Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence

Abstract

Objective To determine the clinical effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care and assess the impact on clinical guidelines. Design Umbrella review of meta-analyses of randomised controlled trials or other study designs in the absence of meta-analyses of randomised controlled trials. Data sources Ten of the most common elective orthopaedic procedures—arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement—were studied. Medline, Embase, Cochrane Library, and bibliographies were searched until September 2020. Eligibility criteria for selecting studies Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that compared the clinical effectiveness of any of the 10 orthopaedic procedures with no treatment, placebo, or non-operative care. Data extraction and synthesis Summary data were extracted by two independent investigators, and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check whether recommendations for each procedure reflected the body of evidence. Main outcome measures Quality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of recommendations in relevant national clinical guidelines. Results Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. No randomised controlled trials specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care. Conclusions Although they may be effective overall or in certain subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations. Systematic review registration PROSPERO CRD42018115917.

Arthroscopic Partial Meniscectomy versus Physical Therapy for Degenerative Meniscal Tear: a Systematic Review

“…Our results are in line with the current trend of caution against the use of APM in patients with OA and a recent umbrella review of level 1 evidence for common elective orthopaedic procedures showing that small benefits of APM for degenerative meniscal tears is reported only for patients without OA. 25 However, improvement at an earlier time point by APM may be interpreted differently depending on the patient preferences, which differs according to the health care system and culture. In some societies, lengthy recovery with PT may not be preferred by patients and pose problems with patient compliance.…”

Variations in policies for accessing elective musculoskeletal procedures in the English National Health Service: A documentary analysis

“…This is likely to be the case in this study, given the evolving (or absent) evidence-base for many of the musculoskeletal procedures examined. 25 …”

“…This is likely to be the case in this study, given the evolving (or absent) evidence-base for many of the musculoskeletal procedures examined. 25 The assumption that commissioning policy criteria should be identical also overlooks the possibility that policy wording may be shaped by local resource considerations. There were references to financial considerations in the background sections of some of the policies examined, but it was unclear if these statements reflected overarching commissioning principles, or factors that specifically guided selection/formulation of the policies.…”

Three orthopaedic operations, over 1,000 randomized controlled trials, in over 100,000 patients

“…Finally, although a recent review has highlighted a lack of RCTs comparing surgery with conservative/placebo treatments in orthopaedics, 23 it is clear that a lack of such trials does not equate to a concern that these procedures lack effectiveness. Our series demonstrate that patients continue to benefit from these surgical interventions worldwide.…”