The BMJ Chimes in on the “Scandalously Poor” Evidence for Orthopedic Surgery
I’ve blogged before about how research study after research study is showing that many common orthopedic surgical procedures don’t work. This morning I’d like to highlight a recent British Medical Journal (BMJ) editorial on the topic. To coin a very British phrase from the paper, the evidence base that supports that orthopedic surgery is helpful to patients is “scandalously poor in parts”.
It’s hard for patients to believe that procedures like meniscus surgery or arthroscopic surgery to “clean up” a knee have been shown to be ineffective. This is because we’re living in an awkward time period when on the one hand, research is being published that common orthopedic procedures are ineffective, yet insurance companies have yet to stop paying for these procedures. In addition, while a few surgeons have read, digested, and assimilated the new evidence into their practice by avoiding these procedures, most have not. Also, while the lack of efficacy of these procedures has been all over the news, most patients don’t check before they sign up.
So how “scandalously poor” is the evidence? The authors state that only 20% of orthopedic procedures have high levels of evidence to support that they work! Ouch! They go on to state that in both orthopedic surgery and sports medicine, it’s unclear whether some surgeries are better than non-surgical alternatives or better than placebo surgery. Recent examples where surgery was shown to have no benefit over things like physical therapy or sham surgery include arthroscopic knee surgery in middle aged and older people and surgical reconstruction of ACL tears in young and active adults. More concerning is that about half the time when orthopedic surgery is compared to fake surgery, the sham surgery turns out to work just as well. The authors concluded that it’s very difficult to justify invasive surgery with it’s associated risks simply to achieve an effect that’s similar to the placebo effect of fake surgery.
This last part I’ll quote directly: “Confirmation bias reigns and we ignore, or do not want to be exposed to, information or opinions that challenge what we already believe, while wanting to hear information and beliefs that confirm what we already believe. This human trait contributes to overconfidence in personal beliefs and maintains and strengthens beliefs in the face of contrary evidence. The effects are stronger for emotionally charged issues and deeply entrenched views. As a result, proponents of questioned interventions fight hard for their interventions and specialties and often delay change, when the appropriate and ethical action would be to abandon ship.”I believe that’s a very proper, British way of saying that the evidence to date is so bad in so many areas that orthopedics needs to reinvent itself or just give up and start over.
The upshot? The BMJ editorial is correct IMHO, in that there is scandalously poor evidence for orthopedic surgery and begs the question what exactly is the rationale for the millions of orthopedic surgeries performed in the United States every year. While a few orthopedic surgeons have taken that message to heart and begun to avoid procedures shown not to work or at least talk to patients about the poor evidence, most have not. A few hearty souls have also realized that perhaps regenerative medicine will provide the lifeboats for the HMS Ortho Titanic. In the meantime, most surgeons have gone the other direction (as mentioned by the authors), with this editorial already sparking an editorial reply that can be summarized as “So what? My patients tell me this stuff works.” IMHO, the handwriting is on the wall and this eroding evidence base will provide an opportunity for much of surgical orthopedics to be replaced by “Inteventional Orthopedics” (procedures performed through injection), a specialty that will use regenerative medicine to hopefully make lemonade from these lemons.