The sexy scalpel: unnecessary shoulder surgery on the rise

 

By Jørgen Jevne @jevnehelse

jorgenWhile we are supposed to be living in the era of evidence-based medicine (EBM), researchers are making us increasingly aware of the long distance between academia and daily clinical practice. This is highlighted by recent writings on low back pain [1] and knee arthroscopy [2].

Clinicians love to cling on to their safe havens and we often cite experience as a reason to uphold the status quo.

However, clinical experience can be deceiving [3] and in the age of evidence it seems rather anachronistic to hold experience above science when our opinions are being questioned.

EBM is not just about clinical experience and scientific studies. Although patient-centred care is an indisputable hallmark of modern medicine, a recent publication in JAMA highlights patients´ tendency to overestimate treatment benefits and underestimate harms [4].

Clinicians need to educate patients sufficiently and inform them about benefits and harms based upon the best clinical evidence, to ensure that they make sound judgements regarding their own health.

Enter science.

The numbers

A number of studies have looked at the rising incidence of acromioplasty for the treatment of what is known as subacromial impingement syndrome [5,6] – now more correctly coined subacromial pain syndrome [7].

A Finish study actually reported declining incidence of surgery, however, this positive development was contrasted by an increase in the private sector [8]. A recent UK study reported a staggering 750% increase in the rate of these surgeries from 2000-2010 [9].

The numbers, albeit large, are not a problem in their own right.

Had clinical outcomes been shown to consistently improve with surgery compared to conservative therapy, the increase could easily have been justified.

Unfortunately, they do not.

Not even close.

The problem

The devious shoulder complex often renders clinicians with frustrating uncertainty [10]. Furthermore, in the spirit of holistic assessments and biopsychosocial models of care, we are gradually cognisant towards other factors that influence patient presentations and outcomes [11-13].

For over twenty years, surgery has failed to provide superior outcomes compared to conservative therapy for the treatment of SAPS. The results are consistent and with methodology more rigorous, the differences are even smaller, as illustrated by recent systematic reviews [14].

Shoulder pain remains somewhat of a medical mystery and the ambiguities are nicely illustrated by a 2009 study, which showed that a bursectomy alone had comparable effects to removing the acromion and bursa [15]. Additionally, as some of the structures being surgically removed for decreasing pain have a stabilizing role in the shoulder-complex [16], the following quote seems appropriate:

It would be hard to imagine that a surgeon would suggest, or a patient would agree to, having the anterior cruciate ligament removed to treat knee pain [17].

Then there is the concept of placebo. Surgeons have generally been reluctant to perform placebo surgery and the reasons are of course multifaceted.

When our long held fortress of beliefs is being attacked, strong reactions are inevitable. The few orthopaedic placebo surgeries that have been published have had discouraging results [18,19] and created fierce debate within the scientific community. However, a recent systematic review does indeed show that the concept of placebo surgery is both warranted and ethically justified [20].

In the words of Carl Sagan: “Extraordinary claims require extraordinary evidence”. And while the claims might not be extraordinary, orthopaedic surgery has enjoyed amnesty from scientific inquiry for far too long [21].

While studies investigating placebo surgery for subacromial pain syndrome remain absent, 2015 seems to be the year we will have our first answers to this riddle [22].

The cure

History is filled with examples of long delays in the dissemination, acceptance, and implementation of high-level clinical evidence into clinical practice.

Make no mistake. There are many unanswered questions within conservative care of shoulder pain. This is not a speech of defense.

We definitely need more research. More honesty. More humility.

But in the light of the current evidence base, the benefits of surgical intervention for the treatment of SAPS seem glorified and overrated.

Conservative treatment appears underutilized and underestimated.

The solution should be obvious.

Providers of conservative care need to lift their game. We need to deliver patient-centered, evidence-informed, high-quality treatment based upon the very best of scientific rigor.

We need to make conservative care attractive. Accessible. Affordable.

We need to educate the public. We need to let patients know that exercise will have similar results as surgery.

That it will be cheaper and have more profound, long-lasting effects on patients’ health [23].

In other words:

We need to make exercise as sexy as the scalpel.

******************************************

Jørgen Jevne is a dedicated musculoskeletal clinician and part-time researcher practicing in the small town of Hønefoss, Norway.

References

  1. O’Sullivan, P.: It’s time for change with the management of non-specific chronic low back pain. Br J Sports Med, 2012. 46(4): p. 224-7.
  2. Jarvinen, T.L., Sihvonen, R., Englund, M.: Arthroscopy for degenerative knee–a difficult habit to break? Acta Orthop, 2014. 85(3): p. 215-7.
  3. Choudhry, N.K., Fletcher, R.H., Soumerai, S.B.: Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med, 2005. 142(4): p. 260-73.
  4. Hoffmann, T.C. , Del Mar, C.: Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests: A Systematic Review. JAMA Intern Med, 2014.
  5. Vitale, M.A., Arons, R.R., Hurwitz, S., Ahmad, C.S., Levine, W.N.: The rising incidence of acromioplasty. J Bone Joint Surg Am, 2010. 92(9): p. 1842-50.
  6. Yu, E., Cil, A., Harmsen, W.S., Schleck, C., Sperling, J.W., et al.: Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study. Arthroscopy, 2010. 26(9 Suppl): p. S142-7.
  7. Diercks, R., Bron, C., Dorrestijn, O., Meskers, C., Naber, R., et al.: Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop, 2014. 85(3): p. 314-22.
  8. Paloneva, J., Lepola, V., Karppinen, J., Ylinen, J., Aarimaa, V., et al.: Declining incidence of acromioplasty in Finland. Acta Orthop, 2014: p. 1-5.
  9. Judge, A., Murphy, R.J., Maxwell, R., Arden, N.K., Carr, A.J.: Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J, 2014. 96-B(1): p. 70-4.
  10. Hegedus, E.J., Goode, A.P., Cook, C.E., Michener, L., Myer, C.A., et al.: Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med, 2012. 46(14): p. 964-78.
  11. Rio, E., Moseley, L., Purdam, C., Samiric, T., Kidgell, D., et al.: The pain of tendinopathy: physiological or pathophysiological? Sports Med, 2014. 44(1): p. 9-23.
  12. Littlewood, C., Malliaras, P., Bateman, M., Stace, R., May, S., et al.: The central nervous system–an additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise. Man Ther, 2013. 18(6): p. 468-72.
  13. M, N.S., Lluch, E., Nijs, J., Struyf, F., Kangasperko, M.: The role of central sensitization in shoulder pain: A systematic literature review. Semin Arthritis Rheum, 2014.
  14. Saltychev, M., Aarimaa, V., Virolainen, P., Laimi, K.: Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Disabil Rehabil, 2014.
  15. Henkus, H.E., de Witte, P.B., Nelissen, R.G., Brand, R., van Arkel, E.R.: Bursectomy compared with acromioplasty in the management of subacromial impingement syndrome: a prospective randomised study. J Bone Joint Surg Br, 2009. 91(4): p. 504-10.
  16. Hockman, D.E., Lucas, G.L., Roth, C.A.: Role of the coracoacromial ligament as restraint after shoulder hemiarthroplasty. Clin Orthop Relat Res, 2004(419): p. 80-2.
  17. Lewis, J.S.: Subacromial impingement syndrome: a musculoskeletal condition or a clinical illusion? Physical Therapy Reviews, 2011. 16(5): p. 388-398.
  18. Sihvonen, R., Paavola, M., Malmivaara, A., Itala, A., Joukainen, A., et al.: Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. N Engl J Med, 2013. 369(26): p. 2515-24.
  19. Moseley, J.B., O’Malley, K., Petersen, N.J., Menke, T.J., Brody, B.A., et al.: A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med, 2002. 347(2): p. 81-8.
  20. Wartolowska, K., Judge, A., Hopewell, S., Collins, G.S., Dean, B.J., et al.: Use of placebo controls in the evaluation of surgery: systematic review. BMJ, 2014. 348: p. g3253.
  21. Aspenberg, P.: Mythbusting in Orthopedics challenges our desire for meaning. Acta Orthop, 2014: p. 1.
  22. Beard, D.J., Carr, A.J., Rees, J.D., Cook, J., Tracey, I., et al.: Can Shoulder Arthroscopy Work (CSAW). https://clinicaltrials.gov/ct2/show/NCT01623011, 2015.
  23. Hallal, P.C. , Lee, I.M.: Prescription of physical activity: an undervalued intervention. The Lancet, 2013. 381(9864): p. 356-357.

 

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  • Kiropraktor Thomas Lauvsnes

    Awesome post. Truly awesome.

  • Rick Howell

    Indeed, this topic is now sufficiently referenced to be delivered to the mainstream public.

  • Michael Poling

    Very nice. The one thing I would say about your intro, though, is thatEBM is a combination of THREE things, research (which can just be observation over time….it doesn’t HAVE to be a RCT), clinical experience and THOUGHT. In my experience (yep, I just said that:)), research AND clinical experience often lack the last component. And much of what we do that is successful with patients involves thought first and foremost, followed closely by observation style research, followed by clinical experience. I put experience last not because it is less important, but because it is less reliable.

  • Great post and great conclusion. We definitely need to raise our game without falling into the surgical trap (or trick?) of quick and complete cure claims. We, as non-operative MSK practitioners, need brand our trade better, but we are probably too reluctant to be salesmen… The other issue is that insurance companies (and of course this will vary from country to country) do not value long rehabilitation processes as much as a much more expensive surgery. Rehabilitation (through physiotherapy in Switzerland) may be too cheap to be of any value, and recent attempts from the physiotherapy association to raise reimbursement for their work were swept away with disdain by most insurance companies. If it is chepap, it doesn’t shine and is not “sexy”.

    Same goes for “exercise” as a health prevention and promotion tool, it definitely needs the help of advertising gurus!

  • Same problem elsewhere; out in Asia insurance companies reimburse based on ‘treatments’ provided. The issue this makes is; physiotherapists & Dr’s in places like China & Korea want to provide ‘modalities’ aka US, Laser, and on & on with EPA’s, Manipulations, Soft-tissue, PRP, Cortisone, drugs++ = because each injection, each electrical modality = a ‘treatment’ modality. But exercise does not. So sports docs & physio’s alike are doing very little active rehab (despite being what is needed), because they don’t make money for it. Yet then i see many my athletes, in China for example, where 6-7 years of chronic reoccurring knee or back pain, one would surely be raising concerns after 1 year of not improving?. Basic of any analysis or reasoning, one would think.

    Another sad point arises, the un-informed (medically) coaches & athletes, have a belief that the more advanced something is (eg. EPA technology, PRP ect..) aka the “sexy treatments” as Jorgen said so well = the more advanced/best management the treatment is. Which is NOT always true.

    If i was insurance company, i be thinking, exercise+rehab = long-term gains = my client is healthier = less likely to get injured = less money for me in the long-term. Ok that be right, if they had some form of ‘risk analysis’ business model they should be thinking like that. Yet they are not in most the world. My home nation of Australia, is probably done great moves ahead in this instant however. Insurance companies back home in Australia, saw it a long time ago, health promotion and reimbursing ‘proven’ injury prevention programs ran by physios. The mining & industrial sector also jumped on it (A rapidly growing sector for physios in Australia now), realizing they could save millions in worker compensation & injury/work insurances payments if they hired fitness trainers & physiotherapists to set up injury prevention, worker conditioning & worker rehabilitation programs for their companies.

    Ok i am biased towards Australia, as i am Australian. As still a lot of not optimal. For example still things like PRP injections & surgery are popular in Australia. Thanks to media focus on what is ‘sexy’ as said so well. Someone doing some “Top athlete xx does some single leg squats in rehab” doesn’t sound as sexy for a newspaper article as “Top athlete xxx recieves new advanced stem cell injection”.