Go with the Flow, or Follow the Evidence?

This guest opinion post comes from Prof. Stig Brorson, DMSc, PhD, Consultant with the Department of Orthopaedic Surgery, Centre for Evidence-Based Orthopaedics at Zealand University Hospital, Denmark, and author of the new open access book Shoulder Fractures in Context: Controversies in Orthopaedic Surgery (Springer).  

Throughout history, medical practitioners have strived to alleviate musculoskeletal pain and restore function. While the performance of surgical interventions, in a modern sense, is relatively new, discussion about the optimal treatments has a long history. In fact, the debate on surgical treatment for proximal humeral fractures has been ongoing among surgeons since Sir Robert Jones’ address to the British Orthopaedic Society in 1912: “Statistics do not seem to throw much light on the vexed question whether or not it is better to operate on fractures of the surgical neck of the humerus, for the percentages of good results are nearly equal by each method”¹. 

Modern orthopaedic practice differs from historical practices in that we can utilize powerful tools to obtain unbiased estimates of the benefits and harms of interventions, allowing critical reflection upon practice. However, over the past few decades, the growth in surgical options and procedures for adults with proximal humeral fractures has been driven in large part by a lack of awareness of the evidence, along with a strong belief in the benefits of surgery and effective marketing. Meanwhile, an increasing body of high-quality clinical evidence has demonstrated no clinically important benefits of surgery compared to nonsurgical treatments, and that the risk of requiring additional surgery is substantial². 

A Call for Reflection

The increase in health-care costs, the environmental impact of surgery, and the demand for evidence-based practices pose a challenge for orthopaedic practitioners. In the case of shoulder fractures, should we rely on the findings from randomized trials reporting no clinically important benefits of surgery, or should we “go with the flow”?  

As a practicing shoulder surgeon and clinical researcher for 25 years, I believe that the persistent preference for surgical solutions calls for reflection. As skilled surgeons and educated practitioners, how do we think and act when clinical evidence does not align with our practices?  

As one illustrative example, consider the adoption of locking-plate osteosynthesis as the preferred treatment for osteoporotic proximal humeral fractures. Five randomized trials have been unable to demonstrate any benefits; complication rates are above 40%, and failure rates exceed 30%³. Nonetheless, the clear clinical evidence has not prompted us to abandon the implant. Instead, we attempt to improve the procedure and the implant. We remain confident that surgery is the optimal first line solution on any displaced long-bone fracture, while nonsurgical management is not considered viable. The “evidence-practice gap” is widening. 

The tension between academia and clinical practice dates back to antiquity, nearly 2,000 years before modern orthopaedic treatments became possible due to advances in anesthesia, aseptics, and radiology. What distinguishes us from our historical predecessors is not only our advanced surgical techniques and implants, but also our ability to critically reflect on our practices and adapt them on the basis of the best available evidence. Evidence-based orthopaedics offers effective tools for achieving this goal. While it took 2,000 years to abandon bloodletting in trauma patients, we could more quickly reconsider the effectiveness of a treatment strategy by relying on current evidence to inform our practice. To continue to perform surgical procedures without considering the evidence would hardly distinguish us from the barber-surgeons of history.  

In orthopaedics, biases still exist in the divisions between practitioners and academics. It is often believed that surgeons who excel academically may lack surgical skills, while those with excellent surgical skills do not need to follow the evidence. The modern orthopaedic surgeon needs proficiency in both. Evidence-based practice does not neglect surgery; we as surgeons must not neglect the evidence.  

Prof. Brorson is the author of  Shoulder Fractures in Context: Controversies in Orthopaedic Surgery (Springer), providing detailed discussion of shoulder fractures, their treatment, and existing controversies within a clinical, academic, and sociocultural framework. The book is available through open access. 

References 

1. Jones R. Presidential address on the present position of treatment of fractures. BMJ. 1912:1389-1394.
2. Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022;6(6):CD000434. doi:10.1002/14651858.CD000434.pub5
3. Barlow JD, Logli AL, Steinmann SP, et al. Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate. J Shoulder Elb Surg. 2020;29(8):1689-1694. doi:10.1016/j.jse.2019.11.026