Unnecessary Surgeries

Too many surgeons are performing operations that are likely to do more harm than good, a leading orthopaedic surgeon says.

About half of orthopaedic surgical procedures have no scientific evidence from randomised trials proving they work better than non-operative treatment, Ian Harris told a meeting of 1900 surgeons this week.

Research showed another 25 per cent are no better than non-surgical alternatives, he said. Yet many of these are still being performed.

Professor Harris, of the University of NSW, said ineffective and potentially harmful operations included knee arthroscopy for arthritis, some forms of spinal surgery for low back pain, Achilles tendon repairs, some shoulder arthroscopic procedures, and wrist and ankle fracture fixations.

Despite many studies showing knee arthroscopy was not beneficial for almost all patients with arthritis, many medical guidelines continue to support the procedure for such people.

Professor Harris said some surgeons also continued to perform spinal fusion surgery to treat low back pain despite studies showing no benefit over non-surgical alternatives.

A 2012 study of people who had the procedure for low back pain through workers’ compensation schemes in NSW found only 3 per cent had returned to pre-injury work duties two years after the surgery. About 70 per cent were still taking strong opioids such as OxyContin in an attempt to manage their pain.

While some surgeons might be unaware of the evidence, Professor Harris said, others were not aware of the strengths and weaknesses of scientific studies and often worked on the basis of “assumed effectiveness”. They think “that’s what my boss did, so that’s what I do, and that’s what everybody else seems to be doing”, he told the Royal Australasian College of Surgeons annual scientific congress in Adelaide.

He said research had also shown clinicians often overestimated the benefits of their work and underestimated the harm of it. One Australian study of more than 300 patients and their surgeons following joint replacements found the doctors were more satisfied with the results than their patients.

“Surgeons think the operation is great,” he said. “The actual satisfaction rate for total knee replacement across the board is about 80 per cent, so there is a 20 per cent dissatisfaction rate.”

Professor Harris told his peers to be more sceptical of new technology and devices, saying a 2011 study of new hip and knee replacements introduced over five years found none of them were superior to the old ones, and 30 per cent were worse.

“We can do better,” Professor Harris said to hundreds of surgeons, urging them to conduct rigorous studies of old and new procedures to protect patients and improve their practice.

His warning comes amid mounting evidence of ineffective, wasteful and harmful medical treatments worldwide, and not just in surgery. In January, an international group of leading doctors and academics said up to one-third of medical interventions were now being done unnecessarily, causing physical, psychological and financial harm that could threaten the viability of healthcare systems.

The Australian government is reviewing the Medicare Benefits Schedule to eliminate ineffective medical services taxpayers should not be paying for, so it can fund more effective care.

Bruce Robinson, an endocrinologist who is leading the review, said he was preparing to release new recommendations about changes for spinal surgery and orthopaedics in coming weeks. He estimated the government would start acting on these recommendations at the end of 2018.

Professor Robinson said that although many surgical procedures and other health interventions did not have evidence to back them, it was sometimes too costly and impractical to conduct rigorous trials.

“We have to accept that some things just feel like they are the right thing to do,” he said. “Like taking out an appendix … Do we really need to do a trial that shows that removing a ruptured appendix is better than leaving it there? Of course not. It would probably be unethical to do it.”

Philip Truskett, the immediate past president of the Royal Australasian College of Surgeons, said the college was focusing on reviewing surgical procedures and examining data that might point to inappropriate care. He said he could not speak for orthopaedic surgeons, but believed knee arthroscopy rates were falling.

“The message is being pushed. Hopefully things will change,” he said.

The reporter travelled to the conference courtesy of RACS

  – Originally titled: Many operations more harmful than beneficial, top  surgeon warns

   Sydney Morning Herald by Julia Medew, Published May 12th 2017

Unnecessary Surgery—A Case Study

A 47 year old male presented with a long history of acute episodes of low back pain, with ongoing chronic soreness in between episodes. Three months prior to attending Healthwise, he developed numbness  and pins and needles in his left foot and some low grade lower back soreness. His GP referred him for an MRI, which showed he had a generalised disc bulge at the L5/S1 segment of his lower spine. He was prescribed antihistamines and sent for physio therapy.

After 3 weeks of physio, his symptoms had worsened and his GP referred him to seek an opinion from an orthopaedic surgeon. The surgeon briefly reviewed his MRI’s and said he would need an operation to reduce the bulge and fuse the L5/S1 segment. The surgeon also reported that he had no other option and that his condition would continue to worsen if he didn’t do something about it.

At that point, the man’s GP referred him to myself at Healthwise, and my examination results agreed with the surgeons diagnosis; however, I did not agree with his management of the condition. As there was no bladder or bowel symptoms, or any progressive muscular weakening if the lower limb, time was on his side.

A treatment regime commenced which included low level cold laser, muscular and release techniques and some gentle mobilization if the lower lumbar spine and lower thoracic spine. The patient reported significant improvement after the second session. By the end of the 6 week mark, the patient was 80% improved from base and a basic strengthening program was prescribed. The patient was reviewed monthly for the next 8 months and by this stage was pain free. He was then discharged for care and put on a 3 monthly review. 18 months on, the patient is pain free and reports that he can self manage any small episodes if he “over does it”.

The goal of Healthwise practitioners is to guide the patient to self managed strategies once their condition stabilises.

 – David Sparavec, Osteopath

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