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)
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.
OBJECTIVE: To evaluate the evidence for the effectiveness of sham surgery in orthopedics by conducting a systematic review of literature.
METHODS: Systematic searches were conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. All randomized controlled trials comparing surgery versus sham surgery in orthopedics were included. «Shockingly few!» Data were extracted and methodological quality was assessed by two reviewers using the Critical Review Form-Quantitative Studies. Levels of scientific evidence, based on the direction of outcomes of the trials, were established following the Australian National Health and Medical Research Council (NHMRC) Hierarchy of Evidence (Australian National Health and Medical Research Council, 1999).
RESULTS: This review includes six randomized controlled trials (RCTs) involving 277 subjects. All six studies were rated as very good on methodological quality. Heterogeneity across the studies, with respect to participants, interventions evaluated, and outcome measures used, prevented meta-analyses. Narrative synthesis of results, based on effect size, demonstrated that sham surgery in orthopedics was as effective as actual surgery in reducing pain and improving disability.
CONCLUSIONS: This review suggests that sham surgery has shown to be just as effective as actual surgery in reducing pain and disability; however, care should be taken to generalize findings because of the limited number of studies.
related content
- Surgery: The ultimate placebo, a book by Ian Harris (book review).
- “The Right to Know That an Operation Is ‘Next to Useless’,” a webpage on www.nytimes.com.
- “The sexy scalpel: unnecessary shoulder surgery on the rise,” a webpage on Blogs.BMJ.com.
- “Use of placebo controls in the evaluation of surgery: systematic review,” an article in British Medical Journal, 2014.
- “The evidence on surgical interventions for low back disorders, an overview of systematic reviews,” an article in European Spine Journal, 2013.
- “Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms,” an article in 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,” an article in BMJ Open, 2015.
- “A controlled trial of arthroscopic surgery for osteoarthritis of the knee,” an article in New England Journal of Medicine, 2002.
- “Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline,” an article in British Medical Journal, 2017.
These fifteen 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 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 — A readable self-help manual for one the strangest of all common musculoskeletal problems, adhesive capsulitis
