To Operate or Not To Operate. That is the Question.

February 22, 2020 Nicole Everett

Watch this highly informative and thought-provoking discussion between Mark Hurworth (Orthopaedic Surgeon) and Ian Dowley (Senior Physiotherapist) about how the decision to operate or not to operate is made. The increasing availability of higher quality radiological imaging often causes a “knowledge explosion” - these images show every little change and irregularity in our bodies. But what is relevant? What is ‘normal’ age-related change and what is actually related to our symptoms? Do these ‘issues’ that have been identified actually need to be surgically ‘fixed’? In a radiological report the complex technical jargon or even the sheer volume of information can be scary and threatening for the patient.

Find out what factors go into the surgical decision-making process and what effective non-surgical options are available. Use this summary blog to get the highlights or watch the full video, Do I Really Need Surgery? here.

A surgical decision should be based on a clinical diagnosis. What is a clinical diagnosis and why should imaging findings alone not be used to make a surgical decision?

A clinical diagnosis is made by combining three things: the patient’s history of pain or injury; the physical examination; and the findings from radiological imaging. The imaging findings should be used to confirm or rule out what is already suspected from the history and examination. They should not be used in isolation to determine the source of a patient’s symptoms. The evidence shows that for age-related conditions like osteoarthritis, there is poor correlation between what is seen on imaging and the severity and nature of a patient’s symptoms (for more information on this, read our blogs – Normal Abnormalities in Our Knees, and Ignorance might be bliss when it comes to medical scans). There might be large amounts of degeneration but no pain, or very minimal damage but severe pain. This is due largely to the complexity of pain itself, and the myriad of factors involved in pain perception other than tissue damage (for more information, go to the pain section on Wrinkle Well).

Two patients may have identical imaging findings – for example a rotator cuff tear in the shoulder, or cartilage damage in the knee - yet need totally different treatment based on the history and examination. A patient with a history of sudden injury or trauma might be more likely to require surgery, while another with gradually increasing pain over several months may be more likely to be treated without surgery.

It comes down to the balance between history, physical examination and imaging. An experienced surgeon, doctor or physiotherapist will use all three to help decide what is best for each individual patient.

Is a surgeon’s bias to operate hard to overcome?

Surgeons are by definition interventionalists, whilst other health professionals like Physiotherapists are non-interventionalists. A surgeon may therefore have a built-in bias towards using the tools they are most familiar with (surgery) to treat the problem in front of them, while a physio may be biased against surgery in favour of exercise rehabilitation. These biases need to be acknowledged and (if necessary) challenged when trying to decide whether we will benefit from elective joint surgery.

Patients may carry their own biases regarding surgery – for example, a belief that surgery always offers a ‘quick-fix’ solution. We need to understand that any surgery is additional trauma to our body, and will make us worse for some time afterwards. It always carries risks, and should not be undertaken lightly.

What are the main factors that a surgeon will consider when deciding to operate?

Injury: Compare a person who has fallen over and sustained a new and painful injury to someone with a painful problem that gradually came on over time.
Age: Compare a young person with a significant rotator cuff injury to an older person with a degenerative rotator cuff lesion.
Severity: Unbearable symptoms may influence a surgeon towards intervening.

What is the benefit of choosing, at least initially, to have non-operative treatment?

1. Many issues resolve over time anyway

The research evidence shows that many conditions will settle down over a period of 3-6 months if treated non-operatively – eg. shoulder pain without a specific trauma. In the case of knee osteoarthritis there is a very clear ‘natural history’ – a predictable pattern to the way it develops over time, without any intervention.

A little bit of cartilage breaks off
The body mounts an inflammatory response, which can cause the knee to become painful, stiff, swollen, hot, red, irritable. This inflammatory response generally lasts 2-3 months
The knee will improve and settle down again

2. Pre-surgical treatment sometimes becomes non-surgical treatment

Many patients have the experience of starting a course of exercise ahead of their planned surgery – maybe to lose some weight, maybe to strengthen some muscles, or maybe just to try and delay the surgery until a more convenient time – only to find that their problem improved so much that they no longer want or need surgery.

Even those patients who still have their elective joint surgery will benefit from a tailored exercise program in the months leading up to the operation. This will build strength and capacity, resulting in a quicker and better outcome following surgery. Maximising pre-operative function is important as most patients have become subtly deconditioned over the years, leading up to deciding to have an elective joint replacement.

What should effective non-operative treatment look like?

Good non-operative treatment should involve:

Time: Allow at least 3-6 months to achieve maximum benefit from the exercise program.
Pain management: Should be holistic and multifaceted, considering factors such as sleep quality, general exercise and activity levels, beliefs and ideas regarding pain and injury, and general mental health.
Education: Self-management, activity pacing, and avoiding flare-ups.
Active treatment: ‘Hands-on’ physiotherapy may provide useful short-term relief, but the real benefit comes from movement and exercise over time.
Targeted exercise: A personalised exercise program designed to improve strength, improve motion, and optimise function.

And may also involve:

Anti-inflammatory medication: If considered safe and appropriate by your doctor, non-steroidal anti-inflammatory medications may be of benefit.
Cortico-steroid injection: An injection of this powerful anti-inflammatory can provide effective but temporary relief for some patients, and may enable us to delay the surgery or to exercise more effectively pre-surgery.
Weight loss: Some procedures (eg. total knee replacement) may not be possible unless we lose weight first, usually with a combination of exercise and diet strategies.

What should not be included in your non-operative treatment?

There are a huge number of products and treatments available that claim to help a person with pain, inflammation or injury. Many have no scientific evidence that they work. Whenever possible, ensure you are spending your time and money on treatments with good scientific research to support its use.

Be very careful of being tricked by the natural progression of your painful episodes. If we start using a new product or treatment just as our 3-month arthritic flare up settles down, we may incorrectly assume that the new product caused the improvement. It is very difficult to avoid biases in research when we are the only subject.