To The Editor:
As Chairman of the Department of Pathology in a five-hospital system
in San Antonio, I took interest in the article entitled "Cost
and Effectiveness of Routine Pathological Examination of Operative
Specimens Obtained During Primary Total Hip and Knee Replacement
in Patients with Osteoarthritis" (82-A: 1531-1535, Nov.
2000), by Kocher et al., and also in the associated editorial by
Clark and Bauer (82-A: 1529-1530, Nov. 2000). I agree with the basic
premises of the authors. A number of years ago, the same issue was debated
in the Baptist Health System. The decision was made to perform gross
exams on these specimens with the proviso that the surgeon could
request a microscopic examination on any specimen and the pathologists could
decide to submit sections if gross features indicated disease other
than osteoarthritis. The total charges, professional and technical,
for gross examination are $86.00, which is substantially
less than those for a microscopic examination. Total costs have
not been calculated but are certainly less than those of a microscopic
exam including decalcification.
Our concerns and reasons for maintaining some sort of routine pathological
examination mirrored those indicated in the article and editorial.
The final decision to perform a gross examination of these specimens rather
than no pathological examination was multifactorial. A few of the
reasons are as follows:
(1) Since the clinical and radiological evaluation of these patients
is done outside of the hospital setting, the gross pathological
examination ensures documentation of diseased tissue and serves
as a quality-assurance tool. (2) Our policy concerning routine gross
examination includes keeping the tissue available for approximately
two weeks after the gross report has been generated. Then, if unsuspected
findings are identified, a microscopic evaluation can be performed,
and if for some clinical reason, such as a postoperative infection,
the specimen needs further review, it will not have been discarded.
(3) There was concern that if specimens were no longer
routinely scheduled for any pathological examination, surgeons would
assume that none of these specimens could be sent for evaluation (despite
the observation of Kocher et al. that many surgeons consider pathological
examination of surgical specimens to be mandatory). (4) Liability
was a major issue for all parties, and the general belief was that
routine gross examination of these specimens would decrease the risk
of liability. If a more detailed examination was required in the
two weeks after surgery, the required tissue could be saved indefinitely.
In summation, I agree that routine microscopic examination of tissue
from primary total joint replacement is not required on a routine
basis. However, gross examination of these specimens decreases costs,
provides a measure of quality assurance, satisfies regulatory requirements,
and theoretically decreases the risk of liability. For these and
other reasons I would recommend routine gross examination of these specimens.
M.S. Kocher, G. Erens, T.S. Thornhill, and J.E. Ready
reply:
We appreciate Dr. Hinchey’s comments regarding our study, and
his perspective as a chairman of a pathology department. Dr. Hinchey
outlines his department’s rationale for routine gross pathological
examination of surgical specimens from total joint replacement,
with microscopic pathological examination performed episodically
at the discretion of the surgeon or the pathologist. This seems
to be a reasonable compromise between a strategy of routine gross
and histological examination and a strategy of no pathological examination,
as it would reduce the cost of examination. However, the effectiveness
of this "gross only" strategy in detecting discrepant
and discordant cases has not been established. In our study we assessed
only a strategy of routine gross and histological
pathological examination. We encourage Dr. Hinchey to report the
results of this strategy with regard to cost and effectiveness.