Are you considering bone or joint surgery? You may not need it., Science News

Are you considering bone or joint surgery? In many cases, surgery may not be more effective than options like exercise, physical therapy, and drug treatments.

Hip and knee replacements, carpal tunnel syndrome surgery, and other orthopedic procedures are some of the most common elective surgeries performed today, but they involve costs, risks, and sometimes weeks or months. recovery. Many of these surgeries are not supported by evidence from randomized trials, according to one review. Even when surgery has been shown to be effective, the review concluded, it may not be significantly better than non-surgical care.

British researchers looked at studies of 10 common orthopedic operations, including knee, hip, shoulder, spine and wrist surgeries. They found good evidence that surgery is superior to other treatments for carpal tunnel syndrome and total knee replacement surgery. For six other common surgeries, randomized trials found little benefit over interventions such as exercise, weight management, physiotherapy, and drug treatment. Researchers could not find any controlled trials comparing hip replacement or repairing knee cartilage with non-surgical care. The study is in the BMJ.

“Our study does not show that these operations do not improve patients,” said lead author Dr Ashley W. Blom, professor of orthopedic surgery at the University of Bristol in England. “And that doesn’t say that treatments don’t work if they haven’t been tested in randomized controlled trials. It’s just that some don’t work any better than the best non-surgical treatments.

Dr Saam Morshed, professor of orthopedic surgery at the University of California at San Francisco, who was not involved in the study, said: “I think it’s fair that we keep the mirror to ourselves. and examine the effectiveness of some of these operations. . It is important to understand where we have gaps in our knowledge of the effectiveness or ineffectiveness 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 the treatment isn’t. ‘is not effective’. Hip surgery, he said, is a good example. There may not be randomized trials of hip surgery, but there is overwhelming observational evidence that it works compared to nonsurgical treatment.

In other common procedures, the image may be different. Arthroscopic surgery to repair the anterior cruciate ligament, or ACL, in the knee, among the most common sports injury surgeries in the United States, has a success rate as high as 97% in some studies. But when the operation was compared to non-surgical treatments, the review found there was little difference in pain scores or the need for additional surgical or non-surgical treatment.

The researchers describe a large review of studies investigating the repair operation of the rotator cuff, the group of tendons and muscles that hold the arm bone in the orbit of the shoulder. Compared with exercise and steroid injections, the review found that there was little or no clinically significant difference in pain, function, quality of life, or patient satisfaction with drugs. results.

Some studies were randomized controlled trials, giving a group of patients a full-blown surgery and a matched group a placebo surgery. In two of these studies of surgery for shoulder impingement, a condition that causes pain when raising the arm, there was no difference between surgery and placebo surgery in terms of patient-reported outcomes or adverse events.

Lumbar spine decompression is an operation to relieve pain caused by a ruptured or bulging disc, sometimes called a pinched nerve, in the lower part of the spine. Although the quality of the evidence is low, three analyzes showed that surgery and non-surgical treatments provided equivalent improvements.

No study has compared surgical repair of the meniscus, the cartilage that covers the knee, with non-operative care or a placebo. But in 10 randomized trials comparing a different procedure known as meniscectomy, or partial meniscus removal, with more conservative treatment, the operation did not provide significant improvement in knee pain, function, or knee pain. quality of life.

“The best non-operative care is often multimodal and can 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 care and the best non-operative care with patients so that patients can consider all options and thus make informed choices. “

Patient outcomes from these surgeries vary widely, and those differences are significant, Morshed said. “Future research will provide more nuanced inferences about the effect of surgery as we begin to understand at the patient level the characteristics that make them more or less likely to respond to a procedure,” he said.

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