This OrthoBuzz guest post comes from Paul E. Matuszewski, MD, in response to a recent article in the New York Times.
The ever-increasing importance of the mindful physician and the doctor-patient relationship is highlighted by a recent New York Times article. Its catchy title, “Considering Bone or Joint Surgery? You May Not Need It,” may draw the audience to the immediate conclusion that the patient should be distrustful of a surgical recommendation. The discerning reader, however, looks deeper and draws a different conclusion.
The article is in response to a recent umbrella review of meta-analyses of studies evaluating common orthopaedic procedures, including arthroscopic anterior cruciate ligament reconstruction, arthroscopic rotator cuff repair, carpal tunnel decompression, total hip replacement (THA), and total knee replacement (TKA), along with 5 other procedures. The study, published in The BMJ, reviewed current evidence (from randomized controlled trials, RCTs, where possible) to determine the clinical effectiveness of operative treatment compared with no treatment, placebo, or nonoperative care for common orthopaedic conditions. The researchers found that, while RCT evidence supports the superiority of carpal tunnel decompression and TKA over nonoperative management, no RCTs compared THA or meniscal repair with nonoperative care, and evidence for the other 6 procedures did not show their benefit over nonoperative treatment.
The researchers’ conclusions: not enough high-level evidence exists supporting many commonly performed elective procedures over nonoperative care; surgeons and funding agencies should target gaps in evidence regarding these high-volume procedures, particularly given the immense expense associated with orthopaedic treatments, both operative and nonoperative.
In the New York Times article, Dr. Saam Morshed, an orthopaedic trauma surgeon from the University of California, San Francisco makes an astute comment that surgeons should “scrutinize [the] effectiveness for some of these operations” but also notes that “just because there isn’t a randomized trial supporting a given treatment, that doesn’t mean the treatment is not effective.”
Sometimes high-level evidence does not exist to support one treatment over another, and we as physicians must rely on our judgment and observations to make recommendations for our patients seeking care. As orthopaedic surgeons, we utilize the best information we have to guide care, and that’s why medicine continues to be both art and science.
It is clear that studies like the one published in The BMJ highlight the need for further investigations, but more importantly, they underscore the ever-increasing need for the mindful physician to interpret the sea of results from these studies (often laden with nuance) in the context of a patient’s needs and the particular injury and situation—and, through a shared decision-making process involving the patient, determine the appropriate course of care.
Randomized trials tell us a lot about compared treatments for a very narrow group of patients with very narrow indications. The results may not apply to everyone. Personalized care is at the heart of the doctor-patient relationship, and deciding between nonoperative and operative interventions is no exception.
Paul E. Matuszewski, MD is the Vice Chair of Research, Director of Orthopaedic Trauma Research, and Associate Professor of Orthopaedic Traumatology in the Department of Orthopaedic Surgery and Sports Medicine at the University of Kentucky and is a member of the JBJS Social Media Advisory Board.