Orthopaedic conditions impact a large segment of the population in Australia, affecting more people than any other national health priority area1. A staggering 30% of Australians (6.9 million people) reported having arthritis and other musculoskeletal conditions in 2014-15 and this number is expected to rise2 .
Chronic orthopaedic conditions such as osteoarthritis and back pain affect the musculoskeletal system, most commonly the bones or joints. These conditions can cause severe pain and dysfunction, making normal daily activities difficult. Orthopaedic conditions cut across demographic boundaries: young children can suffer from arthritis, while osteoporosis is more common among the elderly. Of the total number of Australians affected by an orthopaedic condition, 58.4% are prime working age (25 to 64 years)3.
As orthopaedic conditions become increasingly prevalent, there has been a growing trend toward treatment with surgical procedures that have questionable benefits. In some cases patients are undergoing unnecessary operations that leave them no better, or worse off, than before.
For example, while it is estimated that one in four knee or hip replacement surgeries for people with osteoarthritis are unnecessary4, these procedures continue to be performed at an alarming pace. And there’s no sign of this abating: the incidence of total knee replacements and total hip replacements in Australia for osteoarthritis is estimated to rise by 276% and 208%, respectively, by 20305. According to a professor at the University of New South Wales, about half of orthopaedic surgical procedures have no scientific evidence from randomised trials proving they work any better than non-operative treatment6.
Sports medicine physician Dr. John Mayhew maintains the source of the problem is often surgeons who decide to operate on patients based strictly on the findings from an X-ray or MRI.
“The X-ray or scan makes the diagnosis, but the decision for surgery needs to be based on a patient’s symptoms,” says Dr. Mayhew, who is also a member of the Best Doctors database of expert physicians. “Are we actually going to improve their quality of life? Not just make the X-ray look better.”
Dr. Mayhew cites the use of arthroscopic surgery (a procedure that involves inserting a small camera inside the joint) to treat osteoarthritis of the knee as an example of a procedure that is overused, sometimes with negative consequences.
“It’s been shown know that arthroscopy of the knee for osteoarthritis is a bad operation and it actually makes people worse,” he says, adding that he treats his own patients based on their symptoms, not on what the X-ray shows.
Dr. Mayhew contends physicians should first look at non-surgical ways of treating an orthopaedic condition. This is especially important considering surgery comes with several risks, including pulmonary embolism, deep vein thrombosis, and post-operative infections. Surgical intervention also tends to involve a longer recovery period, in turn impacting the duration of an absence from work. “We should be using physical therapy, weight loss, bariatric surgery and injection type therapies rather than orthopaedic surgery at times,” says Dr. Mayhew.
According to General Practitioner Dr. Amandeep Hansra, another problem is patients who expect surgical intervention to treat their condition after being referred to an orthopaedic surgeon.
“Waiting several weeks to see a surgeon only to be told that you need to do physio or look at conservative treatment methods is often not what patients expect or want to hear,” says Dr. Hansra. “Patients believe they need surgery to relieve their pain – it is incumbent upon physicians to think of how we can stop this cycle and reduce the number of unnecessary surgeries.”
This is evidenced by the experience of Toby Hemming, who had suffered from back pain for several years. Toby’s GP referred him to a surgeon who recommended surgical intervention. Toby reached out to Best Doctors for a second opinion and an expert from Best Doctors’ global database reviewed his case. The expert concluded that surgery was unlikely to result in any improvement and instead suggested physiotherapy, maintaining it would offer better long-term results.
“Despite having it laid out for me in a report from a leading expert, I still found it hard to take my mind away from surgery being the right answer,” said Toby. “I had pain and it felt like surgery was the only way to stop it, especially after a surgeon told me about this option.”
Dr. Mayhew notes that not only can several orthopaedic conditions be successfully treated without surgical intervention, this often leads to better patient outcomes. One example is Achilles tendon rupture. “The available evidence now says that non-surgical treatment of that is as good, if not better, than surgical treatment,” says Dr. Mayhew. Other conditions that may fare better with non-surgical treatment include medial ligament tears of the knee, major hamstring tears, and osteoarthritis of the hip, which Dr. Mayhew says is often unnecessarily treated with arthroscopic surgery.
Back pain is a widespread health concern – 3.7 million Australians live with chronic back problems7. While patients may be tempted to seek a surgical solution, Dr. Mayhew says that spinal fusion (where a number of vertebrae at different levels are fused together) is an overdone procedure that doesn’t normally help resolve lumbar spine pain.
“For people with non-specific back pain to fuse their discs because they look degenerate on an X-ray is a very poor operation to do, with a very poor outcome,” he says.
In many cases patients would be better served by first seeing another specialist rather than immediately seeing a surgeon.
“People go from a sore knee straight to seeing an orthopaedic surgeon and he’s really only got one treatment he can offer you,” says Dr. Mayhew. He adds that a physical therapist or other specialist can help a patient explore non-surgical treatment options that may successfully resolve their issue.
Getting an accurate diagnosis and the right treatment for a chronic orthopaedic condition can make a huge difference in reducing pain, restoring mobility and improving a person’s quality of life. This is illustrated by the case of a young woman whose treating physician had misdiagnosed her with scoliosis and recommended spinal surgery. After her case was reviewed by a leading Best Doctors orthopaedic surgeon, the woman was given a different diagnosis. Not only did she not have scoliosis, the expert advised against spinal surgery and instead recommended pain relief medication along with further testing.
This reinforces the importance of getting the right support and guidance when making a treatment decision for an orthopaedic condition. This is especially true when it comes to surgery, with its attendant risks and the possibility of non-surgical alternatives that might be just as – if not more – effective. The numbers attest to the importance of being cautious before proceeding with surgery: a randomised assessment of 150 Best Doctors case reviews found that in 40% of cases where surgery was considered or scheduled, a non-surgical treatment would result in a better outcome for the patient.
“Getting the appropriate advice is paramount,” says Dr. Mayhew. “An independent, non-biased opinion on what is best managed is very useful.”
In the words of Best Doctors’ members:
“We are greatly satisfied with the personalized treatment and attention we received as well as with the rapid response we received.” -- Father of Daniel, a 12-year-old boy whose misdiagnosis of scoliosis and incorrect treatment plan were corrected by a Best Doctors expert, preventing physical and potential psychological damage.
“My quality of life has really improved since I received the expert’s report and recommendations.” -- Ian, whose diagnosis and treatment plan for a chronic ankle condition were modified after review by a Best Doctors expert.
About Dr. John Mayhew, leading sports medicine doctor
BSc, MBChB, DipObst, DipSpMed(Hon), DOccMed, FRNZCGP
Based in Auckland, New Zealand, Dr. John Mayhew is a highly respected sports team doctor and a member of the Best Doctors database of expert physicians. He is an alumnus of the Faculty of Medical and Health Sciences (MBChB in 1979) and has a Diploma in Occupational Medicine. He was the All Blacks Team Doctor for 15 years – a career that spanned 131 test matches and over 200 games. His experience is recounted in the book Doc Mayhew: Rugby's Medicine Man. John runs a sports medicine practice at Auckland's Millennium Institute and is also the current team doctor for the New Zealand Warriors and Clinical Director for the financial services company Sovereign Assurance Company Limited.
• Projections suggest the prevalence of osteoarthritis in Australia could increase by 41% in the coming decades.
• 1 in 11 Australians (9%) reported osteoarthritis in 2014-15 (approx. 2.1 million people), and 1 in 5 Australians over age 45 have osteoarthritis.
• There’s been a 36% rise in the rate of total knee replacements for osteoarthritis from 2005-06 to 2015-16.
• 12% of all cases handled by Best Doctors Australia are for patients with orthopaedic conditions, making this the most frequently treated condition (along with neurological conditions)
• 27% of Best Doctors members had their treatment modified after using Best Doctors’ Expert Medical Opinion service
• 10% of Best Doctors members had their diagnosis changed after using Best Doctors’ Expert Medical Opinion service
[1] Musculoskeletal Australia, https://www.msk.org.au/wp-content/uploads/2018/07/APWS_Infographic.pdf
[2] “Chronic musculoskeletal conditions,” Australian Institute of Health and Welfare, https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-musculoskeletal-conditions/overview
[3] Musculoskeletal Australia, https://www.msk.org.au/wp-content/uploads/2018/07/APWS_Infographic.pdf
[4] “1 in 4 joint replacement surgeries unnecessary.” 2018. Report published by MOVE, a national consumer-based organisation for muscle, bone and joint health; https://www.hospitalhealth.com.au/content/clinical-services/news/1-in-4-joint-replacement-surgeries-unnecessary-784030259#axzz5iuWqjI7b
[5] Aubusson, Kate. 2017. “Same surgery, different surgeon: huge variations in out-of-pocket costs for orthopaedic operations,” The Sydney Morning Herald, https://www.smh.com.au/healthcare/same-surgery-different-surgeon-huge-variations-in-outofpocket-costs-for-orthopaedic-operations-20170814-gxvppb.html
[6] Medew, Julia. 2017. “Many operations ‘more harmful than beneficial’,” Illawarra Mercury, https://www.illawarramercury.com.au/story/4659510/many-operations-more-harmful-than-beneficial/
[7] Musculoskeletal Australia, https://www.msk.org.au/wp-content/uploads/2018/07/Everybody-MOVE.pdf
[8] Tasker, Sarah-Jane. 2018. “Knee and hip replacements ‘not needed by thousands of Aussies’,” The Australian, https://www.theaustralian.com.au/national-affairs/health/knee-and-hip-replacements-not-needed-by-thousands-of-aussies/news-story/a9e1eb137e2c20842581bfe4274a1670
[9] Chronic musculoskeletal conditions,” Australian Institute of Health and Welfare, https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/chronic-musculoskeletal-conditions/overview
[10] ibid.