Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence, 2021, Blom et al

https://www.bmj.com/content/374/bmj.n1511

1. Ashley W Blom, professor of orthopaedic surgery1 2,
2. Richard L Donovan, clinical research fellow in orthopaedic surgery2,
3. Andrew D Beswick, research fellow in orthopaedic research2,
4. Michael R Whitehouse, professor of trauma and orthopaedics1 2,
5. Setor K Kunutsor, research fellow in evidence synthesis1 2

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1511 (Published 08 July 2021) Cite this as: BMJ 2021;374:n1511

Abstract
Objective To determine the clinical effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines.

Design Umbrella review of meta-analyses of randomised controlled trials or other study designs in the absence of meta-analyses of randomised controlled trials.

Data sources Ten of the most common elective orthopaedic procedures—arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement—were studied. Medline, Embase, Cochrane Library, and bibliographies were searched until September 2020.

Eligibility criteria for selecting studies Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that compared the clinical effectiveness of any of the 10 orthopaedic procedures with no treatment, placebo, or non-operative care.

Data extraction and synthesis Summary data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check whether recommendations for each procedure reflected the body of evidence.

Main outcome measures Quality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of recommendations in relevant national clinical guidelines.

Results Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. No randomised controlled trials specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care.

Conclusions Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.

Systematic review registration PROSPERO CRD42018115917.

 

I had arthroscopic surgery on my right knee -- specifically a lateral release and debridement. It was worse than useless. Not only did I develop deep vein thrombosis and pulmonary embolism (blood clots in the leg and lungs), but I was in worse pain following the surgery. When my dolt of an orthopedist suggested an even more invasive surgery to fix the pain caused by his first surgery, my physical therapist thankfully suggested in no uncertain terms that I get a second opinion. In the end, Celebrex for the arthritis and some physical therapy were far more effective.

While I can't speak the methodological strengths of this study, my n=1 experience is that orthopedists are given far too much rein to slice into people.

 

Didn't you get injections to prevent thrombosis? I got those every day for a few weeks afterwards if I remember correctly. My father had to be the one to inject them after I was taken home and he was way more frightened of this than me.

But mine was a pretty invasive surgery, my entire leg looked like a death metal album cover afterwards and I had to learn to walk again on that leg. It took me several months.

(It did solve the problem though - repeated dislocations - but my knee has been a little bit weaker than the other one since and nothing improved that.)

 

Alas, no. Indeed nobody even mentioned the possibility of blood clots until I was leaving the hospital and a nurse handed me a brochure saying, "oh if your leg hurts, let us know because it might be a blood clot." Which, since they had just done surgery on both my knee and ankle, my whole damn leg hurt. And I had no idea what distinguished the pain of a blood clot (or clotS in my case) and the usual pain associated with surgery. The only preventative measure my orthopedist took was to not use a tourniquet during surgery apparently (because when he visited me in the hospital, he expressed shock that I had DVT & PE because he hadn't used a tourniquet--did I mention he was a bit of a dolt?!).

That said, it was 1998 so maybe they hadn't started doing prophylactic heparin shots yet? Though I did get to experience them aplenty after I had the DVT & PE!

Mine was a bit mixed. While the knee surgery did nothing to solve the instability in my knee, the ankle surgery (which was much more invasive) did seem to stabilize that ankle which I had been spraining just about every 3-4 months for 16 years. Since that surgery, I've only sprained it 3 times. But it came at the cost of making my prodromal/mild ME completely debilitating. So it's also difficult to know if I would be spraining my ankle more if I was more active or if it genuinely was that effective. Not a day goes by, though, when I wouldn't trade spraining my ankle every few months and dealing with grinding knee pain if I could only have my pre-surgery health back.

 

I had an operation in about 94/95 and I was told that because of my immobility I would be given heparin for at least a week after the operation.

Of course, I was in an NHS supplied wheelchair so they probably followed a protocol for that and I was spared the ME prejudice.

 

Is this paper reporting on an early stage in the process of removing all these surgeries from being carried out by the NHS and forcing people to go private?

I also notice that the authors are affiliated with the University of Bristol. Have I got muddled up or am I right in thinking that BPS stuff issues from there?

I've been baffled ever since the NHS stopped doing tonsillectomies. For me personally it was one of the most successful surgeries I ever had in terms of increasing my quality of life. For orthopaedic stuff as described in this paper I imagine there will be similar stories from many other patients if surgeries are no longer given.

 

I think that is something relatively new that they do now after surgeries. My mom ended up with a blood clot after her hip replacement surgery 12 years ago. She recently had surgery and the surgeon told me that today they automatically give people a blood thinner after surgeries that have the potential to cause a clot.

 

I don't see how they could stop doing surgeries such as hip or knee replacements. Without those surgeries too many people would be crippled with pain and have no hope for a good quality of life.

 

Sadly, I think the NHS in conjunction with the BPS crew and the government could find a way of denying or delaying surgery if they wanted to save money.

 

Hm, my surgery was in 2004 (I was very young, my knee problems arose in my teens due to the badly shaped bone). Maybe it wasn't universal for every surgery everywhere. I had no idea it wasn't the norm, looks like I was kind of lucky!