Bone and joint surgery? Consider other options too

stretch-195x300Even as patients in a giant and rapidly graying generation throng orthopedic surgeons’ offices seeking relief from aging’s pain and discomfort, the evidence for these pricey and invasive medical interventions is slim at best and too often is simply unpersuasive.

Those are the findings of an expansive, rigorous “meta examination” of major medical databases and reports on hundreds of reports they contained of clinical trials and other evidence on 10 of the most commonly performed orthopedic procedures. Researchers published their results in the BMJ, a respected medical journal of the British Medical Association.

As the New York Times reported of the experts’ conclusions:

“Considering bone or joint surgery? In many cases, surgery may be no more effective than options like exercise, physical therapy and drug treatments. Hip and knee replacements, surgery for carpal tunnel syndrome and other orthopedic procedures are among the most common elective surgeries performed today, but they involve cost, risk, and sometimes weeks or months of recovery. Many of these surgeries are not supported by evidence from randomized trials, a review found. Even when surgery has been shown to be effective, the review concluded, it may not be significantly better than nonsurgical care.

“British researchers looked at studies of 10 common orthopedic operations, including surgeries of the knee, hip, shoulder, spine and wrist. They found good evidence of the superiority of surgery over other treatments for carpal tunnel syndrome and total knee replacement. For six other common surgeries, randomized trials found little advantage over interventions like exercise, weight management, physical therapy, and drug treatment. The researchers found no controlled trials that had compared hip replacement or knee cartilage repair with nonsurgical care.”

The researchers cautioned that their work should not be read as a blanket rejection of common bone and joint surgeries, which patients often report anecdotally improve their lives, relieving them of pain and discomfort, especially due to age or injury.

But experts quoted by the newspaper said the study should serve as a professional prod, reminding surgeons and patients alike that the serious intervention of cutting, sawing, and replacing body parts should not occur lightly or routinely. All parties concerned should consider, first, if multiple, less drastic measures also can obtain reasonable and equal outcomes. As the newspaper reported:

“An arthroscopic operation to repair the anterior cruciate ligament, or ACL, in the knee, among the most common sports-injury surgeries in the United States, has a rate of success as high as 97% in some studies. But when the operation was compared with nonsurgical treatments, the review found, there was little difference in pain scores or the need for further surgical or nonsurgical treatment. The researchers describe a large review of studies of the operation to repair the rotator cuff, the group of tendons and muscles that keeps the upper arm bone in the shoulder socket. Compared with exercise and steroid injections, the review found, there was little or no clinically significant difference in pain, function, quality of life or patient satisfaction with the results. Some studies were randomized controlled trials, giving one group of patients real surgery and a matched group a placebo operation. In two such studies of surgery for shoulder impingement, a condition that causes pain on raising the arm, there was no difference between surgery and placebo surgery in patient-reported outcomes or adverse events.”

The newspaper also reported this from the study findings:

“Lumbar spine decompression is an operation to relieve the pain caused by a ruptured or bulging disk, sometimes called a pinched nerve, in the lower spine. Although the quality of the evidence was low, three analyses showed that surgery and nonsurgical treatments provided equivalent improvements. There were no studies that compared surgical repair of the meniscus, the cartilage that covers the knee, with nonoperative care or a placebo. But in 10 randomized trials comparing a different procedure known as meniscectomy, or partial removal of the meniscus, with more conservative treatment, the operation did not provide meaningful improvement in knee pain, function or quality of life.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, effective, and excellent medical care. This has become an ordeal due to the soaring cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.

All medical procedures carry risks, and surgeries — even operations like knee, shoulder, and hip replacements that doctors and hospitals insist have become almost routine — should never be undertaken without extensive discussion, preparation, investigation, and care. Too many patients have found that knee surgeries, for example, have their “risks and limitations,” and “doctors are increasingly concerned that the procedure is overused and that its benefits have been oversold,” the independent Kaiser Health News (KHN) service reported not that long ago.

As KHN found, surgeons in 2014 alone performed hundreds of thousands of the procedures at a cost to patients and insures exceeding tens of billions of dollars and:

“Research suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results. A study published … in the BMJ found that knee replacement had ‘minimal effects on quality of life,’ especially for patients with less severe arthritis. One-third of patients who undergo knee replacement may not even be appropriate candidates for the procedure, because their arthritis symptoms are not severe enough to merit aggressive intervention, according to a 2014 study in Arthritis & Rheumatology. ‘We do too many knee replacements,’ said James Rickert, president of the Society for Patient Centered Orthopedics, which advocates for affordable health care, in an interview. ‘People will argue about the exact amount. But hardly anyone would argue that we don’t do too many.’”

Patients, correctly, consider personal mobility a fundamental part of the quality of their lives, and this capacity — along with lives free of pain and discomfort — may argue for the burgeoning surgical business of bone and joint procedures. But we have much work to do to ensure that rigorous evidence exists for individuals and society as a whole before surgeons operate so widely on patients to address issues that might not merit invading the body.

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