“In America the scalpel reigns supreme. Some patients accept that surgery isn’t for them and gladly follow the non surgical recommendations, but others go from surgeon to surgeon until they get the surgery they think they need.”
– Dr. Jennifer Gunter MD, FRCS(C), FACOG, DABPM

I just read a very enlightening post from an MD regarding surgery vs physical therapy.  In To cut isn’t always to cure: knee surgery, health care, and our love affair with the scalpel Dr. Jen Gunter hits several nails very squarely on the head.  First, she discusses research comparing physical therapy alone vs arthroscopic surgery for treatment of knee miniscus repair and osteoarthritis.  What did the study find?  Dr. Gunter says,

“Patients over 45 with OA and a meniscus tear were randomized to typical arthroscopic surgery (which included post operative physical therapy) or physical therapy (PT). They were allowed to cross over to the other group if they so desired. At 6 months and at 12 months those who had surgery were no better off pain or function wise than those who stuck with the physical therapy regimen (30% of people decided to switch from PT to surgery).”

She goes on to discuss our view of surgery, and that we often view surgery as the ultimate best solution for pain.  Couple that view with our widely available yet very expensive MRI technology and we are a society hungering for surgery even when it’s clearly a questionable solution in many cases.  More from Dr. Gunter:

“A lot of people have arthritis of the knee (we know this because of all the knee MRIs that we do in this country at $1200 or so a pop). According to the NEJM study, 9 million Americans have osteoarthritis of the knee confirmed by x-ray or MRI and 35% of people over the age of 50 will have a meniscus tear on MRI. A torn meniscus itself doesn’t necessarily identify the cause of the pain because 2/3 of meniscus tears are totally asymptomatic. MRIs are so sensitive they identify tons of things that are not causative as far as pain is concerned.

Because we have an aging population, because we MRI everyone, because we have a problem with obesity (a major co-factor in osteoarthritis), and because surgery is highly reimbursed almost 500,000 people get their partially torn meniscus trimmed by a minimally invasive surgery called arthroscopy (using a surgical telescope) each year in the United States.

However, recent studies have called into question the value of arthroscopic knee surgery. For example, we know that arthroscopic surgery for osteoarthritis (OA) alone is no better than sham surgery. Yup. Put a patient to sleep, nick the skin with a scalpel. squirt water on his leg or stick a telescope into it and fix what you think needs to be fixed… the outcomes are identical.”

Dr. Gunter makes a great point regarding treatment of arthritis and by addressing obesity via lifestyle:

“And what about diet and lifestyle? Obesity is a major co-factor in osteoarthritis of the knee. Not only because the knee is load bearing, but the fat pad in the knee is metabolically active like the fat around the belly and contributes to the inflammatory changes of arthritis. The average body mass index in the NEJM study was 30. That means that obesity was the norm.”

I’m very pleased to see an MD making these kinds of observations.  The big message is that surgery isn’t always the best solution is tremendously valuable.  We love to think American medical care is wonderful but in so many cases it’s just incredibly wasteful.  We spend the most of any 1st world country on medical care yet our outcomes are questionable when compared to other modern countries.  We spend too much on things we don’t need when there are practical ways to reduce costs and maintain a high quality of care.

I would add that surgery often only treats a symptom rather than the cause of something like arthritis.  Osteoarthritis is typically related to poor movement patterns.  If we can use our muscles to correctly control our joints then we have sloppy movement.  The result is friction within the joint and thus a buildup of bone–arthritis.  The process is similar to the formation of a callous on the skin.  If we only clean up the arthritis and we do nothing to correct movement, then we should expect to continue to have pain.  Surgery doesn’t correct movement.  That’s what physical therapy and similar modalities are for.