Is orthopaedic surgery under siege from an evidence-based revolution? Hell yes

  • Wednesday 01 April 2015

As a clinician with an interest in tendons, I'm frequently asked about my views on surgery for tendinopathy. My answer is always the same: in almost all cases of tendinopathy, patients should undergo a comprehensive rehabilitation program before contemplating invasive surgery. And regarding surgery, the traditional procedure of excision and repair is best avoided. The traditional orthopod is just not welcome.

But spare a thought for the orthopod after Dr Jeremy Lewis's talk on rotator cuff tendons. For anyone who has even a passing interest in shoulder pathology, this is 'must see' lecture. At last, we have a well-respected and experienced clinician who has the guts to say what others are thinking: there is tenuous evidence to suggest surgery trumps rehabilitation in rotator cuff pathology. In an excellent study by Kukkonen et al (2014), patients who presented with atraumatic shoulder pain and supraspinatus tears were randomised into three treatment groups : 1) physiotherapy, 2) physiotherapy and acromiplasty and 3) physiotherapy, acromioplasty and tendon surgery. You're probably not surprised to learn that there was no difference in outcomes between rehab and surgical treatment. Another study (Kuhne et al, 2013) examining atraumatic FULL thickness rotator cuff tears showed that non-operative treatment was effective at 2 years reducing need for surgery in 75%. These results have huge implications for our shoulder patients, the NHS budget, and least of all the cash cow of shoulder surgery.

But it's not just the shoulder where the validity of surgery is being questioned. A recent randomised-controlled trial on young patients with an ACL injury demonstrated good results for rehabilitation obviating the need for reconstruction in 50% of cases. Similarly, recent studies on Achilles' tendon ruptures question the need for surgical reconstruction even in elite athletes. The venerable BJSM has been instrumental in highlighting the controversies of hip arthroscopy. Studies are questioning whether surgery is needed for many cases of labral pathology and CAM lesions. And I won't even mention the paucity of evidence for arthroscopy surgery in anterior knee pain, knee osteoarthritis and degenerative meniscal tears. A innovative randomised study comparing arthroscopic surgery to sham surgery for knee osteoarthritis found sham surgery to be as effective as surgery. (I wonder how much money would be saved if private medicine decided not to fund knee arthroscopy for osteoarthritis).

Make no mistake; this is the start of an evidence-based revolution. Questions are being asked of surgery in an array of common musculoskeletal conditions from shoulder and hip pain to Achilles ruptures to knee osteoarthritis and meniscal tears to tendinopathy. Is orthopaedic surgery under siege? In the words of a current British Labour opposition leader: Hell yes! And it's our job as clinicans and therapists to spread this epiphany.

Tags: evidencesurgery

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