Surgery Not Definitively Superior in Many Orthopedic Situations

By David Douglas

July 16, 2021

NEW YORK (Reuters Health) - Despite a lack of strong evidence, national guidelines often favor elective surgery for treatment of number of common orthopedic condition that may respond as well to other measures, according to U.K. researchers.

As Dr. Ashley Blom told Reuters Health by email, "Our synthesis of published trials showed that for many orthopedic conditions the surgical and non-surgical treatments were equally efficacious. This has very important implications for shared decision making and informed consent."

The studies reviewed by Dr. Blom and her colleagues compared the clinical effectiveness of any of ten orthopedic procedures with no treatment, placebo, or non-operative care.

Among these procedures were arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic rotator cuff repair, carpal tunnel decompression, lumbar spine fusion, total hip replacement, and total knee replacement.

Summary data were extracted by two independent researchers, and along with a third a consensus was reached. The methodological quality of each included meta-analysis was gauged using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. The Jadad decision algorithm, developed to help decision makers to select among discordant reviews, was used when required.

The researchers then went on to use a National Institute for Health and Care Excellence Evidence search to check whether recommendations for each procedure reflected the body of evidence.

The team found that randomized controlled trial evidence "supports the superiority of total knee replacement and strongly supports carpal tunnel decompression over non-operative care."

However, there were no randomized controlled trials specifically comparing total hip replacement or meniscal repair with non-operative care. And regarding the six remaining procedures, there was no evidence of greater benefit than non-operative care.

"Encouragingly," the researchers report in The BMJ, "many of the guidelines from prominent national bodies closely reflect the current body of evidence." However, "a high-quality body of evidence on the clinical effectiveness to definitively support these recommendations does not exist for many procedures."

"This," they point out, "is mainly a consequence of the lack of randomized controlled trials that compare the procedure with non-operative care." Evidence for recommendations "was mostly built on comparisons involving two or more different techniques of the same procedure."

Dr. Blom concluded, "When both options are equally efficacious, patients should be told this clearly and the treatment course and individualized risks of both options clearly explained so that they might make an informed choice as to their care."

SOURCE: The BMJ, online July 7, 2021.