We’re all familiar with the phrase “lesser of two evils,” but I’m an optimist and prefer the phrase “better of two goods.” In the October 2, 2019 issue of JBJS, Ramme et al. compare surgical versus nonsurgical treatment of full-thickness rotator cuff tears. Both cohorts had improved outcomes relative to baseline, but surgical management was the better of two goods.
The authors retrospectively analyzed a prospective cohort of adult patients with full-thickness rotator cuff tears who had elected either surgical or nonsurgical treatment. Ramme et al. utilized propensity score matching to pair up patients in each group according to factors thought to influence outcome, such as age, sex, tear size, chronicity, muscle atrophy, and the Functional Comorbidity Index. This matched-pair analysis is a valiant attempt to eliminate bias that is inherent in retrospective analyses, and this study design also mimics the real-world scenario of shared decision making between physician and patient.
The 2-year follow-up analysis of 107 propensity score-matched patients revealed that both groups improved in 4 patient-reported functional outcomes and pain compared to their baseline measures before treatment. However, the final outcome measurements and magnitude of improvement were statistically greater in the surgical management group (p <0.001).
This study will help shoulder surgeons have more meaningful discussions with their patients about treatment options for full-thickness rotator cuff tears. We know that with proper treatment—either surgical or nonsurgical—patients can expect improvement in pain and function. However, patients who elect surgical management may have the potential for even greater outcomes, and that definitely sounds like the “better of two goods.”
Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media
The concept of asking and accounting for patient preferences in non-emergent treatment decisions has been discussed in the medical literature for nearly two decades. Michael J. Barry, MD and others have quite fully developed this notion of “shared decision making” (SDM). In the context of patient desires, SDM includes a presentation of the treatment options and the data regarding those treatment options, and a discussion of potential complications involved in each option.
The earliest work on SDM centered around patient choices for managing prostate disease, degenerative disc disease of the lumbar spine, and urinary incontinence. Only recently have orthopaedic surgeons embraced this concept, as more of us get training in and practice the necessary communication skills and cultural competency needed to engage our patients in SDM. But we still have a long way to go when it comes to facility with SDM, and this seems to be especially true in the orthopaedic communities of some non-US countries.
In the May 1, 2019 issue of The Journal, Martinez-Siekavizza et al. report results of a survey on the use of SDM among orthopaedic surgeons in Guatemala. Survey recipients were questioned about their SDM techniques in the clinical scenario of intertrochanteric hip fracture, although hip fracture may not have been the ideal condition to focus on, given the worldwide acceptance that this condition is almost always best managed surgically. Nevertheless, the survey showed that 25% of the surgeon respondents ”never” or “hardly ever” allowed their patients to participate in the treatment decision-making process. While the authors cite many systemic reasons for such lack of patient participation (such as surgical consent not being required in Guatemala and the limited resources in many rural areas of the country that often leave no choices available), 75% non-engagement with patients/families strikes me as very high.
The key facet of shared decision making is discussing all the potential treatment options with the patient. This aspect of SDM seems especially important for nontrauma elective cases in which the “best” treatment option may be less clear than in trauma cases. Even so, Martinez-Siekavizza et al. found that surgeons who discussed the different treatment options with patients had an almost 3-fold greater likelihood of allowing patients to participate in decision making than those who did not. This makes intuitive sense, as it would be difficult for patients to take part in treatment decisions if they are not informed about the options that exist.
As surgeons, we need to do our best to ensure that patients understand all their treatment options, and we should sharpen our focus on shared decision making during our patient interactions. JBJS looks forward to receiving more manuscripts from all over the world that explore the techniques and value of SDM in orthopaedic patient management.
Marc Swiontkowski, MD
The orthopaedic community has been abuzz lately with conversations about the value of interdisciplinary teamwork among clinicians and shared decision-making between patients and clinicians. The positive results of both those approaches, implemented with children and adolescents who have cerebral palsy (CP), are revealed in a clinical cohort study by Louwers et al. in the August 15, 2018 JBJS.
The authors engaged 66 patients with CP in a comprehensive, multidisciplinary screening process and shared decision-making to determine each patient’s suitability for upper-extremity surgery. Forty-four patients were deemed eligible for surgery and 39 (mean age of 15 years) underwent surgery. Seven types of surgery were performed, depending on each patient’s predetermined goals, values, and preferences. Seventy-seven percent of patients had surgery that consisted of flexor carpi ulnaris tendon release or transfer and adductor pollicis muscle slide plus extensor pollicis longus rerouting.
The authors itemize the preoperative and postoperative assessment tools used in the study and describe them as “suitable for selecting patients for upper-extremity surgery and for evaluating the effect of that surgery.”
The bottom line: All outcomes improved significantly after patient-specific upper-extremity surgery in those deemed suitable for it and who opted for surgery after the shared decision-making process. Most of the patients experienced clinically relevant improvement in their functional and cosmetic goals and in manual performance 9 months after their operation.
The two patients who chose nonsurgical treatment after going through the assessment and shared decision-making process did so due to a lack of motivation for the intensive postoperative rehabilitation, which began with upper-limb immobilization for 5 to 6 weeks, followed by a program customized for each patient by his or her rehabilitation physician and occupational therapist.
Demographic reality dictates that orthopaedic surgeons will be under ever-increasing pressure to serve aging patients. This explosion in the need for diagnostic and treatment services calls for engaged and informed patients to work with physicians in a shared decision-making process.
In the August 2, 2017 issue of The Journal, Sepucha et al. document the positive impact that patient decision aids—succinct presentations of treatment options and their attendant risks and benefits—have in shared decision making for hip, knee, and spinal complaints. In this prospective cohort study focused on routine orthopaedic care, the authors show that decision aids lead to higher knowledge scores among patients, greater patient involvement in shared decision making, lower surgical rates, and better patient-experience ratings.
The quality of available decision aids is generally excellent, and they are typically more evidence-based than information patients can locate on the Internet. In this time when orthopaedic surgeons are evaluating higher volumes of patients, these tools can inform patients before or after they interact with their orthopaedist. In addition to providing everyday-language explanations of clinical benefits and risks, these aids help individual patients align their health-care decisions with their personal values, needs, and lifestyles. I hope that these tools will find increasing use over the next 5 to 10 years in the orthopaedic practice environment.
Marc Swiontkowski, MD
In the November 4, 2015 Level I JBJS study by Kukkonen et al., patients over the age of 55 were randomized to one of three treatment arms for management of a rotator cuff tear—physical therapy alone and acromioplasty with and without rotator cuff repair. We learn that over a two-year follow up, treatment with physiotherapy produced results as clinically favorable as surgery in this “older” age group, although tear size was significantly smaller in the repair group than in the other two.
As Dr. Ken Yamaguchi points out in his commentary on the study, the average patient age for surgical repair of a rotator cuff tear is currently the mid-50s, and we know that the likelihood of repair failure with lack of healing increases in patients beyond their mid-60s. In fact, historic post-mortem studies have identified rotator cuff tears in 70% to 80% of all subjects, making this is a common wear-and-tear phenomenon among humans, akin to degenerative disc disease and declining hearing and vision.
So is the take-home message from Kukkonen et al. that any patient over the age of 55 should be treated with physiotherapy, with no discussion of surgical repair? I think not. The message is that we should be more supportive of a decision to start down the physiotherapy path with patients in their mid-50s than ones in their mid-40s. Although this study emphasizes the age factor, we should also remember that age is only one data point in a shared decision making discussion. An athletic, fit woman in her mid-50s who participates in yoga and zumba four days a week in addition to resistance training is a very different patient than the sedentary, deconditioned woman of the same age.
In the discussion of what is best for each patient, we need to leverage our knowledge regarding the musculoskeletal problem coupled with the wisdom to consider each patient’s functional demands and goals for activity return. As our population ages and the level of older-patient fitness hopefully increases, these discussions will take more time, but will result in higher-quality decisions for the individual patient.
Marc Swiontkowski, MD
It’s a generally accepted “fact” that total knee arthroplasty (TKA) ranks among the most significant modern medical advancements. But the October 22, 2015 NEJM published the first rigorously controlled randomized study that “proves” that “fact” by comparing TKA to nonsurgical management.
One hundred patients with moderate-to-severe knee osteoarthritis were randomly assigned to undergo TKA followed by 12 weeks of rigorous nonsurgical treatment, or the nonsurgical treatment alone. Over a 12-month follow-up period, TKA was superior to nonsurgical treatment in terms of pain relief and functional improvement, but it was also associated with a higher number of serious adverse events, including deep-vein thrombosis and infection.
The study authors concluded that “the benefits and harms of the respective treatments underscore the importance of considering patients’ preferences and values during shared decision making about treatment for moderate-to-severe knee osteoarthritis.” JBJS Deputy Editor Jeffrey Katz, MD concurred with that conclusion in an accompanying editorial: “Treatment decisions should be shared between patients and their clinicians and anchored by the probabilities of pain relief and complications and the importance patients attach to these outcomes,” he wrote. “Each patient must weigh these considerations and make the decision that best suits his or her values.”