Blog post produced and written by Clinic Manager and Lead Sports Massage Therapist Jason Dodd.
Can even experienced orthopaedic surgeons predict who will benefit from surgery when patients present with degenerative meniscal tears? The indication for arthroscopic partial meniscectomy (for the purpose of this blog we will refer to its common name of knee surgery) is one of the most commonly made decisions in orthopaedic practice and 75% of APMs are performed in patients older than 40 years of age.
However, meniscal tears are a common finding in the general population. Incidental meniscal tears (meaning there is no traumatic link or injury beforehand) are found on MRI in 60% of asymptomatic adults older than 50 years with radiographic evidence of osteoarthritis. This then shows that meniscal tears can be seen as part of a degenerative process of the knee.
Although many trials and studies have shown no clinical benefit (meaning there is a big reason to do whatever it is you are testing) of knee surgery over alternative non-operative treatments (such as exercise) or sham surgery (fake/pretend surgery where they are led to believe they have actually had the surgery!), there is no real decline in the number of knee surgery’s performed in day to day hospitals. There are a number of arguments for this which can include patient expectations, surgeons preference or beliefs that it will work. Unfortunately, none of these points are good enough as they are not supported by evidence.
So, to combat this, a study was set up to gain an insight into how orthopaedic surgeons decided who should have surgery and who shouldn’t based on what their outcomes would be. 194 surgeons took part in the trial and they were sent a set of profile features of a group of participants from ANOTHER trial. The trial in question looked at how a group of people would respond to knee surgery or exercise therapy and then monitored their progress. This trial then gave a set of results which showed how they all performed with their intervention.
The orthopaedic surgeons were then sent the profile pages of some of those who responded really well to exercise therapy and also those who responded really well to knee surgery. The surgeons did not know who had what treatment nor how they responded. They were then asked whether they thought, based on the information presented to them, the patient would be best suited to exercise therapy or knee surgery. Remember now, none of the surgeons knew any of these people nor did they have any idea how they performed in the other trial. The results were quite shocking (naturally!!). The percentage of correct predicted outcomes vs incorrect predicted outcomes was 50%!! YES 50%!!! That basically means that your predicted chances of success from knee surgery is almost as good as flipping a coin (which is what is to be expected given all the potential variables for success or failure).
What made this study even more interesting were a few other questions that were asked to the surgeons. The main one being ‘do you think surgery is a good option for the initial treatment’. It was good to see 89% of those asked said it would not be…..however, in 22% of the cases presented to them, the surgeons suggested that knee surgery would be a good first intervention. What is of even more interesting note is the number of surgeons who recommended surgery as the first option was highest in the profile descriptions of those who actually reported WORSE outcomes after surgery. Meaning, based on all the information they had, the ones that surgeons thought would respond best to surgery actually responded worse and would have probably been better off with an exercise programme to follow initially.
This post is not an opportunity to bash the orthopaedic profession. These surgeons provide an unbelievable service and there are times when surgery is the right thing to do and people will have huge benefits. BUT, that is not always the case. The same way that some people do not respond to Physiotherapy or Osteopathy treatments, it does not mean that they are all useless or rubbish. It is just highlighting the point that we keep making again and again and that is;
“There is no one treatment or modality that will suit every individual but what does exist is a whole load of educational information which can help YOU make an informed decision about what you do next to help YOUR body”.