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When is orthopedic surgery necessary? A British study and North Texas surgeon have different views

Surgeons perform surgery on a patient.
Dr. Christoforetti says patients often have longtime physical therapy before they undergo bone and joint procedures such as knee surgery.

Elective surgeries on the knees, hips, shoulders, spine, and wrist are very common today. Also, risky and costly.

But a study recently published in the British Medical Journal concluded outcomes of some of those surgeries may not be significantly better than with nonsurgical care.

Dr. John Christoforetti, an orthopedic surgeon and sports medicine specialist with Texas Health Allen and Texas Health Frisco, explained to KERA’s Sam Baker why he thinks the study may be misleading to U.S. patients.

Health care in U.S. & Europe: A comparison

In the national health systems in Europe, you're going either to therapy or to surgery. You don't have an arm where it's therapy first and then it fails. And then what do you do?

In most cases in the United States, when we're dealing with the surgical decision, we have already tried various conservative care avenues and those have failed to progress. And that's what's inspired the surgical conversation.

Does physical therapy work for most or many orthopedic problems?

Absolutely. I would suggest that it works for the vast majority of orthopedic problems.

You almost make it sound like surgery is really the avenue of last resort. 

That's a good way of summarizing. I think one of the things to remember is that one person's last resort isn't the same as another person's last resort. I think that's where patient values come in to inform decision-making.

Sometimes there are old sayings like “penny wise and pound foolish” that go along where if a patient's been out of their productive enjoyment of life, the question becomes “How long is it tolerable? How many months?” How many weeks it's OK for one patient may be different than for the next patient.

Is surgery ever the first option? 

There definitely are times — orthopedic emergencies, or emergencies where you have a limb-threatening or life-threatening condition.

Fractures in the elderly are a good example. If you break your hip and you can't get out of bed, we have universal recommendations across all health systems that those fractures need to be stabilized with surgery so that the patient can get up out of bed and prevent life-ending infections of being bedridden.

Do hip or knee replacements fall into that? 

Generally speaking, it's not even months, it's years of conservative management before one decides together with their surgical team for replacement: multiple rounds of things like injection, assistive devices like canes or walkers.

That stated, the National Institutes of Health (NIH) in this country recognizes joint replacement as one of the most health-positive things one can do if they're right for the replacement. It improves mobility. It reduces overall health care costs and needs for that patient and increases their quality of life. It's a very powerful surgery when it's time to be done.

But you know, there are very rare instances — extreme motor vehicle accidents, falls that destroy the joints so badly that all at once, the patient is learning that my joint was normal yesterday, but I've had a massive trauma and there's no way to put these things back together and we need to go right to an artificial joint. That does happen. 

People have choices. They should ask questions. They shouldn't think that they're at the mercy of a doctor.

I think that's absolutely true, and I also feel that there are ways that you can go.

Some of our patients and their families are very comfortable not having to bear the burden of making their own diagnostic pathway for the care teams. Some patients have their own reams of research they need in order to feel good about their decision and what they should go through. These are areas where we have a lot of variation.

However, I would really hate for people to feel is that if they've somehow been recommended for surgery, there would be some sinister motive behind that. Most insured patients are receiving surgical recommendations based on this last resort mentality.

Yes, there should be a discussion about conservative care. That's a great question for patients to ask. I think knowing themselves, which can be the most stressful, how likely would I be to say I was satisfied with conservative care or operative care if I still had discomfort in a year?

Those are things that are hard to imagine. But unfortunately, injuries put us in a position where we’ve got to grow a little bit and we have to learn about those things. 


Considering Bone or Joint Surgery? You May Not Need It.

Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence

Prevalence of Total Hip and Knee Replacement in the United States

Increased Rate of Total Joint Replacements Predicted From 2020 to 2040

This article has been edited for length and clarity.

Got a tip? Email Sam Baker at You can follow Sam on Twitter @srbkera.

Sam Baker is KERA's senior editor and local host for Morning Edition. The native of Beaumont, Texas, also edits and produces radio commentaries and Vital Signs, a series that's part of the station's Breakthroughs initiative. He also was the longtime host of KERA 13’s Emmy Award-winning public affairs program On the Record. He also won an Emmy in 2008 for KERA’s Sharing the Power: A Voter’s Voice Special, and has earned honors from the Associated Press and the Public Radio News Directors Inc.