The Surgery Bandwagon

I wrote about physios and bandwagons a few years ago here and discussed how we love to jump on to popular ideas without thinking and tend to get carried away. There is now a new bandwagon which many therapists are jumping on and you may be surprised to hear me defending it. This bandwagon is the increasing number of therapists criticising orthopaedic surgery.

Challenging orthopaedic surgery has gained some serious momentum over the last few months in light of some online social media campaigns as well as some research that has demonstrated no difference between some orthopaedic surgeries and placebo.

Things such as arthroscopy for knee osteoarthritis (ref) meniscal debridement (ref), spinal surgery for vertebral fractures (ref), and a very recent study published in BJSM on shoulder labrum repairs (ref) and another soon to be published on shoulder acromion decompressions (ref).

Damn You All

Now don’t misunderstand me this research is vitally important to discuss and promote and asks a lot of difficult questions about orthopaedic surgery, and a lot of orthopaedic surgery does need to take a good long hard look at what it does and how it does it. But damn you all to hell for making me write this post defending it.

I need to get a few things cleared up about the increasing criticism directed towards orthopaedic surgery and the surgeons who perform it due to some ridiculous remarks made by some idiots out there.

Firstly, there have been some claims that ALL elective orthopaedic surgery is a placebo. This is complete and utter nonsense. There is no evidence of this at all.

There is ‘growing‘ evidence that ‘some‘ orthopaedic surgery has no significant difference in outcomes when compared to sham surgery. But this is not generalizable to other surgeries. It also isn’t infallible or conclusive evidence, these intriguing studies need to be reproduced before we can conclude with any certainty and conviction that there is no difference.

I believe that there are most likely strong placebo effects with orthopaedic trimming, shaving, suturing, and repairing procedures, but there are undoubtedly times when it does more than placebo to bring two pieces of broken anatomy closer together, or move them further apart and allow natural history to do the rest.

Surgery doesn’t work!

The next ridiculous claim being made is that orthopaedic surgery doesn’t work. This is complete and utter nonsense. Yes it’s not perfect, yes there are failures, but to say orthopaedic surgery doesn’t work is often said by those who have misinterpreted the research.

Even the placebo surgery trials show that orthopaedic surgery works, just not for the reasons originally thought. Why people get better after placebo surgery just as well as those that have ‘true’ surgery is intriguing and due to many factors and is for a completely different blog or three!

Watching some therapists using these placebo surgery studies with vigour and glee to demonstrate how surgery is ‘ONLY’ a placebo need to be very very careful about throwing stones in glass houses. All the therapies, including physiotherapy, have shockingly little to no placebo-controlled studies to compare how much of what /we do is ‘ONLY’ a placebo.

As much as I am an advocate for physiotherapy and us giving simple advice, education, and increasing exercise and activity, I have no doubt that people get better despite our interventions. It’s called natural history and regression to the mean.

The last point I want to discuss is the most worrying and annoying one. I have seen an increasing amount of accusations and negative comments directed towards orthopaedic surgeons in light of these studies.

Some comments have been floating around about how some surgeons do these operations for ulterior or self-motivated reasons. Despite common belief, most orthopaedic surgeons I know are not heartless, ruthless, unethical, money-grabbing, knife welding megalomaniacs intent on screwing over patients at any given opportunity.

Can’t Cut Pain Out!

I work closely with many orthopaedic surgeons and I can assure you that these hard-working, dedicated, and selfless individuals will try everything not to operate on patients. Many of the orthopaedic colleagues I work with are reluctant to operate on patients unless all other options have been exhausted and the patient is fully informed of the risks, benefits and alternatives.

I hear them using terms like “We can’t cut pain out” or “There is no pain that my surgery can not make worse”, or “There is no clear surgical target here for me to address” and have found myself using these sayings often as well.

Thinking that surgeons alone decide when to operate is also nonsense. Most of the surgeons I know get fully informed consent for any intervention far better than most therapists. Surgical patients are given a full written list of pros/cons, risks/rewards, and time frames of what to expect and most don’t enter into surgery without fully understanding these.

So when a patient has exhausted all other options, and feel they have no other options, and think an operation may help, and there is a surgical ‘target’ to address, why not operate?

Yes, of course, some operations are done too quickly, without giving enough time or other options a good enough go. But, and this is a big but, we can not blame surgeons and patients for wanting operations when they ‘fail’ other treatments such as physiotherapy.

The uncomfortable truth for many therapists is that if our interventions were any better at managing and treating issues many patients would not seek surgery. Now I know a lot of therapists do great jobs and many are in difficult positions, pushed for time, resources, and patients don’t always want to do what we ask of them, but we have to recognise our limitations as well as those of our surgical colleagues

Summary

Orthopaedic surgery is coming under the spotlight and this is a good thing. But seeing some jump onto the ‘all orthopaedic surgery is bad‘ bandwagon is not. Finally, it’s repugnant to hear some of the accusations and claims made about our orthopaedic colleagues. This needs to stop now as it’s only harmful to future collaborations and progress. 

As always thanks for reading

Adam