Too Much Surgery?
Since the inception of modern surgery in the 1800’s, it has been viewed and advertised as the ultimate ‘quick fix’ for many medical conditions. Surgical techniques have become more refined and sometimes more experimental, with the number of elective surgeries performed continuing to increase exponentially over the past decades. But is surgery always the answer?
Perhaps we have become so caught up in the idea of “progress” that we do not stop to ask whether these procedures actually work any better than non-surgical treatment. Some researchers are now attempting to answer these questions.
Ian Harris, an Australian Orthopaedic Surgeon explores this question in his book titled, “Surgery, The Ultimate Placebo”. As Dr Harris explains, a treatment that involves signing a long consent form, being put to sleep, being cut open then sewn up, and being spoken to in medical jargon by a person in a white coat the moment you wake up, has all the right theatrical elements to convince our brains that surgery surely must work! Dr Harris is not saying, and neither is this blog, that many surgical techniques are not effective and medically necessary. However, the evidence shows that some common procedures (including knee arthroscopies, shoulder subacromial decompressions, and shoulder labral repairs) are in many cases no more effective than conservative treatment options, and have greater risks.
A study by Moseley et al in 2002 1 compared the outcomes of patients with knee osteoarthritis who one of three operations: sham surgery, a saline water washout of the knee, or an arthroscopic knee debridement (clean out). After their ‘surgery’ all patients received the same pain medications, same walking aids and same exercise rehabilitation. There was no statistically significant difference in the pain levels or function of any of the three groups in the short or long term. The authors conclude that knee arthroscopic debridement is no better than sham or saline, to improve pain or function in patients with knee osteoarthritis.
Sihvonen et al performed a similar study in 2013 2, in which patients with degenerative knee meniscal tears but no osteoarthritis had either a partial removal of the torn cartilage, or sham surgery. Again, there was no statistically significant difference in pain or function between the sham or actual surgical groups.
Schroder et al, in 2017 3, performed a large, high-quality study comparing the outcomes of patients with ongoing pain due to tears of the shoulder labrum who underwent either: a labral repair, biceps tenodesis (where the biceps tendon is released at the shoulder), or sham surgery. Again, every patient received the same medication, sling use and exercise rehabilitation after surgery. There was no statistically significant difference in pain, shoulder instability or function in the short or long term.
Arthroscopic subacromial decompression of the shoulder is a very common procedure or patients with shoulder pain. Many studies have been performed comparing the outcomes patient who have this operation with those who are treated with exercises alone. Studies by Ketola, Lehtinen, and Arnala, 2017; Gebremariam et al in 2011 and Haahr et al in 2005 4, 5, 6, found no difference in pain and function in those who had surgery compared to those who did physiotherapy exercises. The Ketola study followed patients up to 13 years after surgery, and there was still no difference, where they had surgery or not. Biberthaler et al found in 2013 7 that shoulder subacromial decompression surgery was slightly more effective than exercise, but only in those over the age of 57.
How do we explain this? Why are these operations still performed in large numbers if we have good quality evidence supporting conservative treatment instead of surgery? Of course, there will be many reasons. Change is always complex, challenging and slow. Perhaps we are simply stuck in habits or patterns of diagnosis and referral – we do what we have always done. Perhaps we believe or hope that surgery will give us a “quick fix”, and we won’t need to find the motivation, dedication, time and energy that exercise rehabilitation might require.
How can we be part of the change? We can choose exercise-based treatment as our first option to treat our hip, knee and shoulder pain. Yes, sometimes surgery will still need to be used. But, if the outcomes tend to be just as good, and the risks are much lower, let’s choose exercise first!
1. Moseley, J. B., O'malley, K., Petersen, N. J., Menke, T. J., Brody, B. A., Kuykendall, D. H., ... & Wray, N. P. (2002). A controlled trial of arthroscopic surgery for osteoarthritis of the knee. New England Journal of Medicine, 347(2), 81-88.
2. Sihvonen, R., Paavola, M., Malmivaara, A., Itälä, A., Joukainen, A., Nurmi, H., ... & Järvinen, T. L. (2013). Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. New England Journal of Medicine, 369(26), 2515-2524.
3. Schrøder, C. P., Skare, Ø., Reikerås, O., Mowinckel, P., & Brox, J. I. (2017). Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. Br J Sports Med, bjsports-2016.
4. Ketola, S., Lehtinen, J., Arnala, I., Nissinen, M., Westenius, H., Sintonen, H., ... & Rousi, T. (2009). Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?. Bone & Joint Journal, 91(10), 1326-1334.
5. Gebremariam, L., Hay, E. M., Koes, B. W., & Huisstede, B. M. (2011). Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review. Archives of physical medicine and rehabilitation, 92(11), 1900-1913.
6. Haahr, J. P., Østergaard, S., Dalsgaard, J., Norup, K., Frost, P., Lausen, S., ... & Andersen, J. H. (2005). Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up. Annals of the rheumatic diseases, 64(5), 760-764.
7. Biberthaler, P., Beirer, M., Kirchhoff, S., Braunstein, V., Wiedemann, E., & Kirchhoff, C. (2013). Significant benefit for older patients after arthroscopic subacromial decompression: a long-term follow-up study. International orthopaedics, 37(3), 457-462.