Thu Mar 24

3 orthopaedic surgeries that might be doing patients (and their pockets) more harm than good

Written by: Giovanni E Ferreira, NHMRC Emerging Leader Research Fellow, University of Sydney

Orthopaedic surgery (surgery for problems related to bones, joints, tendons and ligaments) is the third most common reason ^[1] Australians go under the knife.

Last year, more than 100,000 orthopaedic surgeries were performed in Australian public hospitals. As most orthopaedic surgeries are performed in private hospitals, the real number is much higher (and unfortunately unknown).

But what most people don’t know is that many common orthopaedic surgeries are not better for reducing pain ^[2] than non-surgical alternatives that are both cheaper and safer, such as exercise programs. Some surgeries provide the same result as a placebo surgery, where the surgeon only conducts a joint examination, rather than performing the real surgery.

And contrary to popular opinions, placebos are not actually very powerful ^[3], so real surgery that isn’t better than a placebo should not be recommended.

In this article we discuss the evidence behind three commonly performed orthopaedic surgeries for back, knee and shoulder pain that might be doing patients (and their pockets) more harm than good.

Spinal fusion for back pain

Spinal fusion is the riskiest type of surgery for back pain and the most expensive ^[5] orthopaedic procedure performed in Australia. Depending on your health insurance arrangements, the total cost of the surgery can be around A$58,000 and out-of-pocket costs might be close to A$10,000 ^[6].

It involves permanently fusing two or more vertebrae together to stop them moving on each other, typically using metal implants and bone from other areas of the body.

It was originally conceived to treat broken spinal bones and some spine deformities, such as severe scoliosis (abnormal curvature of the spine). Surgeons’ justification for using this surgery has expanded over time and it is now the most common surgery to treat everyday back pain that isn’t caused by a serious issue like a fracture or infection.

This is despite evidence that spinal fusion is not more effective ^[7] than non-surgical treatments (such as an exercise program) and often results in complications. About one in six patients ^[8] experience a serious complication, such as an infection, blood clot, nerve injury, or heart failure. In New South Wales ^[9], only one in five workers who have spinal fusion return to work after two years and one in five have another spine surgery within two years.

Man grabs his lower back as though in pain

Spinal fusion is not more effective than non-surgical treatments like exercise programs, and often results in complications. Shutterstock

Arthroscopy for knee and shoulder pain

Arthroscopy is a type of keyhole surgery commonly used to treat knee osteoarthritis and shoulder pain. The surgery is used to remove or repair damaged pieces of bone or cartilage that are thought to cause pain.

Thousands of knee arthroscopies are performed every year. In 2013, more than 33,000 knee arthroscopies ^[11] were performed in Australian hospitals. Since then, this number has reduced by around 40%^[12].

Australian data shows the number of shoulder arthroscopies increased nearly 50% from 2000 to 2009. Since then, numbers have remained stable, at about 6,500 surgeries per year from 2009 until 2021 ^[13].

The cost of these surgeries is substantial. Typical out-of-pocket costs for patients with private health insurance is A$400 ^[14] and A$500 ^[15] for knee and shoulder arthroscopy, respectively. Sometimes, out-of-pocket costs can be as high as A$1,900 to A$2,400, respectively.

High-quality research shows arthroscopy to treat osteoarthritis ^[16], wear and tear of the meniscus in the knee ^[17], and to remove inflamed and thickened bone and tissue in the shoulder ^[18] is no better than placebo surgery.

Even though these surgeries are minimally invasive, they still result in substantial inconveniences ^[19]. For example, it may take up to six weeks after shoulder arthroscopy for patients to perform simple daily activities like reaching above the head or driving, and up to three months to return to heavy work or sport.

Surgeon drills into a knee in operating theatre

Knee and shoulder arthroscopies for common complaints have been found to be no more effective than placebo – which is to say – not very effective. Shutterstock

So what are the alternatives?

Knowing what treatment options are available to you, and their benefits, harms, and costs is important to ensure you make the best choice for yourself. Luckily, there are tools available to help you. We’ve developed decision aids to help people with shoulder pain ^[21] decide whether to have surgery or not (the tool is available here ^[22]).

Our research ^[23] has shown that people with back pain who seek a second opinion can avoid unnecessary spine surgery, including spinal fusion.

And avoid Dr Google. Information on the internet usually oversells the benefits and downplays the harms of common surgeries such as spinal fusion ^[24], shoulder arthroscopy ^[25], and surgery for a torn ACL ^[26] (ligament in the knee). You will find misleading information even on websites from trustworthy sources ^[27] such as government and university websites.

Before making a decision, make sure you ask your doctor the following questions:

am I more likely to get better with surgery than without it?
what happens if I choose not to have surgery?
what are the risks of having this surgery? Both during surgery (for example, anaesthesia) and after surgery (for example, complications)
have I received enough information about the benefits and harms of having surgery compared to other treatments (including doing nothing)?

Sometimes surgery is recommended because non-surgical treatment has not worked. Unfortunately, the failure of non-surgical treatment does not make the ineffective surgery any more effective. It still doesn’t work any more than not operating.

The available evidence tells us that the risks and inconveniences of the three surgeries discussed here do not outweigh the potential benefits.