         a.Organising chairman for a scientific meeting gets 5 pts/ meeting
         b. Topic seminar 1 point/hr
         c. Forum 1 point/hr
         d.Lectures 1 point/hr (postgraduate lectures are not eligible for points)     
         e. Ward rounds 1 point/hr
         f. Clinic attendance 1 point/hr
         g. Hospital clinical meeting 1 point/hr
         h. Video presentation 1 point/hr
         i. Medical video conferencing 1 point/hr
         j. Morbidity and mortality  reviews 1 point/hr
         k. Epidemiological reviews 1 point/hr

A5 --  Presentation at meetings.
Plenary lecture/long paper/free paper/short paper/poster/other lectures, hospital clinical meeting, CME sessions, public medical talks
a. Free paper/ short paper/poster 10 points
b. Plenary lecture / long paper 10 points
c. Lecture presentation 5 points
d. Hospital clinical meeting 5 points
e. CME session 5 points
f. Public medical talk 5 points

A6 ---Publications of original articles in journal/ chapters in book / reports & important role in journal.
Publication of original articles in journal /chapters in books/reports
a. Indexed/peer reviewed journal (authors) 20 points
b. Non-indexed journal (authors) 10 points
c. Chapters in book (authors) 10 points per chapter
d. Reports e.g. Technical reports, working papers etc. 10 points
e. Editor 10 points,
         F. Member of Editorial Board 5 points
         G. Referee/reviewer (per article) 5 points

A7-- Self-study/group study/distance learning.
Reading scientific papers from indexed journals, organised
group discussion under accredited co-coordinator 1point per
paper or session. There needs to be documented evidence of the activity in the form of self administered MCQ  or documented evidence in the form of synopsis / evidence table.

A8-- CME Online. One point  per article or session. It requires accreditation of the providers by the CPD board.

A9--Special interest training courses (Short training courses/ Fellowship / Attachment).
These should be conducted by relevant recognised authorities - local or international which have been verified by the CPD committee.
Points are given only once, on completion of studies.
a. >3 - 6 months 20 points
b. >6 months - 1 year 30 points

The introduction to the guidelines for CPD, for medical practitioners in Malaysia by the Malaysian medical Council states that ‘the medical profession has not only a legal but a moral duty to promote high standards of patient care. Medical practitioners must be updated and competent throughout their working life by regularly participating in continuing professional development activities. The amendments to Medical Act and the Regulations were made to ensure that this objective is realised.

Does obtaining 20 CPD points ensure that the medical practitioner is uptodate and competent?The answer would probably be no.
The guideline encourage the medical practitioners to undertake CPD activities that are relevant to their field of practice and will support their professional development but there is no compulsion to undertake CPD activities relevant to their field of practice. Hence a medical practitioner may accumulate 20 points from an activity which is unrelated to his practice and still be eligible for renewal of his APC.

Lets analyse the MMC-CPD grading system.

Let's take category ‘A1- Medical congress (Local/International)’. A medical practitioner may register for the congress and not attend any of the session during the 3 days and still obtain 20 points. Most of the so called speakers of ‘international standing’ invited for these congresses are sponsored by pharmaceutical and or medical devices companies. How can they impart information which is not biased? Surely they cannot be expected to keep us updated and competent!

Category A 2 --Scientific Meetings of Academy / Universities /Colleges / Association / Institutions. Here too a practitioner may register and not attend any of the sessions and still receive the 20 points. Many of the conferences organised by medical associations and  academies cater for many medical disciplines and are not focused on a particular medical discipline and hence cannot update doctor from several disciplines. The needs of a general practitioner, a neurosurgeon, cardiac and orthopaedic surgeon are very different and cannot be fulfilled by meetings organised by medical associations and academies. Here too many of the speakers are sponsored by pharmaceutical and medical devices companies, who are biased and will not impart knowledge which is necessary to keep us updated and competent.

Category A3--Workshops/Course/ study tour which includes hands-on & skills courses. Points from such courses can be obtained once only and cannot be a source of points every year. These courses will not keep a person uptodate on the latest developments in one's speciality. These courses are basically meant for horning skills which the practitioner already possess.

Category A4--CME session/ other professional activities. Opportunities to participate in these activities are grossly limited. However, the organizing chairman of a scientific meeting gets 5 points. How organising a meeting makes a person uptodate and competent in his/her field of expertise is difficult to fathom. Why giving undergraduate lectures makes one eligible for points and giving postgraduate lecture does not make one eligible for points remains a mystery. One would believe that more in depth knowledge is needed to give postgraduate lecture as compared to an undergraduate lecture.

Category A5--  Presentation at meetings.
Points allocated for plenary lecture/long paper/free paper/short paper/poster/other lectures, hospital clinical meeting, CME sessions and public medical talks are well deserved. Such activities do help the practitioner remain uptodate.

Category A6 ---Publications of original articles in journal/ chapters in book / reports & important role in journal.

Points for publication of original articles in journal /chapters in books/ report are well deserved since such activity keeps the practitioner uptodate and competent.
There is however, some uncertainty as to whether being an editor, member of editorial board, referee/reviewer, helps one remain updated and competent. Whether CPD points should be allocated for such activity will depend on the quality of the journal,its impact factor and the number of issues published in a year. For example, there is a Malaysian journal which publishes 3 issues per year. More than half of the articles are case reports. It has a panel of 100 reviewers and its yearly Impact Factor‎ is ‎0.011 and 5-year Impact Factor is 0.009. Surely the reviewers of this journal do not deserve CPD points.
Points from categories A7 to A9 are unlikely to play a significant role in the CPD activities of medical practitioners.
Medical practitioners keen on keeping themselves updated and competent
will not need to participate in any of the activities prescribed by the MMC-CPD schedule. They will read and write to keep themselves updated. Medical practitioners who are forced to accumulate CPD points for the APC and are not keen to update themselves will find ways to get the points without getting updated. There are limits to professional self-regulation. So what can be done to make sure medical practitioners get updated?

What is the way forward? “Recertification”/Revalidation!

Recertification in USA

The unique strength of American medicine is a voluntary physician-led, nongovernmental process of setting standards. In 1936 the American Board of Internal Medicine (ABIM) was founded and the board set the standards for internal medicine practice and the practice of its subspecialties. It is physician-run organization which is independent of any
physician societies or membership organizations. The standards set by the board which are  measured by the “certification” process, lets the public know that the internist has met the ‘knowledge and practice requirements that ensure a high level of quality of care’ [7]. Though participation in this certification process is voluntary, about 98% of internists attempt certification and about 96% of them achieve certification [7].
In 1990 ABIM instituted a significant change to the program when they limited the validity of the certification to 10 years and after 10 years to maintain their certification the internist had to undergo a Maintenance of Certification (MOC) program. Those who did not do so would no longer be “board certified” [7]. About 85% of Diplomates continue to participate in the MOC program.
Studies show that  the board certified internist have better patient outcomes as compared to those who are not [8-12]. Studies also show that physician knowledge and the quality-of-care outcomes diminish with time, after graduation, with increasing years in practice [13].
The American Board of Medical Specialties (ABMS) is an umbrella organization for 26 specialty board. Most of the specialist boards require recertification every 10 years to maintain board certified status. The ABMS 
require every MOC program to have 4 components i.e ‘evidence of professional standing (license to practice); participation in lifelong learning and self-assessment; evidence of cognitive expertise (examination); and assessment of practice performance’ [7].

Revalidation in UK

The General Medical Council (GMC) in UK introduced revalidation for doctors in December 2012, after several years of discussion and debate.  The doctors in UK need revalidation to show to the GMC that they are uptodate and fit to practice and thereby maintain their licence to practice.
The doctors have to take part in a robust appraisal process and collect evidence to show they meet the necessary standards set by GMC. The revalidation cycle runs for 5 years and they need to revalidate once every 5 years. The first cycle was from 2012 to 2016.

For revalidation the doctor has to fulfill the following requirements:

Take part in an annual appraisal process
Complete at least one appraisal per year based on good medical practice
Collect and reflect on six types of supporting information.
The six types of supporting information include
           1. continuing professional development (CPD)
           2. quality improvement activity
           3. significant events
           4. feedback from colleagues
           5. feedback from patients
           6. review of complaints and compliments.
The above information has to be provided and discussed at their appraisal at least once in each five–year cycle.

Recertification & continual professional development

New Zealand has very comprehensive guidelines on recertification and continual professional development. Doctors in New Zealand must meet recertification and continual professional development (CPD) requirements if they want to maintain the right to be issued with a practising certificate. The Medical Council of New Zealand, requires doctors to undertake 50 hours of professional activity each year, which is directed to the maintenance of professional competence. This includes participation in audit of medical practice, peer review and continuing medical education. There has to be at least one audit per year, which entails ‘a systematic, critical analysis of the quality of a doctor’s own practice and is used to improve clinical and/or health outcomes, or to confirm that current management is consistent with
current available evidence or accepted consensus guidelines’ [14].
 There has to be a minimum of 10 hours of peer review per year. The peer review could involve joint review of cases, review of charts, practice visits to review a doctor’s performance, 360° appraisals and feedback, critique of a video review of consultation and discussion group, inter-departmental meetings that may review cases and interpretations of finding and mortality and morbidity meetings.
Doctors would need a minimum of 20 hours per year of Continuing medical education (CME) which would include attendance at relevant educational conferences, courses and workshops, self-directed learning programmes and learning diaries, assessments designed to identify learning needs in areas such as procedural skills, diagnostic skills or knowledge and journal reading [14]. CME may also include:

• examining candidates for college examinations
• supervising or mentoring others
• Teaching
• publication in medical journals and texts
• Research
• committee meetings with an educational content, such as guideline development
• giving expert advice on clinical matters
• presentations to scientific meetings
• working as an assessor or reviewer for the Council. 

Doctors are subjected to an audit by the Medical Council to ensure that doctors are complying with their recertification. Failure to satisfy requirements can result in the Council proposing to place conditions on the scope of practice or limitations on the practice and in serious cases, the Council can propose to suspend the doctors registration.

References

1. Rodwin MA, ‘Drug Advertising, Continuing Medical Education, and Physician Prescribing: A Historical Review and Reform Proposal’, Conundrums and Controversies in Mental Health and Illnesses. 2010 807-815 (p.809).
2. Charter on continuing medical education/continuing professional development approved by the UEMS Specialist Section and European Board of Anaesthesiology. European Journal of Anaesthesiology 2007; 24: 483–485.
3. Schostak J, Davis M, Hanson J, Schostak J, Brown T, Driscoll P,  Starke I, Jenkins N. The Effectiveness of Continuing Professional Development. A report prepared on behalf of College of Emergency Medicine, Federation of Royal Colleges of Physicians and Manchester Metropolitan University. 2010 College of Emergency Medicine at http://www.aomrc.org.uk/wp-content/uploads/2016/04/Effectiveness_of_CPD_0610.pdf accessed on 20/6/2018.
4. Murgatroyd GB. Continuing professional development -- The international perspective. Intelligence Unit, General Medical Council, July 2011 at https://www.gmc-uk.org/static/documents/content/CPD___The_International_Perspective_Jul_11.pdf_44810902.pdf accessed on 19/6/2018.
5. Lang ES, Wyer PC & Haynes RB. Knowledge translation: closing the evidence to practice gap. Ann Emerg Med 2007; 49 (3): 353-366.
6. Guidelines on Continuing Professional Development (CPD) For Medical Practitioners In Malaysia. Malaysian Medical Council 17 April 2018 at http://www.mmc.gov.my/images/contents/CPD/MMC-CPD%20Guidelines%20(updated).pdf accessed on 26/6/2018.
7. Levison W, Holmboe E. Maintenance of certification: 20 years later. Am J Med 2011; 124: 180-185.
8.  Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36(9):853-859.
9. Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75(12):1193-1198.
10. Chen J, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction. J Gen Intern Med. 2006;21(3):238-244.
11. Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473-481.
12. Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Wenrich MD. Predictive validity of certification by the American Board of Internal Medicine. Ann Intern Med. 1989;110(9):719-726.
13. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-273.
14. Recertification and continuing professional development. Medical Council of New Zealand, April 2018 at https://www.mcnz.org.nz/assets/News-and-Publications/Recertification-and-continuing-professional-development-30-4-2018-v7.pdf accessed on 4/7/18.

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.

References

1. Best Care at Lower Cost: The Path to Continuously Learning HealthCare in America at http://www.nationalacademies.org/hmd/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx.
2. 2018 Budget: Priority given to Rakyat's healthcare needs. The New Straits Time at https://www.nst.com.my/news/nation/2017/10/296500/2018-budget-priority-given-rakyats-healthcare-needs. Accessed on 25/52018.
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8. Preidt R. Medicare wasted at least $1.9 billion a year on unnecessary treatments, study finds at https://www.cbsnews.com/news/medicare-wasted-at-least-1-9-billion-a-year-on-unnecessary-treatments-study-finds/ accessed on 9/1/2018.
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Management of meniscal injuries of the knee

                       Management of meniscal injuries of the knee

                                              Dr KS Dhillon FRCS

Introduction

The role played by the menisci in function of the knee has been well established. It is important to preserve the meniscus whenever possible. Degenerative tears of the meniscus are common and can be present in asymptomatic individual. Arthroscopic partial meniscectomy is and has been one of the most common orthopaedic surgical procedure in most countries around the world. However, there is now good evidence available to show that arthroscopic partial meniscectomy does not benefit most patients with meniscal tears. This article reviews the recent literature and attempts to settles some of the controversies associated with the management of meniscal injuries of the knee.

Anatomy of the meniscus

The are two menisci in the knee, namely the medial and lateral meniscus. The medial meniscus is C-shaped with a triangular cross section. The average width is about 9 to 10 mm and the average thickness is about 3 to 5 mm. The lateral meniscus is almost circular in shape and it covers a large portion of the articular cartilage. Its average width is 10 to 12 mm and its average thickness is about 4 to 5 mm.
The menisci are composed of fibroelastic cartilage. The fibroelastic cartilage is made of an interlacing network of collagen, proteoglycan, glycoproteins, cellular elements and 65-75% water. Ninety percent of the collagen is type I collagen. There are two types of fibres, the longitudinal
(circumferential) and the radial fibres, which allow the meniscus to expand under compressive load, expand the contact area and reduce stresses across the the joint.
The medial inferior genicular artery supplies the peripheral 20-30% of medial meniscus and the lateral inferior genicular artery supplies peripheral 10-25% of lateral meniscus. The central 75% of both menisci receive nutrition through diffusion.

Classification of meniscus tears

A.Descriptive classification of meniscal tear by location

Meniscal tears can occur in the red zone (outer third, vascularized), in the
red-white zone (middle third) or in the white zone (inner third, avascular).

 B.Descriptive classification of meniscal tear by pattern of tear

Meniscal tears can be classified into three types based on the pattern of tear [1]:

1.Basic tears
   A.Longitudinally oriented tears
       i.Horizontal tears (cleavage tears)--These tears are parallel to the    tibial plateau involving one of the articular surfaces or free edge and they divide the meniscus into superior and inferior parts.
        ii. longitudinal tear (vertical tear)--The tear is perpendicular to the tibial plateau and parallel to the long axis of the meniscus. It divides the
divides the meniscus into medial and lateral parts. A Wrisberg rip is a specific subtype, longitudinal tear in the posterior horn of the lateral meniscus that extends laterally from the Wrisberg ligament attachment.
  B.Radial tears -- These tears are perpendicular to both the tibial plateau and the long axis of the meniscus.
  C.Root tears: These tears are typically radial-type tear located at the root of the meniscus.

2.Complex tears
These tears are a combination of all or some of the horizontal, longitudinal and radial-type tears.

3.Displaced tears
Displaced tears are those in which the torn portion of the meniscus is displaced and it can still be attached to the  parent meniscus or detached. There are 3 subtype of displaced tears.
Flap tear: displaced horizontal or longitudinal tears
Bucket-handle tear: displaced longitudinal tear
Parrot beak tear: displaced radial tear

Radiological diagnosis

An MRI has a sensitivity of about 95% and a specificity of 81% for medial meniscal tears and a sensitivity of about 85% and a specificity of 93% for lateral meniscal tears [2]. An MRI of the knee is the modality of choice for investigating a suspected tear of the meniscus and sagittal images are  most useful [3]. A MRI of the knee has an overall 88% sensitivity and 94% specificity for detecting meniscal lesions [4].
There are three MRI criteria for diagnosis of meniscal tears [3]:
A high intrameniscal signal extending to at least one articular surface
The high intrameniscal signal should be seen in at least two slices  (two slice touch rule).
Distortion of the normal meniscal morphology if there has been no prior surgery.
In the T1 sequence a hyperintense line in the meniscus can be due to a tear or due to degeneration. When there is a bucket handle tear an empty groove may be seen.
In the T2 sequence the hyperintense line in the meniscus which indicates synovial fluid in the meniscus may be due to degeneration and not a tear in an adult and due to high vascularity in children [5].
MRI grading system for meniscal signal intensity [6].
The MRI abnormal high meniscal signal intensity can be graded into three:
Grade 1: There is a small focal area of hyperintensity with no extension to the articular surface
Grade 2: There is a linear area of hyperintensity with no extension to the articular surface
2a: There is a linear abnormal hyperintensity with no extension to the articular surface
2b: There is an abnormal hyperintensity which reaches the articular surface on only one single image
2c: There is a globular wedge-shaped abnormal hyperintensity with no extension to the articular surface
Half of the patients with grade 2c abnormal meniscal signals have been found to have meniscal tears on arthroscopy [7]
Grade 3: There is abnormal hyperintensity which extends to at least one articular surface (superior or inferior) which is indicative of a definite tear of the meniscus

A grade 3 MRI signal is indicative of a tear of the meniscus and a "double anterior horn" sign and a "double PCL"  sign are both indicative of a bucket handle tear of the meniscus.

Prevalence of meniscal abnormalities on MRI of the knee

Zanetti et al (8] studied 100 patients with suspected meniscal tears, who had one symptomatic knee and the other asymptomatic knee, with an MRI of the knee to evaluate the prevalence of meniscal abnormalities in the knee. The mean age of these 100 patients was 42.7 years with a range between 18 to 73 years.
They found meniscal tears in 57 symptomatic knees (57%) and in 36 contralateral asymptomatic knees (36%). In the 57 patients who had a tear of the meniscus on the symptomatic side, 63% of these patients had a tear in the contralateral asymptomatic side. In other words, if there is a tear of the meniscus on the symptomatic side, there is a 63% chance that there will be a tear on the opposite asymptomatic side.
Radial, vertical, complex, or displaced meniscal tears and abnormalities of the collateral ligaments, pericapsular soft tissues, and bone marrow abnormalities were mostly seen in symptomatic knees and these findings appear to be clinical significant. Horizontal or oblique meniscal tears on the other hand were frequently seen in both asymptomatic and symptomatic knees and these findings may not often be related to symptoms [8].
Englund et al [9] studied the prevalence of meniscal damage in the general population and the association of meniscal tears with knee symptoms and with radiographic evidence of osteoarthritis. They found that the prevalence of a meniscal tear or of meniscal damage in the right knee as seen on a MRI ranged from 19% (range 15 to 24), among women 50 to 59 years of age, to 56% (range 46 to 66) among men 70 to 90 years of age. Among individuals with radiographic evidence of osteoarthritis (Kellgren–Lawrence grade 2 or higher) the prevalence of a meniscal tear was 63% among those with knee symptoms on most days and 60% among those without symptoms. The corresponding prevalence of meniscal tears among persons without radiographic osteoarthritis were 32% and 23%. Sixty-one percent of the individuals who had meniscal tears in their knees had no symptoms during the previous month.
The authors concluded that incidental findings of meniscal abnormalities on MRI of the knee are common in the general population and increases with age, irrespective of knee symptoms, and often accompanies knee osteoarthritis. Hence clinicians who order MRI of the knee should keep in mind the high prevalence of incidental tears when interpreting the MRI and  planning therapy.
Other authors have reported a high prevalence of meniscal damage ranging from 67 to 91% in patients with symptomatic osteoarthritis of the knee [10,11,12,13].
In the study by Bhattacharyya et al [13], which involved U.S. veterans,  most of whom were men, meniscal tears were noted in 75.5% control subjects who had no knee pain (mean age, 67 years) and had sought medical care for other conditions. They also found that knees with meniscal tear were not more painful than those without a tear and that meniscal tears do not affect functional status in patients with knee OA.
Other studies have also showed that a meniscal tear of the knee is common in individuals who had no symptoms of the knee [14,15,16,17,18].

Treatment of meniscal tears

There are three treatment options for patients with symptomatic tears of the meniscus. These include non-operative treatment, meniscectomy and meniscal repair. Selecting appropriate treatment can often be difficult and will depend on the patient characteristics such as age, co-morbidities and tear characteristics such as the type, location and size of tear.
Non-operative treatment of meniscal tears
There is level I irrefutable evidence that patients with osteoarthritis of the knee with meniscal tears do not benefit from arthroscopic debridement of the joint. Hence the treatment of choice for degenerative meniscus tears is non-surgical.
Moseley et al (19) did a randomised, placebo-controlled trial to assess the efficacy of arthroscopic knee surgery to relieve knee pain and improve function in patients with OA of the knee. They had three groups of patients who either had, joint lavage, joint debridement or sham incisions at the arthroscopic portals. Their study showed strong evidence that arthroscopic lavage with or without debridement is no better than placebo in relieving pain and improving self-reported knee function.
Kirkley et al (20) in 2008 published the outcome of a single-center, randomized, controlled trial of arthroscopic surgery in patients with moderate-to-severe osteoarthritis of the knee. They randomly assigned patients to arthroscopic joint debridement with surgical lavage and  physical plus  medical therapy or to treatment with physical and medical therapy alone. At 2 years follow up they found that arthroscopic surgery for osteoarthritis of the knee provided  no additional benefit as compared to optimized physical and medical therapy.
Sihvonen et al (21) did a multicenter, randomized, double-blind, sham-controlled trial to assess the efficacy of arthroscopic partial meniscectomy in patients who had a degenerative tear of the medial meniscus without knee osteoarthritis. Patients with obvious traumatic onset of symptoms and those with OA were excluded. The study showed that arthroscopic partial meniscectomy was not superior to sham surgery, with regard to pain and functional knee scores assessed during a 12-month follow-up period. The authors concluded that partial meniscectomy for degenerative tears provides no benefit to the patients and that there is no scientific basis for continuing the current practice of doing partial meniscectomy for degenerative tears of the meniscus.
Thorlund et al [22] did a comparative prospective cohort study, to compare patient reported outcomes, of arthroscopic partial meniscectomy in patients with traumatic meniscal tears as compared to that in patients with degenerative meniscal tears, at 52 weeks follow up.
They studied four of five subscales of the knee injury and osteoarthritis outcome score (KOOS) which covered pain, symptoms, sport and recreational function, and quality of life (KOOS4). Their study showed
better self-reported outcomes in patients with degenerative tears as compared to patients with traumatic tears but the difference between the two groups ‘was at no time point considered clinically meaningful’ [22].
The authors questioned the ‘current tenet that patients with traumatic meniscal tears experience greater improvements in patient reported outcomes after arthroscopic partial meniscectomy than patients with degenerative tears’ [22].
So far there have been no randomised controlled trials comparing the outcome of arthroscopic partial meniscectomy with sham surgery or non-surgical treatment for traumatic meniscal tears [23].
Sihvonen et al’s  study (21) provides level I evidence that arthroscopic partial meniscectomy in patients with degenerative tear of the meniscus provides no benefit to the patient when compared with a sham operation. Thorlund et al’s [22] comparative prospective cohort study shows that the outcome of arthroscopic partial meniscectomy in patients with traumatic meniscal tears is no better than that of partial meniscectomy in patients with degenerative tear of the meniscus. This would mean that arthroscopic partial meniscectomy has no role to play in the treatment of partial tears of the meniscus.
Non-operative treatments such as exercise and quadricep strengthening improves knee function and reduces knee pain [24,25,26]. Pain and swelling associated with meniscal tears can be treated non-steroidal medications.
There is definitely no role for surgery in the treatment of degenerative tears of the meniscus. The outcome of partial meniscectomy for traumatic tears of the meniscus is not better than that of partial meniscectomy for degenerative tears as has been believed in the past.

Surgical treatment of traumatic tears of the meniscus

The role played by the menisci in function of the knee has been well established. The main function includes load bearing, shock absorption, stabilisation, joint lubrication, nutrition of the articular cartilage and proprioception [27]. Hence in the management of patients with traumatic meniscal tears all attempts to preserve the meniscus are made.
Pain and mechanical symptoms such as clicking, catching, locking, pinching, or a sensation of giving way associated with unstable meniscal fragment may need surgical intervention.
Unstable meniscal fragments not amenable to repair have to be excised by arthroscopic partial meniscectomy. Tears in the red-red zone, where there is blood supply, can be repaired because there is potential for healing. Some in the red-white zone can heal when repaired. Tears in the rest of the meniscus which is avascular, cannot be repaired, are subjected to a meniscectomy.
Studies comparing the outcome of meniscal repair with meniscectomy are limited. It is difficult to postoperatively define a healed meniscus because postoperative MRIs are not very accurate in defining a successful repair. High signal seen on an MRI may represent oedema, degeneration of the meniscus, an actual tear or postoperative healing and scar [28]. The most accurate way to access a successful repair would be a second look arthroscopy but there can be ethical concerns when second-look arthroscopies are performed to evaluate the success of a meniscal repair. Randomising patients to receive a repair or a meniscectomy can also lead to ethical concern[29].
Seo et al [30] did a second look arthroscopy in 11 patients (who were available for review) out of 21 consecutive patients who underwent arthroscopic pullout suture repair for a posterior root tear of the medial meniscus, at an average of 13.4 months (range 10 to 22 months) follow up. In this case series (level 4 evidence), they found that in none of the patients a complete healing had occurred.
In 5 knees there was lax healing, 2 of which were symptomatic and three asymptomatic. In 4 knees there was scar tissue healing and all 4 were asymptomatic. In  2 knees there was no healing and of the 2, one was symptomatic and one asymptomatic. There was progression of the chondral lesion in one case. The mean Lysholm scores improved from 56.1 preoperatively to 83.0 at follow-up and the mean Hospital for Special Surgery score also significantly increased, from 64.1 to 87.4.
Despite the lack of complete healing in all patients,why there was significant clinical improvement remains unexplained.
Cho et al [31] retrospectively reviewed 13 of 20 consecutive patients who underwent arthroscopic modified pull-out suture repair for a posterior root tear of the medial meniscus. The 13 were available for a second-look arthroscopic evaluation. In 4 cases there was complete healing , in 4 lax healing, in 4 scar tissue healing and in 1 there was no healing. Seven of the 13 patients were asymptomatic. The mean Lysholm scores increased from 34.7 points before the repair to 75.6 points at the second-look arthroscopy and the HSS scores increased from 33.5 to 82. Functional outcome was good in these patients despite incomplete healing of the repair.
Pujol et al [32] evaluated healing of the meniscus after a repair using arthro-CT scans. At 6 months post repair of the meniscus an arthro-CT scan showed complete healing in 58% of the patients, partial healing in 24% and failed healing in 18% of the patients. They also found that the healing in posterior segment tears was lower than that in middle portion tears. Despite the the lack of complete healing in almost half of the patients, the clinical outcome was good in most of the patients.
Paxton et al [33] did a systematic literature review to compare reoperation rates and clinical outcomes after meniscal repair and partial meniscectomy in patients with traumatic meniscal tears. At short and long term follow up partial meniscectomy had lower reoperation rates. The short and long term reoperation rates for partial meniscectomy were 1.4% and 3.9% respectively whereas for meniscal repair were 16.5% and 20.7% respectively. There were a limited number of studies with long term clinical outcome and these small number of studies reported that a meniscal repair was associated with higher Lysholm scores and less radiologic degeneration than partial meniscectomy.
Noyes and Barber-Westin [34] did a systematic review of the literature in 2012 to find out the incidence of meniscectomy, meniscus repair, and tears left in situ during ACL reconstruction in the previous 10 years. In the 159 studies analysed, there were 11,711 meniscal tears. Sixty-five percent of the tears were treated by meniscectomy, 26% of the tears were repaired and 9% were left in situ without any treatment. The incidence of meniscal repair was 26% in patients undergoing ACL reconstruction.
Mutsaerts et al [35] in 2016 did a literature review of all randomized controlled clinical trials which compared various surgical techniques for the treatment of meniscal injuries including; total and partial meniscectomy; meniscectomy and meniscal repair; meniscectomy and meniscal transplantation; open and arthroscopic meniscectomy and various different repair techniques.
This Level I meta-analysis showed that there is a lack of level I evidence to guide the surgical management of meniscal tears.
Degenerative tears of the meniscus do not need any surgery and most traumatic tears of the meniscus also do not need surgery. Patients with traumatic tears who have mechanical symptoms may need surgery. Tears in the avascular region would need a partial meniscectomy. Whether to do a meniscal repair or not remains unclear since there is a lack of level I evidence to guide treatment options. There have been case reports where spontaneous healing of bucket handle tears of the meniscus have occurred, when patients have opted for non-operative treatment or surgery has been delayed for some reason [35,36,37]. Furthermore, definitely there are patients who sustain meniscal injuries and never seek treatment, where spontaneous healing occurs.

Complications of arthroscopic surgery

The overall complications for knee arthroscopy are about 8.2% [38]. Sherman et al [38] retrospectively reviewed 2640 arthroscopic procedures and found an 8.2% incidence of complications,of which 4.8% were major and 3.6% minor complications.The major complications included infections, hemarthrosis, adhesions, effusions, cardiovascular, neurological, reflex sympathetic dystrophy, and instrument breakage, and the minor complications included problems with wound-healing and ecchymosis. Diagnostic arthroscopy had the lowest complication rate and partial medial meniscectomy was associated with a higher complication rate and highest hemarthrosis rate, while partial lateral meniscectomy was associated with the highest rate of instrument breakages. Age more than 50 years and a tourniquet time of more than 60 minutes were risk factors for complications. Surgeon experience had no influence on the complication rates [38].
Salzler et al [39] found a 2.8% complication rate for meniscectomy and a 7.6% complication rate for meniscal repair. They found that the complication rates were higher with sports fellowship-trained surgeons as compared to those who had no sports fellowship training.
Austin and Sherman [40] in a study involving 101 consecutive arthroscopic meniscal repairs found an overall complication rate of 18%. In patient with anterior cruciate tears the meniscus repair was associated with a 20% risk of complication and in those without anterior cruciate injury the complication rate was 14%. The incidence of arthrofibrosis was 10% when there was an ACL tear and 6% when there was no ACL tear in patients undergoing meniscal repair. The overall risk of complications was 19% with medial meniscus repair and 13% with lateral meniscus repairs. The reoperation or rehospitalization rate (excluding repair failures) was 8%.

Infection
Septic knee arthritis following simple arthroscopy procedures is uncommon but it is dreaded complication. The incidence of septic arthritis following simple arthroscopic procedures ranges from 0.009% to 1.1% [41].
In this study the most common pathogen causing infection was Staphylococcus , both coagulase positive and negative. Other bacterias implicated included Enterobacter cloacae, Streptococcus spp. and Serratia marcescens [41].
Risk factors for septic arthritis include age more than 50 years, tourniquet time more than 60 min, longer duration of surgery, male sex, diabetes, morbid obesity, tobacco use, use of intra-articular steroids and complex procedures [41].

Thromboembolic complications
Venographic incidence of deep-vein thrombosis (DVT) after arthroscopy can be up to 17.9% [42]. Most of these are distal and of not much clinical significance.
The incidence of symptomatic and proximal thromboembolic disease,
which can progress to pulmonary embolism (PE), is less than 1% in patients undergoing knee arthroscopy [43-47]. Routine thromboprophylaxis is not recommended for patients undergoing arthroscopy unless certain risk factors such as older age, history of cancer, complexity of surgery, female sex, longer duration of surgery, history of previous DVT, obesity, immobility, varicose veins and use of oral contraceptives, are present [48,49]. A postoperative high index of suspicion is essential in patients where these risk factors are present.

Vascular complications
The Committee on Complications of the Arthroscopy Association of North
America, reported 12 vascular injuries (0.0032 %) in 375,069 knee arthroscopies carried out in North America. Out of these 12 cases of vascular injury reported, 4 required an amputation [50]. DeLee [51], in the
AANA review of complication of arthroscopy in the US, reported six cases of penetrating injury to the popliteal artery (0.005%) in 118,590 arthroscopic procedures. In 4 of these 6 patients an amputation was required.
Although the incidence of vascular injury is low in patients undergoing arthroscopy, a high index of suspicion is necessary and a prompt diagnosis, and early surgical intervention is essential to prevent a risk of loss of limb or life.

Neurological injury
Rodeo et al [52] reported that there are 4 mechanisms by which nerve injury can occur during arthroscopy.These include, direct trauma, pressure
secondary to a compartment syndrome occurring as a result of extravasation of fluid, damage related to the use of a tourniquet and due to reflex sympathetic dystrophy. The reported incidence of neurological injury following knee arthroscopy ranges between 0.01 to 0.6 percent [51]. The nerves that can be injured include the saphenous, tibial and peroneal nerves. The most commonly injured nerve is the saphenous nerve followed by the peroneal nerve. Neurological complications are more often seen with meniscus repairs.

Conclusions

A clinical diagnosis of meniscus tear should be made when a patients complains of knee pain following trauma to the knee. A history of mechanical symptoms of catching, click and giving way would suggest the presence of an unstable meniscus tear which would require treatment. All other tears of the meniscus do not need treatment and hence there is no need for radiological investigations. When clinical diagnosis of an unstable tear of the meniscus which requires surgery is made, an MRI of the knee would be a useful investigation. There is no role of arthroscopic meniscectomy in the treatment of degenerative and traumatic tears when the tear is stable.
There is, however, a lack of Level I evidence to guide the surgical management of traumatic meniscal tears. Studies comparing the outcome of meniscal repair with meniscectomy are limited and of not good quality. Arthroscopy and meniscal surgery can be associated serious complication although the incidence of serious complications is low.




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