- Email: [email protected]
UNNECESSARY MENISCECTOMY
235
What is the next move? Firstly, an epidemiological survey should be mounted to determine whether or not there really is a problem-is the failure-rate 5% or 20%? This investigation could show, secondly, whether failure-rates are substantially higher from some centres than from others: big discrepancies would suggest that technical factors are important and that the solution lies in training and logistics. What if the investigation did point the finger at inexperienced surgeons? There simply are not enough experienced surgeons to operate on all the hips that require replacement. We face three options: firstly, only the hips that can be operated on by competent surgeons should be treated (leaving the rest, perhaps 50%, disabled); secondly, all
treated, some by inexperienced surgeons (which may mean that 20% are disabled); thirdly, we are
arrange for
hip replacements to be done by non-medically-qualified technicians. The last possibility would represent an entirely novel and indeed heretical approach in British medicine, but it might some
well be the best of the three. Other countries are already training paramedicals to do set-piece operations : many non-medical people have the manual dexterity to do an operation such as hip replacement. Such a technician would, of course, play no part in preoperative selection nor in postoperative care and would operate only under the general supervision of an orthopaedic surgeon. For routine replacement of the hip, however, such a person might be less readily bored than the average orthopaedic surgeon, as well as being technically more dextrous.
UNNECESSARY MENISCECTOMY
reported sequelæ;7 but, oddly, radiographic changes unrelated
to
knee
symptoms.8 Pope9
1. Watson-Jones, R. Fractures and 1956. 2 Fairbanks, T. J. J.Bone Ft Surg.
one
roscope had influenced management in half their 800
THERE is a dictum that a surgeon seeking a torn meniscus is committed to a meniscectomy, for without doing the operation he may miss a posterior-horn tear: Watson-Jones1 declared, "the cartilage must be removed whether the split is seen or not". On this basis, normal meniscuses are probably removed in their thousands, though the operation notes may record a "transverse tear of the mid-portion" (often caused by linear traction on a curved structure) or a "frayed posterior horn". Does losing a pristine meniscus matter? It was Fairbanks2 who, ahead of his time, drew attention to radiological abnormalities after meniscectomy, and controlled studies3 have since laid the blame squarely on’ the operation. Ten years or so after operation, around 85% of patients have degenerative changes.4-6 Pain, instability, sensations of locking, and painful catches on flexion are seem
cartilage reduced the whole joint’s energy-absorbing capacity by half, and removal of both reduced it by four-fifths. A number of surgeons imply that they seldom remove a normal meniscus,10-14 though Steward remarks that "one is astute who can keep his errors in diagnosing tears as low as 10%". In a prospective study reported last year, 16 the clinical diagnosis was incorrect in 28% of cases; Smillie, 17 in his unsurpassed series, removed a normal meniscus in only 4% of operations. An error-rate of even this low order would mean roughly a thousand normal meniscuses being removed each year in the United Kingdom-the lowest price to be paid for not neglecting a posterior-horn tear. Smillie’s figures18 suggest that the large majority of these posterior tears are horizontal cleavage lesions, and there is little evidence that leaving a torn meniscus in situ will necessarily be harmful. Noble and Hamblen,19 examining subjects who came to necropsy (most of them elderly), found that nearly two-thirds had at least one horizontal cleavage lesion; in their view, not all were likely to have had symptoms. Subsequently Noble 20 reported that patients with horizontal tears were usually improved by meniscectomy, but fewer than half were completely relieved of symptoms. Tapper and Hoover4found that ten to thirty years after meniscectomy 45% of males and 10% of females had symptom-free knees, and the experience of Johnson et al,21 was much the same. Clearly, to cut is not always to cure. We need to know more about the natural history of meniscus complaints and about their response to non-surgical treatments; Cassells22 and Le Quesne et al.23 claim success with juxta-meniscal1 steroid injections in meniscus degeneration. The only two advances in meniscus management since Annandale’s paper of 188524 have been arthrography and arthroscopy. Arthroscopy was described over half a century ago;25 advocates16 26 claim that, by identifying normal meniscuses, it saves operation in at least a quarter of cases. Dandy and Jackson26 thought the arthremoval of
found that
Joint Injuries; vol. II, p. 769. Edinburgh,
1948, 30B, 664. 3 Jackson, J. P. Br. med. J. 1968, ii, 525. 4 Tapper, E., Hoover, N. W.J. Bone Jt Surg. 1969, 51A, 517. 5 Gear, M. W. L. Br. J. Surg. 1967, 54, 270. 6 Huckell, J. R. Can. J. Surg. 1965, 8, 254. 7. Dandy, D. J., Jackson, R. W.J. Bone Jt Surg. 1975, 57B, 349. 8. Smillie, I. S. Injuries of the Knee Joint; Edinburgh, 1970, p. 127.
patients. They also reported resolution of symptoms in 73 of 92 patients in whom meniscectomy was withheld because of arthroscopy. In expert hands arthroscopy clearly eliminates almost all diagnostic error. Whether many centres will be able to acquire the necessary experience, or even an arthroscope, is another matter. ’Therefore, it is some comfort that interest in arthrography has reawoken. High rates of diagnostic accuracy have been claimed by some 21 but not all.21 Meniscec9.
Pope, M. H., Johnson, R., Weinstein, A., Wilder, D. J. Bone Jt Surg. 1975, 57A, 570. 10. Murdoch, G. Clin. Orthop. 1960, 18, 123. 11. Helfet, A. Disorders of the Knee; Philadelphia, 1974, p. 117. 12. Lotem, M., Fried, A. Isr.J. med. Sci. 1971, 7, 733. 13. Wynn-Parry, C. B., Nichols, P. J. R., Lewis, N. R., Ann. phys. Med. 1958, 4, 201. 14. Appel, H. Acta orthop. scand. 1970, suppl. 133. 15. Stewart, M. Campbell’s Operative Orthopædics; p. 909, St. Louis, 1971. 16. DeHaven, K. E., Collins, H. R.J. Bone Jt Surg. 1975, 57A, 802. 17. Smillie, I. S. Injuries of the Knee Joint; Edinburgh, 1970, p. 96. 18. Smillie, I. S. ibid. p. 50. 19. Noble, J., Hamblen, D. L.J. Bone Jr Surg. 1975, 57B, 180. 20. Noble, J. Br. J. Surg. 1975, 62, 97. 21. Johnson, R. J., Kettelkamp, D. B., Clark, W., Leaverton, P. J. Bone Jt Surg. 1974, 56A, 719. 22. Cassels, S. W. Clin. Orthop. 1971, 76, 123. 23. Le Quesne, M., Bensason, M., Kemmer, C., Anouroux, J. Ann. rheum. Dis. 1970, 29, 689. 24. Annandale, T. Br. med. J. 1885, ii, 525. 25. Takagi, K. J. Jap. orthop. Ass. 1933, 8, 132. 26. Dandy, D. J., Jackson, R. W.J. Bone Jr Surg. 1975, 57B, 346. 27. Nicholas, J. A., Freiberger, R. H., Killoran, P. J. ibid. 1970, 52A, 203.
.
236
tomy is a very common and usually easy operation from which most patients benefit. But amazingly little is known about the function of the removed structure, the benefits and drawbacks of its removal, or the true significance of its various tears. Meanwhile, for those with-
arthroscopy or arthrography services, who discover obvious disease at arthrotomy, simple closure of the joint may have much to commend it.
out
document is itself an indictment of the service given many of the young disabled, the aged, the mentally ill, and the mentally handicapped. Only a persistent, imaginative, and vigorous effort for another decade in all long-stay hospitals is likely to make this important booklet obsolete. a
to
no
BARBARA CASTLE REVISITS THE N.H.S.
LIVING-OR EXISTING-IN HOSPITAL
plight of people living in long-stay hospitals has slowly improved over the past decade, and one hopes that the scandalous revelations of that period are now behind us for good. Further improvements, however, may prove more difficult to achieve although the need is as great as before. A quarter of a million people in Britain still reside more or less permanently in hospitals, and no-one could say that care is now uniformly excellent. The danger of stagnation of effort is again severe, at a time when money is short, political effort is directed elsewhere, and publicity settles on more interesting subjects. One organisation which has done a great deal to help improve the lot of long-stay patients, largely by spreading knowledge of pioneering ideas, is King Edward’s Hospital Fund for London. The latest publication from the King’s Fund, Living in Hospital,deserves a particularly wide readership. It is concerned with the THE
alterations to the social environment needed to transform an institution into something approaching a home, and with the organisational changes needed to stimulate independence in apathetic residents. Inevitably the suggestions sound banal, and hospital doctors may well complacently dismiss this booklet as peripheral to their interests. They cannot, however, escape a share of responsibility for the continuing inexcusable inadequacies in the social environment of longstay hospitals. Indeed, sins of omission make a major contribution to the failure. Doctors who are unwilling to discharge their wider responsibilities to patients, by participating vigorously in the team effort to encourage greater independence, must retreat to a narrower medical role--and must do so explicity, lest they be seen as leaders on whom other care-staff should model their behaviour. If the doctor has no interest in his patients’ clothing, further education, or opportunities for sexual activity, or in the residents’ committee, then he should make it clear that he expects someone else to be given responsibility for these important social matters. There is a fundamental conflict of aims in a progressive long-stay hospital, and this conflict ought to be discussed frequently. The patients need treatment because of some chronic disability, and the organisation is set up to perform this task; but the efficient running of the organisation must never be allowed to subjugate the patients so that conformity, obedience, and unobtrusive cooperation are seen as model behaviour. Living in Hospital should become a primer for all staff in long-stay hospitals-and indeed for the staff of those community homes which are supposed to replace them eventually. The need for such 1.
Living in Hospital:
the Social Needs of People in Long-term Care. By JAMES ELLIOIT. Obtainable from King’s Fund Centre, 24 Nutford Place, London W1H 6AN. £2.50.
MRS CASTLE’S distinctions as Secretary of State for Social Services are two-fold. In the first place, as a doughty fighter within the Cabinet, she has achieved more of the gross national product for the N.H.S. than ever before, and saved it from excessive cuts in the current review of Government expenditure. Secondly, her tenure in office has been a superb example of the politician at work. This is, of course, linked with the first distinction and it is because of attitudes arising from the latter than the former is in danger of being overlooked, The text’ of the Nye Bevan Memorial Lecture given on Dec. 3, 1975, contains insights into the politician side at work. This dateline, when Mrs Castle was in the heart of her negotiations with both the consultants and junior hospital doctors, gives it an added interest. It is natural that in such a lecture the contribution of Nye Bevan, as the Minister responsible for creating the N.H.S. in 1948, should be to the fore but Mrs Castle’s recollections of his past battles with the medical profession seem to have been chosen with our contemporary troubles in mind. Does she see herself under like attack? Perhaps so: "The language used against Aneurin Bevan as the row went on is an immense consolation to me at the present time’’; she writes, and later she quotes a telling phrase of Bevan’s in 1948 when he answered a rhetorical question about his own "unreasonableness" by saying it was a quality that he appeared to have in common with every Minister of Health whom the B.M.A. had met. Many Ministers since may have equally well taken consolation from that phrase. Elsewhere Mrs Castle says that Bevan "won" in his determination to introduce the service because "he kept his nerve and at the eleventh hour he broke their [docof resistance by accepting Lord Moran’s remnants tors] suggestion"-a situation akin to that in late 1975 when, after her insistence that all pay beds must be phased out and after heavy fire from the doctors, the Goodman compromise of a phased withdrawal, supervised by an ...
independent commission, was suddenly produced. Otherwise the pamphlet goes over old ground: the N.H.S. has been deprived of its "fair share of natural resources" largely because of the undemocratic nature of the Service’s structure. On budgeting, Mrs Castle explains that the myth that large extra resources would be available if private money were allowed to play a larger part in financing the N.H.S. is "one reason why the government has agreed to set up the Royal Commission." Clearly she sees public sympathy as a force to be reckoned with. Unfortunately there is no hint here of offer National Health Service beds—and apparently preferential treatment-to patients free overseas. It will be interesting to see how public sympathy responds to the latest manceuverings.
her scheme
to
1. N.H.S. Revisited. Barbara Castle. Fabian Tract 440 (available from Fabian Society, 11 Dartmouth Street, London SW1H 9BN, price 35p post
free).
What is the next move? Firstly, an epidemiological survey should be mounted to determine whether or not there really is a problem-is the failure-rate 5% or 20%? This investigation could show, secondly, whether failure-rates are substantially higher from some centres than from others: big discrepancies would suggest that technical factors are important and that the solution lies in training and logistics. What if the investigation did point the finger at inexperienced surgeons? There simply are not enough experienced surgeons to operate on all the hips that require replacement. We face three options: firstly, only the hips that can be operated on by competent surgeons should be treated (leaving the rest, perhaps 50%, disabled); secondly, all
treated, some by inexperienced surgeons (which may mean that 20% are disabled); thirdly, we are
arrange for
hip replacements to be done by non-medically-qualified technicians. The last possibility would represent an entirely novel and indeed heretical approach in British medicine, but it might some
well be the best of the three. Other countries are already training paramedicals to do set-piece operations : many non-medical people have the manual dexterity to do an operation such as hip replacement. Such a technician would, of course, play no part in preoperative selection nor in postoperative care and would operate only under the general supervision of an orthopaedic surgeon. For routine replacement of the hip, however, such a person might be less readily bored than the average orthopaedic surgeon, as well as being technically more dextrous.
UNNECESSARY MENISCECTOMY
reported sequelæ;7 but, oddly, radiographic changes unrelated
to
knee
symptoms.8 Pope9
1. Watson-Jones, R. Fractures and 1956. 2 Fairbanks, T. J. J.Bone Ft Surg.
one
roscope had influenced management in half their 800
THERE is a dictum that a surgeon seeking a torn meniscus is committed to a meniscectomy, for without doing the operation he may miss a posterior-horn tear: Watson-Jones1 declared, "the cartilage must be removed whether the split is seen or not". On this basis, normal meniscuses are probably removed in their thousands, though the operation notes may record a "transverse tear of the mid-portion" (often caused by linear traction on a curved structure) or a "frayed posterior horn". Does losing a pristine meniscus matter? It was Fairbanks2 who, ahead of his time, drew attention to radiological abnormalities after meniscectomy, and controlled studies3 have since laid the blame squarely on’ the operation. Ten years or so after operation, around 85% of patients have degenerative changes.4-6 Pain, instability, sensations of locking, and painful catches on flexion are seem
cartilage reduced the whole joint’s energy-absorbing capacity by half, and removal of both reduced it by four-fifths. A number of surgeons imply that they seldom remove a normal meniscus,10-14 though Steward remarks that "one is astute who can keep his errors in diagnosing tears as low as 10%". In a prospective study reported last year, 16 the clinical diagnosis was incorrect in 28% of cases; Smillie, 17 in his unsurpassed series, removed a normal meniscus in only 4% of operations. An error-rate of even this low order would mean roughly a thousand normal meniscuses being removed each year in the United Kingdom-the lowest price to be paid for not neglecting a posterior-horn tear. Smillie’s figures18 suggest that the large majority of these posterior tears are horizontal cleavage lesions, and there is little evidence that leaving a torn meniscus in situ will necessarily be harmful. Noble and Hamblen,19 examining subjects who came to necropsy (most of them elderly), found that nearly two-thirds had at least one horizontal cleavage lesion; in their view, not all were likely to have had symptoms. Subsequently Noble 20 reported that patients with horizontal tears were usually improved by meniscectomy, but fewer than half were completely relieved of symptoms. Tapper and Hoover4found that ten to thirty years after meniscectomy 45% of males and 10% of females had symptom-free knees, and the experience of Johnson et al,21 was much the same. Clearly, to cut is not always to cure. We need to know more about the natural history of meniscus complaints and about their response to non-surgical treatments; Cassells22 and Le Quesne et al.23 claim success with juxta-meniscal1 steroid injections in meniscus degeneration. The only two advances in meniscus management since Annandale’s paper of 188524 have been arthrography and arthroscopy. Arthroscopy was described over half a century ago;25 advocates16 26 claim that, by identifying normal meniscuses, it saves operation in at least a quarter of cases. Dandy and Jackson26 thought the arthremoval of
found that
Joint Injuries; vol. II, p. 769. Edinburgh,
1948, 30B, 664. 3 Jackson, J. P. Br. med. J. 1968, ii, 525. 4 Tapper, E., Hoover, N. W.J. Bone Jt Surg. 1969, 51A, 517. 5 Gear, M. W. L. Br. J. Surg. 1967, 54, 270. 6 Huckell, J. R. Can. J. Surg. 1965, 8, 254. 7. Dandy, D. J., Jackson, R. W.J. Bone Jt Surg. 1975, 57B, 349. 8. Smillie, I. S. Injuries of the Knee Joint; Edinburgh, 1970, p. 127.
patients. They also reported resolution of symptoms in 73 of 92 patients in whom meniscectomy was withheld because of arthroscopy. In expert hands arthroscopy clearly eliminates almost all diagnostic error. Whether many centres will be able to acquire the necessary experience, or even an arthroscope, is another matter. ’Therefore, it is some comfort that interest in arthrography has reawoken. High rates of diagnostic accuracy have been claimed by some 21 but not all.21 Meniscec9.
Pope, M. H., Johnson, R., Weinstein, A., Wilder, D. J. Bone Jt Surg. 1975, 57A, 570. 10. Murdoch, G. Clin. Orthop. 1960, 18, 123. 11. Helfet, A. Disorders of the Knee; Philadelphia, 1974, p. 117. 12. Lotem, M., Fried, A. Isr.J. med. Sci. 1971, 7, 733. 13. Wynn-Parry, C. B., Nichols, P. J. R., Lewis, N. R., Ann. phys. Med. 1958, 4, 201. 14. Appel, H. Acta orthop. scand. 1970, suppl. 133. 15. Stewart, M. Campbell’s Operative Orthopædics; p. 909, St. Louis, 1971. 16. DeHaven, K. E., Collins, H. R.J. Bone Jt Surg. 1975, 57A, 802. 17. Smillie, I. S. Injuries of the Knee Joint; Edinburgh, 1970, p. 96. 18. Smillie, I. S. ibid. p. 50. 19. Noble, J., Hamblen, D. L.J. Bone Jr Surg. 1975, 57B, 180. 20. Noble, J. Br. J. Surg. 1975, 62, 97. 21. Johnson, R. J., Kettelkamp, D. B., Clark, W., Leaverton, P. J. Bone Jt Surg. 1974, 56A, 719. 22. Cassels, S. W. Clin. Orthop. 1971, 76, 123. 23. Le Quesne, M., Bensason, M., Kemmer, C., Anouroux, J. Ann. rheum. Dis. 1970, 29, 689. 24. Annandale, T. Br. med. J. 1885, ii, 525. 25. Takagi, K. J. Jap. orthop. Ass. 1933, 8, 132. 26. Dandy, D. J., Jackson, R. W.J. Bone Jr Surg. 1975, 57B, 346. 27. Nicholas, J. A., Freiberger, R. H., Killoran, P. J. ibid. 1970, 52A, 203.
.
236
tomy is a very common and usually easy operation from which most patients benefit. But amazingly little is known about the function of the removed structure, the benefits and drawbacks of its removal, or the true significance of its various tears. Meanwhile, for those with-
arthroscopy or arthrography services, who discover obvious disease at arthrotomy, simple closure of the joint may have much to commend it.
out
document is itself an indictment of the service given many of the young disabled, the aged, the mentally ill, and the mentally handicapped. Only a persistent, imaginative, and vigorous effort for another decade in all long-stay hospitals is likely to make this important booklet obsolete. a
to
no
BARBARA CASTLE REVISITS THE N.H.S.
LIVING-OR EXISTING-IN HOSPITAL
plight of people living in long-stay hospitals has slowly improved over the past decade, and one hopes that the scandalous revelations of that period are now behind us for good. Further improvements, however, may prove more difficult to achieve although the need is as great as before. A quarter of a million people in Britain still reside more or less permanently in hospitals, and no-one could say that care is now uniformly excellent. The danger of stagnation of effort is again severe, at a time when money is short, political effort is directed elsewhere, and publicity settles on more interesting subjects. One organisation which has done a great deal to help improve the lot of long-stay patients, largely by spreading knowledge of pioneering ideas, is King Edward’s Hospital Fund for London. The latest publication from the King’s Fund, Living in Hospital,deserves a particularly wide readership. It is concerned with the THE
alterations to the social environment needed to transform an institution into something approaching a home, and with the organisational changes needed to stimulate independence in apathetic residents. Inevitably the suggestions sound banal, and hospital doctors may well complacently dismiss this booklet as peripheral to their interests. They cannot, however, escape a share of responsibility for the continuing inexcusable inadequacies in the social environment of longstay hospitals. Indeed, sins of omission make a major contribution to the failure. Doctors who are unwilling to discharge their wider responsibilities to patients, by participating vigorously in the team effort to encourage greater independence, must retreat to a narrower medical role--and must do so explicity, lest they be seen as leaders on whom other care-staff should model their behaviour. If the doctor has no interest in his patients’ clothing, further education, or opportunities for sexual activity, or in the residents’ committee, then he should make it clear that he expects someone else to be given responsibility for these important social matters. There is a fundamental conflict of aims in a progressive long-stay hospital, and this conflict ought to be discussed frequently. The patients need treatment because of some chronic disability, and the organisation is set up to perform this task; but the efficient running of the organisation must never be allowed to subjugate the patients so that conformity, obedience, and unobtrusive cooperation are seen as model behaviour. Living in Hospital should become a primer for all staff in long-stay hospitals-and indeed for the staff of those community homes which are supposed to replace them eventually. The need for such 1.
Living in Hospital:
the Social Needs of People in Long-term Care. By JAMES ELLIOIT. Obtainable from King’s Fund Centre, 24 Nutford Place, London W1H 6AN. £2.50.
MRS CASTLE’S distinctions as Secretary of State for Social Services are two-fold. In the first place, as a doughty fighter within the Cabinet, she has achieved more of the gross national product for the N.H.S. than ever before, and saved it from excessive cuts in the current review of Government expenditure. Secondly, her tenure in office has been a superb example of the politician at work. This is, of course, linked with the first distinction and it is because of attitudes arising from the latter than the former is in danger of being overlooked, The text’ of the Nye Bevan Memorial Lecture given on Dec. 3, 1975, contains insights into the politician side at work. This dateline, when Mrs Castle was in the heart of her negotiations with both the consultants and junior hospital doctors, gives it an added interest. It is natural that in such a lecture the contribution of Nye Bevan, as the Minister responsible for creating the N.H.S. in 1948, should be to the fore but Mrs Castle’s recollections of his past battles with the medical profession seem to have been chosen with our contemporary troubles in mind. Does she see herself under like attack? Perhaps so: "The language used against Aneurin Bevan as the row went on is an immense consolation to me at the present time’’; she writes, and later she quotes a telling phrase of Bevan’s in 1948 when he answered a rhetorical question about his own "unreasonableness" by saying it was a quality that he appeared to have in common with every Minister of Health whom the B.M.A. had met. Many Ministers since may have equally well taken consolation from that phrase. Elsewhere Mrs Castle says that Bevan "won" in his determination to introduce the service because "he kept his nerve and at the eleventh hour he broke their [docof resistance by accepting Lord Moran’s remnants tors] suggestion"-a situation akin to that in late 1975 when, after her insistence that all pay beds must be phased out and after heavy fire from the doctors, the Goodman compromise of a phased withdrawal, supervised by an ...
independent commission, was suddenly produced. Otherwise the pamphlet goes over old ground: the N.H.S. has been deprived of its "fair share of natural resources" largely because of the undemocratic nature of the Service’s structure. On budgeting, Mrs Castle explains that the myth that large extra resources would be available if private money were allowed to play a larger part in financing the N.H.S. is "one reason why the government has agreed to set up the Royal Commission." Clearly she sees public sympathy as a force to be reckoned with. Unfortunately there is no hint here of offer National Health Service beds—and apparently preferential treatment-to patients free overseas. It will be interesting to see how public sympathy responds to the latest manceuverings.
her scheme
to
1. N.H.S. Revisited. Barbara Castle. Fabian Tract 440 (available from Fabian Society, 11 Dartmouth Street, London SW1H 9BN, price 35p post
free).