The State of Orthopedic Surgery Research: Poor Grades for Common Procedures
Given that orthopedic surgery is the norm for millions of people a year, you would think that we have copious high-level research supporting its efficacy. As we have discussed with countless employers these past few years, that assumption would be wrong. In fact, based on the research, those millions are exposed to surgical risks, oftentimes even after research shows that the procedure doesn't work. Let's explore that a bit this morning.
The History of the Problem
While research studies have long been published for decades showing here or there that various spine surgeries are ineffective or minimally helpful, the problems with common orthopedic joint surgeries are newer. Back in the early 2000s, researchers at Baylor College of Medicine published a study showing that the most common knee surgery at the time (lavage and debridement) was no better than placebo, or a fake surgery. Since then, the pace of research showing that common orthopedic procedures are no better than either physical therapy or sham surgery has quickened.
How Is Research Graded?
Most patients don't know that research can be graded and that these grades often determine whether insurance companies will cover a procedure. While many different research quality metrics are out there, they all sort of follow a consistent pattern. The best research that an insurance company will generally accept is a randomized controlled trial (RCT). Then moving down the list is a comparison trial (comparing one treatment to another). After that, there are case series, which are studies where the results of many patients are looked at in isolation (i.e., not compared to another therapy). Finally, there are things like case reports, which are investigations that look at how one person has fared with a procedure.
My Grading Scale
I spent a few hours going through the research to assign a research grade to several major orthopedic procedures in the knee, shoulder, and low back. The scale is modified from the existing quality of research grades to mimic the grades we all know from grade school. A is the best research support, and F is the worst. In fact, an F here means that good research has shown the procedure doesn't work.
The Orthopedic Surgery Grades
As you can see from my video above, orthopedic surgery fares very poorly on this and other grading scales. I'm not the only one who thinks this as this fact has been the subject of countless editorials and discussions. As I discuss above, the following procedures got Fs (which means we know they don't work):
- Arthroscopic debridement of the knee for knee arthritis
- Partial meniscectomy for all indications of meniscus tear (no arthritis, arthritis, and locking)
- ACL reconstruction for an ACL tear
- Shoulder rotator cuff repair with decompression for a rotator cuff tear
- Shoulder rotator cuff repair for a full-thickness tear
- Lumbar fusion for DDD
There are other procedures I didn't include in the video that also get Fs:
This procedure is either an A or an F, meaning that despite there being one RCT showing it works, the results were poor at best:
- Total knee arthroplasty (TKA, or knee replacement) for knee arthritis
To learn more about how bad knee replacement results were, see my video below:
Most Patients Are Unaware
Given that all of these procedures have high-quality research showing they don't work, patients must now get appropriate consent. Meaning, the patient would need to be informed in plain language that the invasive procedure they are about to receive has been shown to be no better than a sham procedure or physical therapy. In my experience, this is not happening.
The Orthopedic Response
So what is the orthopedic surgery response to these studies that show that many common procedures are ineffective? I've heard several. Sometimes it's that there are other studies that show that these procedures work. While that's true, those studies are lower-level research, and in the world of evidence-based medicine, higher-level studies like these always trump lower-level research. Other times the surgeons will argue that while these procedures don't work on average, they can pick the right patients on which they are effective. That's a bit like saying, in the absence of evidence, that you can accurately pick which day next year it will rain or be sunny.
The upshot? It's only a matter of time before many of these procedures lose insurance reimbursement. We're already seeing that begin to happen in national healthcare systems. However, as I have brought up many times, the lack of evidence for these invasive procedures is a great opportunity for less invasive interventional orthopedics to become the standard of care.