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Scientific Articles   |    
The Clinical Value of Histologic Examination in Shoulder Arthroscopy
Richard E. McClain, DO1; Carisa D. Hotari, BS2; Christopher L. Scribner, BA3; David A. Detrisac, MD4
1 Goshen Orthopedic Associates LLC, 1824 Dorchester Court, Goshen, IN 46526
2 821 South Michigan Avenue, Howell, MI 48843
3 804 Owego Drive, Pontiac, MI 48341
4 East Lansing Orthopedic Association, P.C., 3394 East Jolly Road, Suite A, Lansing, MI 48910
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at Ingham Regional Medical Center and Genesis Surgery Center, Lansing, and Michigan Surgical Center, East Lansing, Michigan

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Feb 01;90(2):281-283. doi: 10.2106/JBJS.F.00912
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Abstract

Background: The clinical value of histologic examination of tissues removed during shoulder arthroscopy has not been determined. The guidelines of the College of American Pathologists require routine histologic examination of all surgical specimens not specifically exempted by individual hospitals. Previous orthopaedic studies have examined the clinical value of these examinations in total hip and knee arthroplasty, lumbar discectomy, knee arthroscopy, and thumb arthroplasty. Those studies demonstrated that routine histologic examination rarely altered the diagnosis and increased the costs. This study examines the clinical value of histologic examination of shoulder arthroscopic specimens. We regard clinical value to include both diagnostic value and cost of the procedure.

Methods: Between 1989 and 2005, 2144 consecutive shoulder arthroscopies were performed by one surgeon. We retrospectively reviewed the pathology report from every procedure to determine whether the histologic diagnosis affected patient care. We then estimated the total cost of histologic examination in 2005 dollars.

Results: In all cases, the histologic examination confirmed the findings at arthroscopic surgery. In no case did the histologic findings alter patient care. In 2005 dollars, the total cost of reviewed histologic examinations is estimated to be $160,543.

Conclusions: Histologic examination of surgical specimens from arthroscopic shoulder surgery does not alter patient care, and it increases costs. On the basis of this study, histologic examination in shoulder arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.

Level of Evidence: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David A. Detrisac, M.D.
    Posted on July 22, 2008
    Dr Detrisac et al. respond to Dr. Richards
    NULL

    We appreciate the interest of our pathologist colleagues in our article(1). Their 9 cases have been reviewed. One patient, with a known history of non-Hodgkin’s lymphoma, had an arthroscopic acromioplasty and open resection of the distal clavicle. Histologic examination of the distal clavicle revealed findings diagnostic of non-Hodgkin’s lymphoma. None of the other cases involved arthroscopic surgery.

    In reviewing the other 8 non-arthroscopic cases,five(including 2 pathologic fractures) had known malignancy prior to surgery and histology revealed no new diagnoses. Two new diagnoses of lymphoma and one of atypical lymphoid aggregates, a possible pre-malignant lesion, were found. These 3 patients are being followed by each patient’s oncologist. No treatment based on the histology diagnoses has yet been initiated in these 3 patients.

    The source of the payment information is based on Medicare payments in 2005 dollars.

    We stand by our conclusion that histologic examination following our arthroscopic shoulder surgery cases did not influence patient care or provide any new diagnoses. We believe that any unusual arthroscopic findings during surgery should warrant submission for histology and that, in these cases, histology in concordance with the arthroscopic findings will provide the best patient care. We also believe that the surgeon should be the one to judge when histologic examination of arthroscopic surgery specimens is indicated.

    References:

    1.Richard E. McClain, Carisa D. Hotari, Christopher L. Scribner, and David A. Detrisac The Clinical Value of Histologic Examination in Shoulder Arthroscopy J Bone Joint Surg Am 2008; 90: 281-283

    James E. Richard, DO
    Posted on May 28, 2008
    Another field of view
    Capital Area Pathologist, P.C., Lansing, MI

    To The Editor:

    The findings in the article, "The Clinical Value of Histologic Examination in Shoulder Arthroscopy"(1) are discordant with our experience. We are the pathology department that interprets the histologic material from two of the three institutions listed in the article. In the past twelve months, there have been nine cases of malignancy or probable malignancy from orthopedic specimens that gave no indication of disease on the tissue request slip or in the history charts of our institutions, including two shoulder cases from one of the authors of this article. These specimens came from patients between the ages of 61 and 88 and included arthroplasty specimens as well as arthroscopic shavings. Tissue sites included hips, knees, shoulder, and lumbar spine. The diagnoses in these cases included metastatic carcinoma, lymphoma, probable lymphoma, and one case of systemic mastocytosis. The total number of surgical pathology specimens from all surgical procedures in our community hospital averages 16,000 per year.

    We were not involved in the result comparison of the histologic findings with the clinical or intraoperative diagnosis. We can state, however, that the information regarding payment is somewhat misleading given the insurance mix in our area of Michigan. Our average reimbursement is well below that listed in the article's calculations.

    The controversy regarding the submission of specimens to pathology should be based upon patient care. When good patient care is reduced to a monetary standard, then patient care and patient safety may become secondary. The diagnoses rendered in the above mentioned cases required microscopic examination of these tissues. Even experienced surgeons have been surprised by unexpected findings in the most innocuous tissue samples that have altered the course of the patient's care.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. McClain RE, Hotari CD, Scribner CL, Detrisac DA. The Clinical Value of Histologic Examination in Shoulder Arthroscopy. J Bone Joint Surg Am 2008;90:281-3.

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