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In today’s health care environment, should second-look knee arthroscopy be reevaluated as a clinical practice?
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Objective assessment of advanced techniques
The concept of second-look arthroscopy of the knee joint has some importance in the research realm and the clinical realm. It can be a valuable tool to objectively document and advance improvements in surgical techniques. In addition, it can be used to objectively assess if a complex surgery, such as for advanced articular cartilage resurfacing procedure or a radial meniscus tear, has worked and may guide a high-level athlete’s decision on returning to play.
For research purposes, second-look arthroscopy has been utilized effectively to advance the care of patients in orthopedics. Examples of this include second-look arthroscopies after autogenous cartilage implantation procedures and microfractures in patients at University of Oslo done by Lars Engebretsen, MD, PhD, and colleagues. They were able to document by second-look arthroscopy that objective histologic assessments between the two surgeries were effectively the same with a fibrocartilage healing tissue rather than hyaline cartilage replacement tissue, which has helped advance the field in strides to improve articular cartilage resurfacing procedures. Another example is our colleagues in South Korea who performed second-look arthroscopy after posterior horn medial meniscus root repairs. These second-look arthroscopies documented that patients who started ambulation before the 6-week point after root repair had a higher retear rate. This has led most of us to use a period of 6 weeks of non-weightbearing after a medial meniscus posterior horn root repair to ensure patients have the best chance of healing of the repair.
Second-look arthroscopy may also be used to determine if one’s complex surgery, such as a radial repair of a lateral meniscus tear in a high-level athlete, has healed. This may be important to obtain an objective assessment of a patient’s subjective improvements when a professional or Olympic-level athlete wishes to return to full competition.
Overall, most surgical procedures can be objectively assessed using stress radiographs and high-field, 3T MRI scans. However, there may be instances where an MRI scan may be indeterminate in the objective assessment of healing of a complex knee surgery. In these circumstances, second-look arthroscopy may be beneficial to ensure healing has occurred and to ensure objectively that the surgical treatment is secure enough to withstand an athlete’s full activity load. Overall, second-look knee arthroscopy should be used for objective assessments of advanced surgical techniques for research studies, and for those rare indications where one’s diagnosis on stress radiographs or high-field MRI scans may be in doubt.
- References:
- Kim SB, et al. Arthroscopy. 2011;doi:10.1016/j.arthro.2010.08.005.
- Knutsen G, et al. J Bone Joint Surg Am. 2004;86-A:455-464.
Robert F. LaPrade, MD, PhD, is chief medical officer of the Steadman Philippon Research Institute and of Complex Knee and Sports Medicine Surgery at The Steadman Clinic in Vail, Colorado.
Disclosure: LaPrade reports no relevant financial disclosures.
Must benefit patients
Second-look knee arthroscopy does not mean the same thing to the patient, payer, surgeon, study sponsor or an institutional review board. First, what is a “second-look” arthroscopy? Is the second-look an incidental part of an arthroscopy planned for a medically necessary indication or is the arthroscopy planned for the sole purpose of evaluating a previous intervention within a joint? The former is easy to accept as it allows some outcome information regarding a previous procedure at the time of a medically necessary arthroscopy. The latter requires more consideration.
Second-look arthroscopy for the sole purpose of evaluating a prior procedure is viewed differently by each party. As physicians, we are patient advocates. What value do we bring to the patient with a single-purpose second-look surgery? Is the risk-reward ratio appropriate even at a time where in-office “needle” arthroscopy under local anesthetic and high-quality MRIs are available? Patient inconvenience is real (eg, time off work or school), pain is present though minor and there is the rare risk of unforeseen complications. The physician must always ask if the results of this procedure change the decision-making that would otherwise occur absent of information gained from simply looking.
There may be a benefit to a select number of patients who want to know the status/success of a prior procedure. For example, has a salvage meniscus repair healed to the point of allowing advancing activity? On the other hand, for most patients, MRI would suffice to gather adequate data to allow a similar decision. More importantly, a clinical decision can often be made based upon a proper history and physical, even absent of the added information learned from imaging or arthroscopy given the poor correlation of many anatomic findings to clinical symptoms. The payer will typically be involved to determine if a proposed procedure is “medically necessary.” In the current cost-conscious health care environment, it would be rare for a carrier to allow an isolated second-look. In clinical research, new products are often in FDA trials and due to the cost of these trials, most are industry-sponsored. For articular and meniscal cartilage, second-looks may seem important for verification to the sponsor and FDA, yet the devil is in the details. There is variation in surgeon-to-surgeon assessment of implants/repair, and while biopsies may seem to be a “gold standard,” biopsy material may vary in different regions of the implant/repair. MRI allows a more global assessment of not only soft tissue healing, but also the underlying bone. The next consideration is many institutional review boards with study oversight will object to a pure second-look knee arthroscopy since they function as the ultimate patient advocate. Finally, as surgeons, we are visual, tactile and innately yearn to see how our procedures have performed. However, this must be tempered with what is best for the patient and health care economic environment. In the end, we must ask ourselves: Will this information change my clinical decision-making and is it in the best interest of the patient?
Jack Farr II, MD, is medical director, Knee Preservation and Cartilage Restoration Center at OrthoIndy Hospital in Indianapolis.
Disclosure: Farr reports no relevant financial disclosures.