To The Editor:

I read with interest the recent article, “The future of the orthopaedic surgeon-proceduralist or keeper of the musculoskeletal system” by Boden,et al. In discussing the impact of imaging technology on orthopaedic surgery, magnetic resonance imaging was cited as an example of a technique that "... remove(d) the diagnostic aspect of patient care and transferred it to the non-operative physician.” While this phenomenon may, in fact be occurring, I would argue (and I imagine the authors would agree) that no matter what imaging studies may have been performed or what diagnosis may have been formulated by the referring physician, the orthopaedist is responsible for arriving at an independent assessment of all pertinent data prior to arriving at a diagnosis upon which treatment decisions, especially operative, depend.

Many physicians often assume that the MRI findings (by a radiologist who has neither interviewed nor examined the individual) are equivalent to the actual diagnosis responsible for a patient’s symptoms. I often see patients with an MRI-based diagnosis of a “torn meniscus” that is, in fact, an incidental finding, having no connection to their symptoms. Further, many diagnoses of clinical significance are unimageable by any current technology (including synovial impingement and neuromas) that can only be made by one who is thoroughly knowledgeable in the complex anatomy and pathophysiology of the musculoskeletal system. An independent, thorough history and physical examination provides an invaluable data base from which to properly assess the validity of any ancillary information including that provided by imaging. Of all physicians with an interest in the musculoskeletal system, we orthopaedic surgeons must resist the temptation to become over-reliant on the radiologists’ opinion, thus leading inevitably to the atrophying of our own diagnostic skills.

As an important and perhaps crucial, aspect of remaining the “keeper of the musculoskeletal system” we must not abrogate the diagnostic responsibilities to others. We can do this by practicing the essential principles of orthopaedic surgery, i.e. lifelong study of anatomy and pathophysiology, performing a thorough history and physical examination prior to the consideration of imaging data, no matter how advanced, and to integrate all information prior to arriving at a diagnosis and treatment recommendation.