Caution, common sense needed when introducing techniques and technologies

ESSKA presenter urges orthopaedic surgeons to more clearly define the indications for surgery.

Issue: Issue 4 2006

INNSBRUCK, Austria — Orthopaedic surgeons must define indications for surgery even though long-term evidence on outcomes is sometimes lacking.

Surgeons must also adopt new techniques and technologies judiciously, Robert Marx, MD, MSc, FRCSC, of the Hospital for Special Surgery, New York, said at the 12th ESSKA Congress, here.

“We haven’t had sufficient evidence always, but sometimes,” Marx said. “In some cases, yes, but in others we don’t have evidence. The [evidence] is not always [clearly defined], but we still have patients and we still have to make decisions for them, evidence or not.”

Indications crucial

Marx cited a 1999 American Academy of Orthopaedic Surgeons (AAOS) survey showing widely varied return to sport intervals and brace use. He also cited a 1999 Journal of Bone and Joint Surgery paper reporting wide geographic variations in shoulder procedures. In that study, the authors called for more clinical research to find the variations’ causes and study appropriate indications.

“So, why is there such variability in clinical decision-making?” Marx said. “It’s often been said, ‘A good surgeon is sometimes wrong but never in doubt.’ When it comes to elective surgery, that [attitude] is not well-tolerated, certainly not by patients … and it’s not tolerated well by physicians.”

Training, experience and/or literature often drive care decisions, he said, but training can vary widely among centers and among countries. Likewise, the quality of research and trials can also differ and can sometime be inconclusive, Marx added.

“So, how do you decide [what patients should get] while recommending elective surgery?” he said. “There’s a lack of evidence for who needs surgery in some cases, and there is a lot of controversy and significant resources involved as well. There are also the patients. Insurance companies in the United States want to control costs and are limiting access to medical care. So, I think it’s up to us to define the indications for surgery.”

“New isn’t always better”

Many newer techniques, like double-bundle ACL reconstruction, have advantages, but again, little long-term data, he said. Also, the procedures’ indications and “learning curves” vary — and some surgeons adopt new techniques more readily than others.

“Who is responsible for disseminating knowledge that a technique is bad and has problems associated with it?” Marx said. “Most papers report good results; few report bad or terrible results. In general, some surgeons are more rapid adopters than others, but we can’t always wait for the randomized trial. If we did, there would no arthroplasty or arthroscopy.”

Marx cited a “catastrophic” minimally invasive hip arthroplasty in which the surgeon adopted the new technique for fear of losing patients. “That’s not a good rationale for adopting technology,” Marx said.

He added, “I think we must try to make the best decisions possible for and with our patients. Sufficient evidence is not always available or possible. And further research is indicated in this area, in my opinion. Caution and common sense are required when implementing new techniques and technologies. We need data on this technology rather than rapid implementation by everyone. New isn’t always better.”

Marx is orthopaedic director at the Sports Medicine Institute for Young Athletes and director at the Foster Center for Clinical Outcome Research, Hospital for Special Surgery; and associate professor of orthopaedic surgery and public health at Weill Medical College, Cornell University, Ithaca, U.S.A.

For more information:
Marx R. Clinical decision-making in sports traumatology and evidence-based medicine (surgery). Highlight lecture. Presented at the 12th ESSKA Congress and 5th World Congress on Sports Trauma. May 24-27, 2006. Innsbruck, Austria.
Vitale MD, MPH, Krant J, MD, Gelijns A, et al. Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair. J Bone Joint Surg Am. 1999;81:763-772.