SGEM#365: Stop! It’s Not Always Hammer Time

Date: April 16th, 2022

Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021

Guest Skeptic: Dr. Matt Schmitz, Pediatric Orthopedics, Adolescent Sports Medicine and Young Adult Hip Preservation Surgeon at San Antonio Military Medical Center in Texas.

Disclaimer: The views and opinions of this blog and podcast do not represent the United States Government or the US Military.

Case: A 55-year-old man comes into the emergency department (ED) for increasing knee pain and decrease in function. He’s had an anterior cruciate ligament (ACL) repair and used to run marathons. However, he is finding it more difficult to even put his socks on. Physical exam shows varus deformity at the knee, decreased range of motion, crepitus, no locking and neurovascularly intact distal. X-rays show severe, tri-compartment arthritis.

Background: Musculoskeletal complaints are one of the most common presentations to emergency departments. Often emergency physicians are assessing, treating, and answering patients question about orthopedic surgical procedures. How good is the evidence for the most common elective procedures?

Before we answer that question, let’s remind everyone that only a small number (2.8%) of interventions published in SRMA and relevant to emergency medicine have unbiased and strong evidence for improved outcomes (SGEM#361).

This is a broader problem in medicine. Tricoci et al. JAMA Feb 2009 looked at the ACC/AHA guidelines from 1984 to 2008. They found 53 guidelines with 7,196 recommendations. Only 11% of recommendations were considered Level A, 39% were Level B and 50% were Level C.

An update was published by Fanaroff et al in JAMA 2019. The level of high-quality evidence had not changed much when looking at the ACC/AHA guidelines from 2008-2018. There were 26 guidelines with 2,930 recommendations. Now Level A recommendations were down to 9%, Level B 50% and Level C 41%.

Time to turn our skeptical eye to the evidence for elective orthopaedic procedures.

Clinical Question: What is the effectiveness of common elective orthopaedic procedures compared with no treatment, placebo, or non-operative care?

Reference: Blom et al. Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence. BMJ 2021

* Population: Meta-analyses of randomised controlled trials

* Exclusions: Network meta-analyses (when pairwise meta-analyses were available), narrative reviews, systematic reviews that did not pool data or do a meta-analysis, and meeting abstracts

* Intervention: Surgery

* Comparison: No treatment, placebo, or non-operative care

* Outcome: Quality and quantity of evidence behind the ten most common elective orthopaedic surgeries and comparisons with the strength of recommendations in relevant national clinical guidelines.

Authors’ 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.”

Quality Checklist for Therapeutic Systematic Reviews:

* The clinical question is sensible and answerable.  Yes/Unsure

* The search for studies was detailed and exhaustive. Yes