Four orthopedic surgeries no better than placebo

PainSci summary of Louw 2016?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided at the bottom of the page, as often as possible. ★★★★☆?4-star ratings are for bigger/better studies and reviews published in more prestigious journals, with only quibbles. Ratings are a highly subjective opinion, and subject to revision at any time. If you think this paper has been incorrectly rated, please let me know.

This review of a half dozen good quality tests of four popular orthopedic (“carpentry”) surgeries found that none of them were more effective than a placebo. It’s an eyebrow-raiser that Louw et al could find only six good (controlled) trials of orthopedic surgeries, and all of them were bad news.

Surgeries have always been surprisingly based on tradition, authority, and educated guessing rather than good scientific trials; as they are tested properly, compared to a placebo (a sham surgery), many are failing the test. This review introduction is excellent, and does a great job of explaining the problem. As of 2016, this is the best academic citation to support the claim that “sham surgery has shown to be just as effective as actual surgery in reducing pain and disability.” The need for placebo-controlled trials of surgeries (and the damning results) is explored in much greater detail — and more readably — in the excellent book, Surgery: The ultimate placebo, by Ian Harris.

The surgeries that failed their tests were:

• vertebroplasty for osteoporotic compression fractures (stabilizing crushed verebtrae)
• intradiscal electrothermal therapy (burninating nerve fibres)
• arthroscopic debridement for osteoarthritis (“polishing” rough arthritic joint surfaces)
• open debridement of common extensor tendons for tennis elbow (scraping the tendon)

~ Paul Ingraham

original abstract†Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

related content

• Surgery: The ultimate placebo (book), by Ian Harris (book review).
• “The Right to Know That an Operation Is ‘Next to Useless’,” Gina Kolata, www.nytimes.com.
• “The sexy scalpel: unnecessary shoulder surgery on the rise,” Jørgen Jevne, Blogs.BMJ.com.
• “Use of placebo controls in the evaluation of surgery: systematic review,” Karolina Wartolowska, Andrew Judge, Sally Hopewell, Gary S Collins, Benjamin J F Dean, Ines Rombach, David Brindley, Julian Savulescu, David J Beard, and Andrew J Carr, British Medical Journal, 2014.
• “The evidence on surgical interventions for low back disorders, an overview of systematic reviews,” Wilco C H Jacobs, Sidney M Rubinstein, Paul C Willems, Wouter A Moojen, Ferran Pellisé, Cumhur F Oner, Wilco C Peul, and Maurits W van Tulder, European Spine Journal, 2013.
• “Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms,” J B Thorlund, C B Juhl, E M Roos, and L S Lohmander, British Medical Journal, 2015.
• “To what extent are surgery and invasive procedures effective beyond a placebo response? A systematic review with meta-analysis of randomised, sham controlled trials,” Wayne B Jonas, Cindy Crawford, Luana Colloca, Ted J Kaptchuk, Bruce Moseley, Franklin G Miller, Levente Kriston, Klaus Linde, and Karin Meissner, BMJ Open, 2015.
• “A controlled trial of arthroscopic surgery for osteoarthritis of the knee,” JB Moseley, K O’Malley, NJ Petersen, and others, New England Journal of Medicine, 2002.
• “Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline,” Reed A C Siemieniuk, Ian A Harris, Thomas Agoritsas, Rudolf W Poolman, Romina Brignardello-Petersen, Stijn Van de Velde, Rachelle Buchbinder, Martin Englund, Lyubov Lytvyn, Casey Quinlan, Lise Helsingen, Gunnar Knutsen, Nina Rydland Olsen, Helen Macdonald, Louise Hailey, Hazel M Wilson, Anne Lydiatt, and Annette Kristiansen, British Medical Journal, 2017.

These eighteen articles on PainScience.com cite Louw 2016 as a source:

• PS A Guide to Sciatica Treatment for Patients — A guide to buttock and leg pain (which may or may not involve the sciatic nerve)
• PS Save Yourself from IT Band Syndrome! — All your treatment options for Iliotibial Band Syndrome reviewed in great detail, with clear explanations of recent scientific research supporting every key point
• PS Save Yourself from Low Back Pain! — Low back pain myths debunked and all your treatment options reviewed
• PS Save Yourself from Patellofemoral Pain Syndrome! — Patellofemoral pain syndrome (aka runner’s knee) explained and discussed in great detail, including every imaginable self-treatment option and all the available scientific evidence
• PS Save Yourself from Plantar Fasciitis! — Plantar fasciitis explained in great detail, including every possible treatment option, and all supported by recent scientific research
• PS Save Yourself from Neck Pain! — A complete guide to chronic neck pain and the disturbing sensation of a “crick”
• PS Alternative Medicine’s Choice: Alternative to What? — Alternative to what? To cold and impersonal medicine? Or to science and reason?
• PS A Historical Perspective On Aches ‘n’ Pains — We are living in a golden age of pain science and musculoskeletal medicine … sorta
• PS Should You Get A Lube Job for Your Arthritic Knee? — Reviewing the science of injecting artificial synovial fluid, especially for patellofemoral pain
• PS Do Nerve Blocks Work for Neck Pain and Low Back Pain? — Analysis of the science of stopping the pain of facet joint syndrome with nerve blocks, joint injections, and nerve ablation
• PS Repetitive Strain Injuries Tutorial — Five surprising and important facts about repetitive strain injuries like carpal tunnel syndrome, tendinitis, or iliotibial band syndrome
• PS Spinal Fracture Bracing — My wife’s terrible accident, and a whirlwind tour of the science and biomechanics of her spine brace
• PS Medical Errors in Perspective — Medical error rates should not be used to spread fear, uncertainty and doubt
• PS Knee Surgery Sure is Useless! — Evidence that arthroscopic knee surgery for osteoarthritis is about as useful as a Nerf hammer
• PS Does Cartilage Regeneration Work? — A review of knee cartilage “patching” with autologous chondrocyte implantation (ACI)
• PS Frozen Shoulder Guide — An extremely detailed & readable guide to one of the strangest of all common musculoskeletal problems, for both patients and pros
• PS Knee Replacement Surgery Doubts — Knee replacement is extremely popular, but still not yet based on good evidence of efficacy
• PS Achilles Tendinitis Treatment Science — Evidence-based guidelines for recovering as fast as possible

This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:

• A Bayesian model-averaged meta-analysis of the power pose effect with informed and default priors: the case of felt power. Gronau 2017 Comprehensive Results in Social Psychology.
• The neck and headaches. Bogduk 2014 Neurol Clin.
• Agreement of self-reported items and clinically assessed nerve root involvement (or sciatica) in a primary care setting. Konstantinou 2012 Eur Spine J.
• Effect of NSAIDs on Recovery From Acute Skeletal Muscle Injury: A Systematic Review and Meta-analysis. Morelli 2017 Am J Sports Med.
• Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. Paige 2017 JAMA.