The most common bone and joint (orthopedic) procedures, such as hip replacements and shoulder repair surgeries, are not supported by high quality evidence, mainly due to a lack of trials definitive, suggests an analysis of the data released by the BMJ today.
Yet despite the lack of strong supporting evidence, some of these procedures are still recommended by national guidelines in certain situations, the results show.
Musculoskeletal conditions affect around 1 in 4 UK adults and account for over 25% of all NHS surgeries at a cost of £ 4.76 billion each year.
National clinical guidelines recommend a range of interventions, but there is concern that many surgical procedures do not have readily available or high-quality evidence on their clinical effectiveness to support their use.
To further explore this, a team of British researchers used data from previous analyzes of randomized controlled trials and other studies to compare the clinical effectiveness of the 10 most common orthopedic procedures without treatment, placebo or non-operative care.
They then compared the results of each procedure with national guidelines to check whether the recommendations reflected all of the available evidence.
Interventions included repair of knee cartilage (meniscus), shoulder rotator cuff repair, carpal tunnel decompression surgery, and total hip and knee replacements.
Researchers found evidence from randomized controlled trials supporting the superiority of carpal tunnel decompression and total knee replacement surgery compared to non-operative care.
However, no randomized controlled trial has specifically compared total hip replacement or meniscal repair with non-operative care. And trial evidence for the other six procedures showed no benefit over non-operative care.
They also found that although seven of the procedures were recommended for use by national guidelines, a high-quality body of evidence to definitely support these recommendations does not exist for most of them.
This, they say, is mainly due to a lack of randomized controlled trials comparing the procedure with non-operative care.
They point out that this lack of evidence from trials does not mean that interventions are ineffective, but without evidence from randomized controlled trials, it is extremely difficult to determine the true effect of treatment.
This review has some limitations that may have influenced the results, such as the inclusion of different study designs of varying quality. But the researchers point out that this is a comprehensive analysis of well-known databases and guidelines, and the recommendations can be applied to other healthcare settings.
As such, they say there is an urgent need to prioritize research, especially for procedures with a limited evidence base, and for definitive designs of randomized controlled trials to assess their clinical efficacy.
“This will improve patient care, reduce health care costs, make more efficient use of our resources and increase society’s confidence in orthopedic procedures,” they write.
In addition, their results support the idea that with 10 million patients in England awaiting surgery, “now is the perfect time to invest in large testing platforms”.
Blom, AW, et al. (2021) Common elective orthopedic procedures and their clinical efficacy: general review of the level 1 evidence. BMJ. doi.org/10.1136/bmj.n1511.