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 study is in The BMJ.
“Our study doesn’t show that these operations don’t make patients better,” said the lead author, Dr Ashley W. Blom, a professor of orthopedic surgery at the University of Bristol in England. “And it does not say that treatments do not work if they have not undergone testing by randomized controlled trials. It’s just that some don’t work any better than the best nonsurgical treatments.”
Dr Saam Morshed, a professor of orthopedic surgery at the University of California, San Francisco, who was not involved in the study, said, “I think it’s fair that we hold the mirror up to ourselves and scrutinize effectiveness for some of these operations. It’s important to understand where we have gaps in knowledge of the efficacy or nonefficacy of common surgical treatments.”
At the same time, he said, “It’s also important to understand that just because there isn’t a randomized trial supporting a given treatment, that doesn’t mean that the treatment is not effective.” Hip surgery, he said, is a good example. There may be no randomized trials of hip surgery, but there is overwhelming observational evidence for its effectiveness compared with nonsurgical treatment.
In other common procedures, the picture may be different. 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 percent 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.
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.
“The best nonoperative care is often multimodal and may involve a combination of physical, medical and psychological interventions, and it should not be assumed that these are necessarily the easiest or most cost-effective options for patients,” Blom said. “Clinicians should discuss both operative and the best nonoperative care with patients so that patients can consider all options and thereby make informed choices.”
Patient outcomes from these surgeries vary greatly, and these differences are important, Morshed said. “Future research is going to provide more nuanced inferences on the effect of surgery as we begin to understand on a patient level those characteristics that make them more or less likely to respond to a procedure,” he said.
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