Why are there so many utter douchebags within my profession?

I’m coming across so many cases of poor practice on such a regular basis now that I think the time has finally come to share some of these stories. Sadly, they paint a very poor picture of some of my ‘colleagues’ within my profession. However, I think it’s important that people are aware of what’s actually happening out there, as forewarning people might perhaps help save at least one or two patients from simply accepting what is clearly and blatantly poor practice. This story is just one of many similar shockers, which I’ll share with you in due course…

Case History

A lady comes to see me in clinic for a second opinion. She fell skiing a couple of years ago and felt something ‘go’ in her knee, followed by pain and some (but not a lot of) swelling. Afterwards, her knee felt stable. She had an MRI, and was told that she ‘might’ have had an ACL tear, but the surgeon she saw was not sure. The rest of her knee was apparently OK. The decision was made to managed things conservatively, with rehab. At this stage, her knee still felt stable to her.

A year or so later, the patient then slipped and fell down a few steps, twisting her knee, and this was followed by further pain and swelling in the knee. The patient had another MRI: she was then told by her surgeon that she now had a definite ACL tear, plus medial and lateral meniscal tears. The surgeon recommended surgery, with an ACL reconstruction and meniscal trims.

The patient then went and got herself a second opinion from a well-known very high-volume knee surgeon at a ‘famous’ clinic in London. In clinic, this second surgeon looked at the lady’s MRI report, but not the actual imaging. Shockingly, the patient said that this surgeon did not even actually examine the patient’s knee!!?! The surgeon told the patient that she needed an ACL reconstruction, and that “I’ve done thousands of these: I know what you need”.

The patient then came to see me for what was then a 3^rd opinion.

Key details when I saw the patient:

• c/o mild achy pain at front of knee, in region of tibial tuberosity. No medial or lateral joint line pain. No pain posteriorly.
• Not confident on knee now on stairs, but no episodes of instability at all.
• No sudden sharp pains, no painful clicking, no catching, locking or giving way.

Examination:

• No medial or lateral joint line tenderness.
• No pain posteriorly with forced deep flexion.
• McMurray’s test negative.
• Thessaly’s functional test for meniscal tears negative.
• Anterior drawer negative.
• Lachman negative.
• Pivot shift difficult to assess… but not positive.

Up-to-date MRI:

• relatively minor partial tear of ACL (not fresh),
• orientation of PCL = normal (i.e. no anterior tibial subluxation, implying that there is still decent tension in the remnant of the ACL),
• other ligaments all intact,
• extensive complex degenerate tear in posterior horn of medial meniscus,
• complex tear in posterior horn of lateral meniscus as well,
• no articular cartilage damage and
• patellofemoral compartment fine.

So… the ‘top’ surgeon that this lady went to see was actually encouraging this patient to go ahead with an ACL reconstruction

1. when she’s not complaining of any functional instability,
2. with a negative Lachman’s and a negative pivot shift,
3. when her MRI scan actually showed that her ACL injury was only a relatively minor partial tear, and, most shockingly…
4. without him even having examined her knee!!!

My suggested plan of action:

1. Despite the clear evidence on the MRI of medial and lateral meniscal tears, the patient does not actually seem to be complaining of any specific meniscal type symptoms at present, and her clinical examination failed to show any specific positive meniscal signs. Therefore, there is no need to rush in with an arthroscopy specifically just to deal with the meniscal tears (with what would definitely end up being major meniscal trims, not repairs).
2. I’ve referred the patient to one of our really excellent local physiotherapists, for some gentle cautious rehab.
3. The patient has a significantly elevated BMI and expressed concern about this: I’ve therefore also referred the patient to a weight-loss specialist for further advice/assistance.
4. I’ve sent the patient a load of information to read about:
   • meniscal tears, meniscal repair and meniscal trimming,
   • the consequences of meniscal damage / loss,
   • the role of knee arthroscopy in general,
   • a copy of the latest professional guidelines from The British Association for Surgery of the Knee (BASK) about the appropriate management of meniscal tears and about the role (or otherwise) of knee arthroscopy,
   • ACL tears,
   • ACL reconstruction, and
   • the pros and cons of surgical reconstruction of ACL tears vs conservative management.
5. I’ve offered to review the patient back in clinic in a couple of months’ time with a fresh up-to-date 3-Tesla MRI scan so that we can then take another look at things and so that we can then chat further… but (hopefully) by then, the patient will know a lot more about her knee issues and the various potential options open to her, and by then she will hopefully be far better informed, and therefore in a much better position to make a proper fully-informed decision about what she might or might not want to have done to her knee.

So… questions for you all:

1. Do you want me to name the Consultant Orthopaedic Surgeon in London who is a well-known very high-volume knee surgeon at a very well-known clinic?
2. Should that surgeon be reported for poor practice, for recommending major invasive surgery for a patient A) without looking at their MRI himself (he only looked at the report), B) for not having actually examined the patient’s knee, and C) for advising the patient that she needed to have her knee stabilised when the knee is not actually even unstable?
3. Do you agree with my slower, more cautious, more measured and more conservative approach
4. Would you like me to post a follow-up to this sorry story in a couple of months’ time, when the patient (potentially) comes back to clinic again?
5. Why are there so many utter douchebags within my profession?