Some Question Marks Over Orthopaedic Surgery

Let me start this blog post by stating that I am not a surgeon. You can tell by the type of car I drive……

The purpose of this blog post is not to run down orthopaedic surgery or our surgical colleagues as many of them do wonderful work. I also know some fantastic evidence based orthopaedic surgeons who are moving with the times and altering their surgical practice based on the evidence base or lack thereof. If only a large amount of the physiotherapy profession would demonstrate the same willingness about some of our treatments!

Unfortunately, or fortunately, however you look at it, orthopaedic surgery has a very similar evidence-base behind many of its treatments, much like physiotherapy does. Those who are regular readers of evidence-based management and other blogs would be aware that in recent times there has been a significant emerging evidence base regarding the lack of superior outcomes for many orthopaedic surgeries when compared to conservative management (predominantly exercise based interventions). For those of you unfamiliar with much of this recent evidence base I will summarise some of it briefly now.

Shoulder Impingement/Subacromial Pain Syndrome:

A number of recent trials and systematic reviews have strongly concluded that there is little evidence in favour of superior outcomes from surgery for this condition compared to conservative management. Acromioplasty has been strongly suggested to not be cost-effective, and that structured exercise treatment is a far better choice for management of this entity. Please see the following links here, here, here and here for further information.

Interestingly, as Adolfsson reported, even Neer back in 1983 was adamant about recommending at least one year of nonoperative treatment for subacromial impingement before surgery was considered.

Rotator Cuff Tears:

Emerging research is questioning the value of operative treatment versus conservative management in relation to non-traumatic rotator cuff tears (1, 2 and 3). While I acknowledge that most of the research is in relation to supraspinatus tears, isn’t it interesting that trials are reporting no significant difference in clinical outcomes when comparing operatively repaired treatment groups to conservative treatment (exercise) groups.

Lower Back Pain and Radiculopathy:

While surgery for lumbar radiculopathy appears to convey faster pain reduction in the short term, as we can see  here, here, here and here, in the long term both conservatively treated patients and surgically treated patients have similar positive outcomes (even athletes). The general consensus appearing to me being that should patients have reasonable pain control  that they can be recommended, and encouraged, to continue with conservative management.

Even massive lumbar disc prolapses appear to have a very favourable clinical course with time.

Finally, the following study found on average that there was no difference in patient outcomes comparing lumbar fusion to multidisciplinary cognitive behavioural and exercise rehabilitation for chronic lower back pain.

Knee Meniscectomy and Anterior Cruciate Ligament Reconstructive Surgery:

The research evidence base (1, 2, 3 and 4) seems to currently strongly conclude that surgery for meniscal tears appears to have no significant benefit over sham surgery or conservative management. Exercise therapy and conservative management appears to be the first line treatment choice for patients with meniscus tears.

Even the well established anterior cruciate ligament reconstruction in the knee is beginning to be strongly questioned by the evidence base (see here and here) with many patients progressing well without surgical management with no ongoing significant deleterious effects (currently up to 5 years following the avoidance of surgery).

The Placebo Effect and Surgery:

The other interesting trend to emerge from the research base in relation to surgery is the strong non-specific effects (including placebo) of surgery and other invasive procedures. Not surprisingly, much like in the physiotherapy profession, there appears to be significant non-specific effects in surgery (see the following links for more information – 1, 2 and 3).

Conclusion:

So where does this leave us?

I have no doubt that surgery has its place in management of some patients. I do however, see many patients offered surgery very early on in their pain experience often without having a reasonable trial of conservative management to ascertain if that will assist. Clearly based on the above we can have good confidence that it will, assuming patient compliance and correct implementation of the conservative management (exercises need to be the priority, not passive treatment).

Importantly surgery also clearly has a significantly higher risk of complications compared to conservative treatment (cutting people open is far more likely to have a significant complication than doing some manual therapy or providing exercises).

In my opinion, given the emerging evidence base that I have briefly covered above, I strongly suggest most patients should be encouraged to undertake, or at least be offered, a trial of conservative management for at least a 2 month period prior to undertaking surgery for musculoskeletal complaints. Just to be clear, I am not talking in relation to “Red Flag” presentations!

At the very least patients should be informed on the evidence base behind their proposed surgery so they can then make a fully informed decision. While most of us reading this are not surgeons, I think it important that as physiotherapists we still act as advocates for our patients and educate them on the merits of trialling conservative management, especially when the evidence base is there to support doing so.

So I hope this has been of some interest, and I am happy to expand on some other orthopaedic surgery evidence if this post is well received.

Interestingly, there is also a reasonably robust evidence base regarding factors that can lower the success rate of surgery. This is a critical factor that also needs to be taken into account for our patients, and something I will post about next.

Thanks for reading.