Magnetic resonance imaging, knee arthroscopy, and clinical decision making: a descriptive study of five surgeons.

OBJECTIVES: A randomized controlled trial (RCT) showed magnetic resonance imaging for patients waiting for knee arthroscopy did not reduce the number of arthroscopies. Our study aimed to identify decisions made by orthopedic surgeons about whether patients on a waiting list should proceed to arthroscopy, and to describe surgeons' decisions. METHODS: Five surgeons were asked to Think Aloud (TA) as they made their decisions for twelve patients from the original RCT. Audiotapes of the decision making were transcribed for analysis. RESULTS: For five patients, surgeons agreed about proceeding with arthroscopy, although reasoning differed. In no cases did surgeons agree about not proceeding to arthroscopy. Agreement was more likely in patients with clinically diagnosed meniscal abnormality, and less likely in patients with osteoarthritis. CONCLUSIONS: Surgeons' decisions were influenced by patient wishes. For some patients, the decision to proceed with arthroscopy was based solely on clinical diagnosis; MRI may not be advantageous in these instances. Surgeons disagreed more often than they agreed about the decision to proceed with arthroscopy, particularly when OA was diagnosed. This has implications for decision making in the current NHS patient choice environment. Patients may choose a treatment provider from a list of available providers at time of original clinical assessment and diagnosis. The treating surgeon does not necessarily re-examine the patient until the day of surgery. Given the variation between surgeons about the merits of proceeding with arthroscopy, surgeons may end up in the invidious position of providing surgery to patients whom they do not believe will benefit from arthroscopy.

Conservative, open or percutaneous repair for acute rupture of the Achilles tendon.

PURPOSE: To review the complications and recovery of patients with Achilles tendon rupture managed by percutaneous repair, open repair, and non-operative means in a tertiary referral centre between 2001 and 2003. METHODS: The operating theatre register and logbooks of the Consultants were used to identify surgically managed patients, while plaster room records were used for conservatively managed patients. We collated demographic and management details. RESULTS: The number of plaster changes (p < 0.001), median length of time in cast (p < 0.001), and number of outpatient visits (p < 0.05) was greater in conservatively managed patients. We performed no formal statistical analysis given the small numbers. Conservative management was the least expensive and open surgery the most costly modality of management. Percutaneous surgery was approximately a third of the cost of open surgery when performed under local anaesthetic. CONCLUSION: In our setting, percutaneous repair and conservative management are viable alternatives to open surgery, which carries higher complications rates and was the most costly of the three. Individual patients will have different needs due to their age, occupation, or level of sporting activity.