All aboard the surgery band wagon…

I wrote about physios and band wagons a few years ago here and discussed how we love to jump on to popular ideas without thinking enough and tend to get carried away, and as expected this is still happening. There is now a new band wagon which many therapists are jumping on to and which is causing me some angst and frustration, and you may be surprised to hear me defending it. This band wagon is the increasing number of therapists criticising orthopaedic surgery.

Challenging and criticising orthopaedic surgery has gained some serious momentum over the last few months in light of some online social media campaigns as well as some research that has demonstrated no difference between some orthopaedic surgeries and placebo. Things such as arthroscopy for knee osteoarthritis (ref) or meniscal debridement (ref), spinal surgery for osteoporotic vertebral fractures (ref), and a very recent study published in BJSM on shoulder labrum repairs (ref) and another soon to be published on shoulder acromion decompressions (ref).

Damn you…

Now don’t misunderstand me this research is important to discuss and promote and asks a lot of difficult questions about orthopaedic surgery, and a lot of orthopaedic surgery does need to take a good long hard look at what it does and how it does it, and damn you all to hell for making me write this post defending it. However, I need to get a few things cleared up about the increasing criticism directed towards orthopaedic surgery and the surgeons who perform it due to some ridiculous remarks made by some idiots out there.

Firstly, there have been some claims that ALL elective orthopaedic surgery is placebo. This is complete and utter nonsense. There is no evidence of this at all. As mentioned there is ‘growing‘ evidence that ‘some‘ orthopaedic surgery has no significant difference in outcomes when compared to sham surgery. But this is not generalizable to all other surgery. It also isn’t infallible or conclusive evidence, these intriguing studies need to be reproduced before we can conclude with any certainty and conviction that there is no difference.

I do believe that there is likely to be very strong placebo effects with these orthopaedic trimming, shaving, suturing, and repairing procedures, but there are undoubtedly times when it does do more than placebo to bring two pieces of broken anatomy closer together, or even move them further apart and allow natural history to do the rest.

Surgery doesn’t work!

The next ridiculous claim being made is that orthopaedic surgery doesn’t work. What complete and utter nonsense this is again. Yes it’s not perfect, yes there are failures, but to say orthopaedic surgery doesn’t work is hogwash and often said by those who have misinterpreted the research. Even the placebo surgery trials show that orthopaedic surgery works, just not for the reasons originally thought. Why people get better after placebo surgery just as well as those that have ‘true’ surgery is intriguing and due to many factors and is for a completely different blog or three!

However, watching some therapists using these placebo surgery studies with glee to demonstrate how surgery is ‘ONLY’ a placebo need to be very careful about throwing stones in glass houses. All the therapies, including physiotherapy, have shockingly little to no placebo controlled studies to compare how much of what /we do is ‘ONLY’ a placebo. As much as I am an advocate for physios giving simple advice, education, and increasing exercise and activity in all we see, I have no doubt that people get better despite our interventions. It’s called natural history and regression to the mean. Deal with it!

Finally, the last point I want to discuss is the most worrying and annoying one. I have seen an increasing amount of accusations and negative comments directed towards orthopaedic surgeons in light of these studies. I have seen some comments that surgeons do these operations too soon, too easily, and for ulterior or self-motivated reasons only. Now, this may be true in some rare isolated cases. But despite common belief orthopaedic surgeons are not ruthless, soulless, money grabbing, knife welding megalomaniacs intent on screwing over their patients at any given opportunity.

Can’t cut pain out!

I work closely with many orthopaedic surgeons and I can assure you that these intelligent, hard working, dedicated people will try everything not to operate on patients. Many of my orthopaedic colleagues ensure patients are well aware that surgery is often only to be used as the last resort, and that it’s not guaranteed to help, and doesn’t come without risks. I hear them using terms like “We can’t cut the pain out” or “There is no pain that my surgery can not make worse”, and have found myself using these sayings often as well.

Thinking that surgeons alone decide when to operate is also nonsense. Most of the surgeons I know get informed consent for any intervention far better than most therapists I know. Surgical patients are often given the full list of pros/cons, risks/rewards, and time frames of what to expect and most don’t enter into surgery without fully understanding these.

So when a patient has exhausted all other options, when they feel they have no other options left, when they think an operation will help, when there is a clear surgical ‘target’ to address, why not operate? Yes, some operations are done too quickly, without giving enough time or other options a good enough go. But, and this is a big but, we can not blame surgeons and patients for wanting operations when they ‘fail’ other options such as physiotherapy.

The unfortunate truth for us therapists is that if we and our interventions were any better at managing these issues many patients would not seek surgery. Now I know a lot of therapists do great jobs and many are in difficult positions, pushed for time, resources, and patients don’t always want to do what we ask of them, but as I said we have to recognise our limitations as well as those of our surgical colleagues

So in summary, some orthopaedic surgery is coming under the spot light in how it works and this is a good thing. But seeing some jump onto the ‘all orthopaedic surgery is bad‘ band wagon is not a good thing. Finally, it’s repugnant to see and hear some of the accusations and claims made about our orthopaedic colleagues. This just needs to stop, it’s only harmful to future collaborations and progress. There is no surgery OR therapy, there is no surgeon OR therapist, there is no us OR them, there is just us!

As always thanks for reading

Adam

 

4 thoughts on “All aboard the surgery band wagon…

  1. I totally agree with all of this and as much as I WANT to believe physical therapy is the best option – sometimes it’s not and a surgical procedure is warranted. Where I do see a problem is the information given to patients. While I’m sure they receive the pros and cons etc., I often feel MDs don’t have the time to truly know if their messages are getting through. I all too often get patients that express frustration over not knowing how difficult of a road the recovery process will be and if they had known they might have opted against surgery. Most likely they were informed of the timeline and what it would entail but did they actually listen and comprehend it? Is this an MDs job to make sure they truly grasp the effects of surgery? I don’t know but know it would help matters if patients did have a better grasp on the reality of the situations.

  2. THANK YOU for posting this. Physicians care just as much as any profession. I hate that they get characterized as money hungry people who automatically promote surgery; some out there probably, but not most. Good article Adam.

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