Surgical vs Non-Surgical Procedures – The “Great Debate” of 2022

FIGUR8’s clinical experts discuss the findings of a recent BMJ study, not the size and scope of the universe as Shapley and Curtis did in 1920.

A recent New York Times article summarized a study published in the British Medical Journal that examined the effectiveness of common orthopedic surgical procedures. Their findings outlined that for many common procedures, non-surgical options like diet, exercise and physical therapy are just as effective. The FIGUR8 communications team sat down with our Chief Medical Officer, Dr. Michael Oberlander who is an orthopedic surgeon, and our Business Development Manager, Josh Williams, a physical therapist himself, to discuss the implications of these findings.

FIGUR8: Thank you both for taking the time to speak with us today. Someone reading the article in the New York Times, at first glance, may think that surgery should never be an option, though this is probably not true. Dr. Oberlander, I’ll start with you, when is surgery the right choice for someone?

Dr. Oberlander: Generally speaking, surgery is indicated for MSK conditions when conservative treatment has failed and a valid procedure will result in a successful outcome in the majority of patients. In a small percentage of cases such as specific fractures, major soft tissue injuries, and certain tumors, surgery is primarily indicated. For the other 90% of cases, conservative care is the primary treatment of choice.

FIGUR8: That’s very helpful to know. So, for 90% of cases conservative treatment should be the first choice. The article mentions exercise, diet and physical therapy as effective options for many bone and joint issues. Are these the most common options? What other alternatives are available to people if surgery is not appropriate?

Josh Williams: Yes, these are very common management strategies that a primary care provider might prescribe to address a musculoskeletal (MSK) issue. I would add education as an additional tool to help people manage their concerns. Sometimes when we are in pain, it is accompanied with feelings of anxiety and uncertainty. Working with a health professional to understand the underlying condition and the steps that you can take to reduce pain and improve function can be a very empowering and effective approach. There are also other non-surgical options available.

Dr. Oberlander: Yes, for many MSK conditions, both acute and chronic, physical therapy, home exercise +/- a period of relative rest are often the mainstays of conservative treatment. Additionally, anti-inflammatory medication and other over-the-counter medications like Tylenol may be helpful to control the pain. Steroid injections, hyaluronic acid or biologics such as PRP (Platelet Rich Plasma) and lipogems may also be helpful.

Diet is clearly beneficial for certain conditions that involve the weight bearing joints of the lower extremity, like the hips and knees as well as the spine, and that is because these joints experience exponential stress with certain activities. Patients with a high body mass index (BMI) can experience a significant reduction in their pain levels and an improvement in function in these locations with simple weight loss. For example, the knee experiences 3-7x the weight of the body during activities like stair climbing, squatting, kneeling or even walking. That means a loss of 10 lbs is like losing 30-70 lbs. on your knees with those activities. Bracing of a joint can also be beneficial in certain situations to support the joint and allow for healing during recovery.

It’s best to speak to your medical provider about these and other options if you are experiencing pain and a loss of function related to a MSK injury or disorder.

FIGUR8: So with all of these non-surgical options available and with the evidence for surgery lacking, what are the factors that lead to the high volumes of procedures that appear to offer little value when compared to non-surgical treatment?

Dr. Oberlander: First off, there should be clear evidence that surgery is beneficial in a significant percentage of patients prior to recommending this treatment option to a patient. The main issue in my opinion is that a lot of patients, as well as some surgeons, prefer a quick fix if one is available.

This should be considered only after a detailed discussion of the risks, alternatives and possible complications of both conservative and operative treatment. Unfortunately, there is often insufficient time for this educational discussion. The end result may be that the patient is unable to fully participate in the shared decision making process.

The US health system additionally favors reimbursement for surgical procedures over medical management, which at times may also play into the decision making process.

Josh Williams: Those are both good points Dr. Oberlander, and I agree. Often, reimbursement dictates clinical care and a recent example of this was the explosion of virtual care as a result of COVID-19. For years, there was evidence of the benefits of virtual care but it wasn’t until the introduction of a billing framework by Medicare and other regulatory bodies that this became a consistent part of care delivery.

And on the topic of quick fixes, diet, exercise and physical therapy can be burdensome and the results are not always quick. Many MSK injuries take weeks or months to fully heal and require a concentrated effort on the part of the injured individual to attend their PT appointments, do their home exercises consistently and often work through pain.

FIGUR8: The BMJ study was an analysis of only randomized, controlled trials (RCT) but there are other ways to assess the effectiveness of medical treatments like case studies, observational analysis and expert opinions. Are randomized, controlled trials the only way that we should be evaluating the effectiveness of orthopedic surgical procedures?

Dr. Oberlander: Randomized controlled trials are one of the best ways to measure the value of medical and surgical treatment but by no means are they without inherent bias as well or the only means of measuring such. In many situations, a RCT with a blinded control group is unethical or impractical for humanitarian or financial reasons. They are also logistically difficult to set up and complete, requiring significant monetary support and human resources.

Josh Williams: RCTs are often held up as the gold standard in research and my training as a physical therapist happened at a time when evidence-based medicine was the predominant theoretical construct. Since then I think we have learned that there are other ways to evaluate medical interventions. Recently with COVID, we have seen real-world evidence inform policy decisions around public health measures or vaccination schedules. One of the drawbacks with RCTs is the ability to recreate the conditions in the real world. Oftentimes people don’t fit the characteristics of the sample size, or can’t fully commit to the intensity of a treatment regime because of other things going on in their lives like work or family commitments. These things are not often considered in the design of a large-scale trial.

FIGUR8: So moving forward what measurements or methodologies do you think we should be using to determine if a surgical or non-surgical treatment was beneficial?

Dr. Oberlander: Utilizing established validated peer reviewed patient reported outcome measures as well as functional outcome measures are the most effective ways to quantitatively and qualitatively assess the beneficial effects of treatment.

Josh Williams: I think that there is also tremendous value in highly accurate and reproducible data solutions like the FIGUR8 platform. This type of applied science will become the standard of care for measurement and data for musculoskeletal conditions. Because the platform is accessible at the point-of-care and deployed in a real-world environment, many of the shortcomings of RCTs are mitigated. The extremely rich data sets, when compiled at scale, will yield tremendous insights and uncover the effectiveness of various treatment approaches to inform a more precise approach to individualized patient care.

Disclaimer: The opinions contained within this interview are that of the participants and should not be considered medical advice. If you are managing a musculoskeletal condition, please speak to your physician or primary care provider about the options available to you.