A recent article published by Kaiser Health News and The Chicago Tribune attempted to determine which procedures physicians felt were the most unnecessary in hopes of freeing patients from additional expenses. In their article the authors reference the “Choosing Wisely” campaign, a brainchild of the American Board of Internal Medicine that attempts to pinpoint five procedures in specialty industries that doctors and patients should be skeptical about considering.
The ABIM has published these “lists of five” for 54 specialty industries, one of which being orthopedic care. Today, I’m going to examine their list and explain why I agree or disagree with the ABIM’s position.
1. Avoid performing routine post-operative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty.
The rates of DVT and Pulmonary Embolism are so high after these procedures you can understand why there is reluctance by physicians to let go of what might be a life-saving test. The radial blood clots after total joint replacement without anticoagulation can reach 40-60%. Most physicians are aware of this number and anticoagulation can be part of their postoperative routines. However, it takes only one death or near-death experience to make a physician regularly err on the side of caution. Furthermore, in today’s litigious environment, physicians often imagine courtroom proceedings with a vignette in which the plaintiff’s attorney says: “Now Dr., could this simple doppler ultrasound have identified this blood clot and saved your patient’s life.”
It doesn’t take long to see why this would be a hard habit to break or prevent.
2. Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief.
This refers to the treatment of irrigating and knee joint using a syringe and a needle. I have to agree with the this point when the authors suggest, “The use of needle lavage in patients with symptomatic osteoarthritis of the knee does not lead to measurable improvements in pain, function, 50-foot walking time, stiffness, tenderness or swelling.”
Most orthopedic surgeons do not perform this procedure. This is more commonly directed to rheumatologists who may perform this procedure in their office. But, looking at how careful the language is as it is followed with, “for long-term relief,” it certainly leaves open the possibility of using this procedure for short-term pain relief. It can most certainly be successful in the short-term. This point is a little misleading in its wording.
3. Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
Many patients are eager to avoid surgery if possible, and glucosamine and chondroitin can help patients manage their discomfort. The evidence supporting the use of these drugs is poor, but that doesn’t change the fact that it’s a multi-billion dollar industry that supports its claims daily on our TV, radio and print ads.
4. Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
This recommendation is against the non-sensical act of trying the “bank shot” with the foot (i.e. Knock the foot over one way to impact the knee angle). It is true that certain rotational conditions improve if the ankle motion is stabilized and gait is normalized. Hip and back pain improve if leg length is equalized. Lateral wedges can be helpful in certain situations, and over-generalization of this recommendation can actually prevent good treatment.
5. Don’t use post-operative splinting of the wrist after carpal tunnel release for long-term relief.
This was a controversial topic many years ago, but as far as controversies that could save money and troubles, it is a little mundane.
Related source: Kaiser Health, The Chicago Tribune, ABIM