Expectations vs. Reality: The HUGE Difference Between What Surgical Patients Believe and Reality

Published on Jan 22, 2022

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I love blogging about what I experience. This month a kid hurt his finger and ended up with a surgery that didn’t need to happen. As I contemplated why that occurred, I came across research on the difference between surgical expectations and reality. In addition, if we are ever able to bend the Orthopedic cost curve down, we need a system that will head this stuff off at the proverbial pass. Let’s dig in.

A Hurt Finger

I recently was asked to look at imaging on a high school kid who hurt his finger playing sports. His MRI showed a partial tear of the Collateral Ligament, which acts as the “duct tape” that holds the joint together side to side. The injury was not surgical and is often managed just by splinting the finger and letting it heal, which it will do rapidly in a high school age patient. The kid was eager to get back to sports and was told that he would need to be out for 10 weeks, so I also discussed a precise PRP injection into the ligament using ultrasound guidance. In a kid this young, if we pursued that course, in my clinical experience he would be back in the game in about a month to 6 weeks. Ultimately, the kid ended up on a surgeon’s schedule for an injury that usually isn’t considered surgical. Why?

As a physician who has witnessed the outcome of thousands of Orthopedic surgeries in young people during my career, I know that this finger is more likely to be worse off in the long run because of surgery. Why? As I always say, surgery is damage to accomplish a goal. When the damage from an injury is small, like this partial tear, it’s best not to operate as the damage you do with surgery will likely exceed the damage you’re trying to repair.

However, to his parents, it’s the opposite, right? They believe that surgery is the definitive answer to repair the damage and that their son’s finger is almost certainly to be perfect after the surgery and will be screwed up if left alone to heal. The problem is that their view, based on my clinical experience, isn’t reality.

So what’s happening here? Is the difference between the real outcomes of surgery and what patients believe will happen a bigger problem? Yep, and it’s a well-studied issue.

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A Recent Hip Arthroscopy Study on Expectations

I live in one of the Hip Arthroscopy hotspots in the US. If there’s a hip with pain and an MRI showing often an incidental Hip Labral Tear, then there’s an excellent chance that the hip will get operated. Why? Because patients don’t know that a Hip Labral Tear seen on MRI is often just a sign of normal aging. They also believe that the surgery offered to “fix” that tear will result in a normal hip again. Let’s dive into a recent study that demonstrates that phenomenon.

In a new study, researchers measured the expectations of patients about Hip Arthroscopy surgery for the treatment of Impingement and compared that to what patients believed would happen (1). In this case, the questionnaire used goes from 0-100 with 100 being perfect hip function (iHOT). First, patients recovered only about 3/4 of their function after the procedure (a score on average of 75.9) with huge variability in outcomes. Think about that for a second. The average return of function was nowhere close to 100%.

It gets more interesting when we begin to look at patient expectations for this surgery. When asked where they thought they would end up, that answer was not the 76% improvement that happened, but 84% better (HPSES score of 83.8). Now, what happens when we add athletes into this expectation game? It gets FAR WORSE.

The Expectation Game for Athletes

More than three hundred patients who were about to undergo Hip Arthroscopy were studied about their expectations. In this study, younger and athletic patients were more likely to believe that surgery would dramatically improve their athletic performance, despite the fact that this usually doesn’t happen after this procedure (2). For example, in another study of the real outcomes after Hip Impingement surgery, the researchers found that only 57% returned to their pre-injury sports performance level (3). When those athletes who did return to their pre-injury sports level were asked if their play was now “optimal”, only a paltry 1/3 of that group were in that category. In the end, only 17% of the whole group met the expectation that the surgery would improve their degraded athletic performance.

This Isn’t Unique to Hips

This isn’t just hip surgery as the same thing happens in ACL surgery, Rotator Cuff surgery, as well as Knee and Hip Replacement (4-7). For example, let’s look at Knee Replacement expectations versus reality.

We often see commercials for Knee Replacement devices with smiling and happy older couples riding their bikes or doing something else physically demanding. However, a study of the government-run OAI database (a long-term knee arthritis study) wasn’t able to confirm what we see in the commercials. When researchers compared 60 patients who had a Knee Replacement to 63 patients who needed the surgery but didn’t get it, there was no difference in activity levels (accelerometers were worn by both groups) (8). Meaning the Knee Replacement patients were no more active. In fact, only 1 in 20 Knee Replacement patients met basic physical activity level standards.

How Do You Relay This to Patients?

The challenge for those who have adopted high-level Interventional Orthobiologics is how do we insert ourselves into the inappropriate march toward surgery? In the case above, a clear non-surgical patient ended up operated due to expectations that aren’t real. While I can blog and that helps to reach some people, we need a more widespread educational campaign.

At Regenexx, we can intervene by leveling the playing field on insurance reimbursement. Meaning we have contracts with 500 companies to cover the less invasive Orthobiologic procedure. However, even then you need to get to these patients early and educate them often.

Cutting the Insurance Coverage Umbilical Cord

As a practical matter, unnecessary surgeries will continue to happen as long as insurers agree to pay for them. Hence, we need systems that can screen millions of claims and intervene well before the patient gets on a surgery schedule. Once those claims are identified as surgery not being needed or a less invasive alternative is appropriate, coverage for the procedure needs to be pulled or modified. As one example, a $500 deductible increases to $2,000 if the patient chooses the surgical option in a case where surgery is overkill. That will ultimately put a dent in the problem.

The upshot? What patients believe about surgical outcomes and the reality are often two dramatically different things. An example of a finger that didn’t need surgery is one way to illustrate how big a problem we have in this country. The knee-jerk reaction of patients is that surgery will solve all of their issues. The reality is that surgery often doesn’t deliver on high expectations. Because of that fact, surgery should never be offered unless there is no other option.

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References:

(1) Factor S, Vidra M, Shalom M, Clyman S, Roth Y, Amar E, Rath E. Preoperative Expectations Do not Correlate With Postoperative iHOT-33 Scores and Patient Satisfaction Following Hip Arthroscopy for the Treatment of Femoroacetabular Impingement Syndrome. Arthroscopy. 2021 Nov 25:S0749-8063(21)01045-8. doi: 10.1016/j.arthro.2021.11.027. Epub ahead of print. PMID: 34838646.

(2) Mancuso CA, Wentzel CH, Kersten SM, Kelly BT. Patients’ Expectations of Hip Preservation Surgery: A Survey Study. Arthroscopy. 2019 Jun;35(6):1809-1816. doi: 10.1016/j.arthro.2019.01.028. Epub 2019 May 6. PMID: 31072723.

(3) Ishøi L, Thorborg K, Kraemer O, Hölmich P. Return to Sport and Performance After Hip Arthroscopy for Femoroacetabular Impingement in 18- to 30-Year-Old Athletes: A Cross-sectional Cohort Study of 189 Athletes. Am J Sports Med. 2018 Sep;46(11):2578-2587. doi: 10.1177/0363546518789070. Epub 2018 Aug 1. PMID: 30067071.

(4) Cole BJ, Cotter EJ, Wang KC, Davey A. Patient Understanding, Expectations, Outcomes, and Satisfaction Regarding Anterior Cruciate Ligament Injuries and Surgical Management. Arthroscopy. 2017 May;33(5):1092-1096. doi: 10.1016/j.arthro.2017.01.049. Epub 2017 Mar 28. PMID: 28363420.

(5) Cole BJ, Cotter EJ, Wang KC, Davey A. Patient Understanding, Expectations, and Satisfaction Regarding Rotator Cuff Injuries and Surgical Management. Arthroscopy. 2017 Aug;33(8):1603-1606. doi: 10.1016/j.arthro.2017.03.004. Epub 2017 May 9. PMID: 28499920.

(6) Mancuso CA, Sculco TP, Salvati EA. Patients with poor preoperative functional status have high expectations of total hip arthroplasty. J Arthroplasty. 2003 Oct;18(7):872-8. doi: 10.1016/s0883-5403(03)00276-6. PMID: 14566742.

(7) Kahn TL, Schwarzkopf R. Does Total Knee Arthroplasty Affect Physical Activity Levels? Data from the Osteoarthritis Initiative. J Arthroplasty. 2015 Sep;30(9):1521-5. doi: 10.1016/j.arth.2015.03.016. Epub 2015 Mar 31. PMID: 25882608.

(8) Kahn TL, Schwarzkopf R. Does Total Knee Arthroplasty Affect Physical Activity Levels? Data from the Osteoarthritis Initiative. J Arthroplasty. 2015 Sep;30(9):1521-5. doi: 10.1016/j.arth.2015.03.016. Epub 2015 Mar 31. PMID: 25882608.