Editor’s Spotlight/Take 5: Arthroscopic Partial Meniscectomy for a Degenerative Meniscus Tear Is Not Cost Effective Compared With Placebo Surgery: An Economic Evaluation Based on the FIDELITY Trial Data

I used to believe that if a treatment is not effective, then by definition, it can't be cost-effective. While this generally is true, it isn't always. For example, surgical treatments that intend to reduce pain—a subjective endpoint—are associated with a strong placebo effect. That's no justification to operate, of course, but the placebo effect (if not accounted for) could affect the apparent costs of care in ways that overestimate the value of an ineffective intervention. More commonly, different studies about an intervention don't always arrive at the same conclusions, and if a cost-effectiveness study chooses a particularly favorable (and perhaps not-so-robust) source for its effectiveness data, that's likely to make surgery look better than it is in its analysis. Although the best available evidence—represented by numerous high-quality systematic reviews, meta-analyses of RCTs, and other informative study designs [3, 17, 35, 38]—has concluded that arthroscopic surgery for degenerative meniscal tears is ineffective, somehow the procedure remains among the most-common ones performed by orthopaedic surgeons. And a recent cost-effectiveness analysis [39] that drew its effectiveness data from an open-label trial about the procedure suggested that arthroscopic partial meniscectomy in this setting is sometimes cost-effective, and so should remain a benefit that insurance payers cover. Round and round we continue to go. I still believe that ineffective treatments should be avoided; that ineffective surgery is, by definition, harmful; and that both of these assertions apply directly to arthroscopic meniscectomy for degenerative meniscal tears. Despite that, in some narrow settings—depending on how one defines "effective" and how one tallies "cost"—enthusiastic parties have kept the conversation about arthroscopic surgery for the degenerative meniscus tear going. And although not every reader of CORR® treats the adult knee, I believe every reader should care about this signal example that shows how our specialty uses (or doesn't use) high-quality evidence to guide the choices we make. For that reason, I am excited to feature this month's Editor's Spotlight article, "Arthroscopic Partial Meniscectomy for a Degenerative Meniscus Tear Is Not Cost Effective Compared With Placebo Surgery: An Economic Evaluation Based on the FIDELITY Trial Data" [16], by Teppo L. N. Järvinen MD, PhD (Fig. 1), and his colleagues from Finland. They drew effectiveness data from what may have been the best designed RCT on the topic: the FIDELITY (Finnish Degenerative Meniscal Lesion Study) paper [33]. This multicenter, placebo surgery–controlled efficacy RCT blinded both participants and outcomes assessors, and evaluated costs robustly from the societal perspective.Fig. 1: Teppo L. N. Järvinen MD, PhDIn this issue of CORR®, Järvinen and his colleagues [16] show that arthroscopic meniscectomy in this context did not deliver lower postoperative costs and that it did not convincingly improve quality of life scores compared to placebo surgery. Its incremental net monetary value was only positive at unrealistically high willingness-to-pay (WTP) thresholds: about 65,000 Euros per quality-adjusted life year (which is slightly over USD 70,000 as of today). A more reasonable WTP threshold for a cost-effective procedure would be in the ballpark of 35,000 Euros. The procedure generally resulted in higher costs and no meaningful clinical improvements relative to placebo surgery over the 2-year time horizon of the study. While it's human nature to be permissive graders of our own work, let's agree that any operation we recommend should beat sham surgery handily, regardless of whether the endpoint is clinical outcomes or cost. As an aside, if you're not familiar with FICEBO—The Finnish Centre for Evidence-Based Orthopaedics (www.FICEBO.com)—I'd encourage you to change that now. They've produced what I believe are the determinative RCTs on some of the most important clinical questions in our specialty: proximal humerus fracture treatment [30], subacromial decompression [26], arthroscopic meniscal tears [33], and numerous studies about the overuse of diagnostic imaging and other related topics [5]. I've mentioned them on the editorial pages in here before [20], but would hate to think any well-read person might not know the lengths to which this remarkable research group is going to protect our patients from overdiagnosis and ineffective treatments. Regardless of whether or not you do knee surgery, the lessons here about how to use what we know—which come from a group that is at the top of the world in terms of producing high-quality clinical evidence—deserve your attention. For that reason, I'm hoping you'll join me in the Take 5 interview that follows with Dr. Järvinen. Take 5 Interview with Teppo LN Järvinen MD, PhD, senior author of "Arthroscopic Partial Meniscectomy for a Degenerative Meniscus Tear Is Not Cost Effective Compared With Placebo Surgery: An Economic Evaluation Based on the FIDELITY Trial Data" Seth S. Leopold MD:Congratulations on this thought-provoking paper. You'll recall that when you first sent it in, I almost sent it back, since I didn't understand why one would explore the cost-effectiveness of a procedure that you and so many others have found to be clinically ineffective. The premise didn't make sense to me. I tried to explain what I was missing in my commentary above, but I bet you can do it better. Can you clarify this important point? Teppo Järvinen MD, PhD: It's understandable to question the necessity of a cost-effectiveness analysis given the substantial evidence showing that arthroscopic partial meniscectomy (APM) is clinically ineffective. However, when we—the FIDELITY investigators—considered the need for a cost-effectiveness analysis based on the FIDELITY trial data, proponents of APM presented a new model-based cost-effectiveness analysis from an open-label trial [39], which argued that "optional APM after an initial physical therapy period is cost-effective compared with physical therapy alone," and recommended that APM remain a covered treatment option. Given my previous work on cost-effectiveness models [12], I recognized the importance of verifying or refuting these recent model-based cost-effectiveness findings with actual trial data. It's crucial to understand that model-based cost-effectiveness analyses rely heavily on various assumptions, particularly the weight assigned to certain events. Therefore, we felt it was necessary to conduct another cost-effectiveness study using actual trial data. Additionally, different therapeutic alternatives can lead to distinct impacts on resource utilization or productivity loss, even if their clinical outcomes are similar. Dr. Taimela, a member of our FIDELITY team, highlighted a trial [34] in which graded activity reduced the number of missed workdays due to low back pain more effectively than did standard care, despite not showing improvements in functional outcomes or pain reduction compared to standard care. Dr. Leopold:A couple years ago, CORR published a paper [25] and an interview [21] with its author about arthroscopic meniscectomy, the usage of which went up during a span of time when the procedure was already well known to be generally unhelpful, in a country that did not have strong financial incentives favoring the overuse of surgery. I believe surgeons in the United States think that procedures sometimes persist despite the evidence mainly because of financial incentives, but it's obviously more complicated. How do you see it? Dr. Järvinen: The persistence of ineffective treatments—such as various arthroscopic procedures for knee, shoulder, and hip pain—is indeed a multifaceted issue. As Upton Sinclair said, "It is difficult to get a man to understand something, when his salary depends on his not understanding it." But while financial incentives undoubtedly play an important role, the problem extends beyond mere economics. Cognitive biases at both the individual and group levels contribute substantially to the persistence of ineffective treatments. Cognitive dissonance and confirmation bias are well-documented phenomena in which individuals struggle to accept evidence that contradicts their pre-existing beliefs. These biases can lead clinicians to continue recommending procedures they have long believed to be effective, despite new evidence to the contrary. Group-level biases, such as guild interests and herd mentality, also play a critical role. Guild interests refer to the collective priorities and self-preservation tendencies of professional groups. In medicine, this can manifest as resistance to abandoning established procedures that define a specialty's identity or economic foundation. Surgeons, for example, may be reluctant to give up procedures like arthroscopic meniscectomy because it has been a core part of their practice and training. Herd mentality, which is the tendency to conform to the practices and beliefs of one's peer group, further reinforces the status quo. In the medical community, deviating from established norms can be professionally risky. Practitioners may fear criticism or ostracism if they abandon widely accepted procedures, even when evidence suggests they should. Additionally, in-group biases can create an environment where new ideas and evidence are met with skepticism, particularly if they challenge the prevailing wisdom of the group. This can slow the adoption of new practices and the abandonment of outdated ones. Dr. Leopold:Many surgeons say that evidence from randomized trials seems discordant with their observations in practice, or even that the findings don't apply to them (I found this Letter to the Editor on this topic very poignant [2], so much so that I replied to it [22]). And this goes way beyond knee arthroscopy—as you know, widely discredited but still widely used procedures persist in shoulder, spine, and hip surgery. We can't get people to re-examine their practices by criticizing them, and seemingly pointing to RCTs doesn't do the trick, either [4, 23]. What, then, might work better? Dr. Järvinen: Sadly, I take a somewhat pessimistic view on this. What sets medical professionals apart from other "healers" is the scientific method. Yet, when researchers adhere to the most rigorous standards when studying the viability of various medical interventions and find that those interventions do not withstand scientific scrutiny, their efforts are met with resistance from colleagues, who frequently resort to anecdotal evidence, insisting "I just know" (Fig. 2).Fig. 2: When established medical interventions are shown to lack scientific validity, it is common for physicians to resist at first, falling back on anecdotal evidence rather than adhering to conventional hierarchy or the levels of evidence. © 2024 Malcolm WillettBut back to your question: What, then, might work better? I recently wrote an essay for another journal summarizing my views on this [14]. A monstrous crisis of credibility is ravaging medical research, making true replicant findings a treasure. This crisis has many faces, a bit like the many-headed hydra. In addition to a growing list of medical reversals where once-cherished treatments are later proven futile [8], the heads of this hydra include the popular backlash against vaccines and other public health measures; the evidence showing that most healthcare interventions tested in Cochrane Reviews are not effective [9]; the general replication crisis in science, where landmark studies supposedly proved something and then could not be repeated reliably [11]; and perhaps, most troublesome, a growing body of evidence is revealing how financial incentives have corrupted much of clinical research [6, 15]. Not surprisingly, the costs of medical interventions keep ballooning with diminishing returns, threatening to make healthcare even more unaffordable and unsustainable [7]. If we fail to value all of these concerning issues, we risk ruining trust in medicine. Science still has much to teach us as frontline practitioners, including the limits of our judgment. For instance, studies have shown that orthopaedic surgeons are no better at predicting outcomes from APM in patients with meniscal tears than someone flipping a coin, regardless of their clinical experience [37]. While we should acknowledge the limitations of RCTs, simply trusting our judgment is not a viable solution either. If we are to retain our agency and autonomy––the ability to make individual judgment calls––we need to embrace change. Failing to reform could lead to public revolt and heavy-handed regulation, jeopardizing the very autonomy we seek to preserve. Essentially, we risk being seen as accomplices rather than opponents of the many-headed Hydra that threatens our field and medicine more broadly. A possible scenario is that healthcare administrators and funders might adopt the BMJ Rapid Recommendation guideline panel's guidance [32] and use the number of arthroscopies performed in middle-aged and older patients with degenerative joint disease as an indicator of poor-quality care. The most desirable next step is to exercise our agency in a new way: by spreading the word and educating our colleagues and hospital administrators. This approach has been effectively demonstrated by orthopaedic specialists in Spain, who have curtailed the use of APM in their clinics despite an increase in its use nationwide [21], and by specialists in Finland, where its use has significantly decreased across the country [1]. In summary, while RCTs and scientific evidence are crucial, changing entrenched practices requires more than just presenting data. It involves education, dialogue, and a willingness to challenge in-group biases and herd mentality. By fostering a culture of critical thinking and openness, we can move toward true evidence-based practices and improve patient outcomes. Dr. Leopold:You and your colleagues at FICEBO have found a few commonly used procedures in our specialty to be no better than placebo surgery or harmless interventions like exercise. To me, this suggests that we ought to shun those surgical procedures. But sometimes, I hear surgeons suggest the following as reasons to operate: (1) Patients are desperate, have "tried everything" (or worse, "failed conservative therapy" [31]), and need us to "do something," or (2) these operations indeed make a subset of patients better (even if this means they are using the "real" intervention as a placebo). What's the best way to try to persuade people who believe strongly in the righteousness of these beliefs that there may be better approaches? Dr. Järvinen: I would like to refer once again to ideas that I have already shared, this time here in CORR [13]. My first argument would be that if our field does not adhere to the scientific method and its findings, we risk losing our credibility and the trust of our patients. As medical professionals, our integrity is grounded in our commitment to science and evidence-based practice. When procedures with higher risks, such as shoulder or knee surgery, are not demonstrably superior to lower-risk interventions, like exercise therapy, or even placebo interventions, we must reconsider their use. If patients were to learn that an intervention we recommended did not meet these standards, their trust in us would be compromised, and rightly so. We need to embrace the more time-consuming and less remunerative tools of care and empathy. This involves slowing down, listening to our patients, and sharing what we know—including the limits of our knowledge and the limitations of our interventions. We should communicate the favorable natural history of many musculoskeletal conditions. Being honest and empathetic builds trust; offering operations that are no better than placebo treatments erodes it. This approach not only aligns with scientific integrity, but also fosters a stronger and more trustworthy doctor-patient relationship [13]. If we lose the trust of our patients, we lose our ability to help them. Dr. Leopold:What's ]next at FICEBO? What studies are you most excited about that our readers should look for, and how might they change some important conversations? Dr. Järvinen: FICEBO was initially founded with the vision of producing cutting-edge research evidence on common medical practices, primarily in the field of musculoskeletal medicine. However, about 5 years ago, we made a deliberate and ambitious decision to broaden our scope beyond orthopaedics and traumatology to include researchers and projects from other medical disciplines, such as epidemiology and neurosurgery. This expansion resulted in us undertaking a number of new and challenging studies on diverse topics [10, 24, 36], which has stretched us to our limits, and I am immensely proud of our team of dedicated experts who have tirelessly pushed forward, despite significant obstacles. The year 2024 has already been very productive for us. We have published three major trials in top-tier medical journals: One reports the 5-year results of our pivotal FISH trial on humeral shaft fractures [29]. Another is a comparative effectiveness trial that evaluated surgery, needle fasciotomy, and collagenase injection for treating Dupuytren contracture [27]. Finally, we released the results of our first-ever FICEBO neurosurgical trial on the necessity of irrigating chronic subdural hematoma [28]. Additionally, we have several other manuscripts currently under peer review. One notable example is our collaborative effort with a research team from the University of Oulu on unstable ankle fractures [19]. This trial is an extension of our previous collaboration that led to a publication in the prestigious BMJ [18]. These studies are exciting not only for their immediate findings, but also for their potential to influence clinical practice across various medical fields. By challenging existing norms and providing robust evidence, we hope to encourage more nuanced and evidence-based discussions in the medical community.