The case for conservative treatment of orthopedic injuries & conditions

November 19, 2020
Jack M. Bert, MD, FACS, FAAOS

Dr. Jack Bert Bio

  • Mayo Clinic trained, board certified orthopedic surgeon. 40 years of practicing orthopedic surgery
  • Adjunct professor at the University of Minnesota School of Medicine
  • Teaches nationally and internationally over 10 times per year
  • Teaches courses on conservative and surgical treatments of osteoarthritis of the knee
  • Past president of the Arthroscopy Association of North America with over 5,700 surgeons as members
  • Authored 72 articles and 21 book chapters in peer reviewed journals
  • Performed over 25,000 surgical procedures in his career
  • On the Board of Directors of the Retired NFL Players Association

Orthopedic surgery deals with diseases and injuries to the bones, joints, and spine of the human body.

There are multiple methods of treating almost any orthopedic condition and often both the patient and surgeon are confronted with the question of whether a conservative approach is more appropriate than a surgical solution for a particular orthopedic condition

Unfortunately, there is not a single orthopedic surgical procedure that has a 100% success rate and complications such as infection can occur with ANY surgical procedure despite the usage of antibiotics or excellent surgical technique. A classic example of this phenomenon is total knee replacement (TKA) which is estimated to increase 4 fold in the next 10 years. There are now 14 published articles which confirm that TKA only has an 80 to 82% success rate (Scott et al, JBJS, 2016) and up to 41% of patients still complain of stiffness, pain, and limitation of normal activities.(Parvizi et al, CORR,2014).

As noted in an article that I authored in the Journal of Orthopedics in October of 2018, there are multiple injectable treatments for patients with osteoarthritis of the knee that postpone total knee arthroplasty in patients with moderate to severe disease as long as 7.8 years.

In my personal practice, I have patients with significant osteoarthritis of the knee that I have been injecting with high molecular weight hyaluronic acid every 6 months for over 10 years. Not only can this reduce the need for total knee replacement and decrease a patient’s osteoarthritic pain, but based upon 2 different QALY (quality of life year) studies (Hatoum et al, Jrnl Med. Econ. 2014, & Miller & Block, Clin. Med., 2014), it may save up to $12,800/yr.  The reason for this is that TKA and total hip replacement (THA) have survivorship data that confirms that these procedures only last about 12 to 15 years as an average before they require revision. Every time a revision is performed, the success rate for the procedure drops by as much as 20%.

A similar argument can be made for patients with partial rotator cuff tears. If they only require an injection of steroids every 3 to 6 months, there is little argument for performing surgery unless they have intractable pain with overhead use and night pain which interferes with their sleep. Unfortunately, the recurrence rate of rotator cuff tear is as high as 10 to 15%.

Cervical spine (neck) and lumbar spine (low back) surgery should be avoided whenever possible unless there is a significant neurologic deficit associated with a herniated disc impairing function of the upper or lower extremities. This is a rare occurrence and conservative modalities of care should ALWAYS be utilized unless a neurologic deficit can be documented on clinical exam, with an EMG, or definitively with an MRI. Anytime surgery is performed on the neck or back, future surgery often occurs due to degeneration of the disc space above and/or below the area of surgery especially if a fusion is performed (my personal experience of having 4 neck surgeries over a 15 yr. period confirms this clinical fact). Thus, anti-inflammatories are often utilized to reduce the inflammatory response in the area of the spinal disease. Often short doses of steroids are utilized and/or steroid injections adjacent to the disc space or into the facet joints for pain relief.

Utilizing a conservative approach is useful more often than not unless there is fracture, e.g. a hip, femur, or tibial fracture that requires a surgical approach to allow for rapid mobilization. Furthermore, there are muscle or tendon avulsions that simply cannot be treated easily conservatively such as quadriceps tendon or hamstring origin avulsions or Achilles tendon insertional ruptures. However, the majority of orthopedic conditions should be treated conservatively to avoid complications associated anytime surgery is performed.

MDDirect’s musculoskeletal staff orthopedic surgeons have had decades of experience and use evidenced based protocols as the basis for recommendations for patient care and treatment.  

Are we delaying the inevitable surgical procedure?

Surgery is not always successful and conservative care should ALWAYS be exhausted for many reasons including;

  1. Survivorship, which means the time to a revision of a total joint replacement, is only 10 - 15 years for a total hip or knee. If you are 60 years old that means by the time you are 70 - 75 you will need a revision of your joint.  Ask your doctor what the survivorship of the implant is?
  2. Increasing life span has resulted in lowering success rates of surgical procedures because patients are outliving the survivorship of implants! Furthermore, revision surgery carries a much lower success rate and is becoming more common as patients live longer.
  3. Infection rates for any orthopedic procedure range from between .7% to 4%. Infections can have devastating effects on joint surfaces or within bones especially if osteomyelitis occurs.

This article does not constitute medical advice and is for information purposes only. Please consult your physician.

Other orthopedic references:

https://www.inquirer.com/philly/blogs/sportsdoc/Meniscus-tears-when-DO-I-need-surgery.html
https://www.hss.edu/conditions_conservative-management-of-osteoarthritis.asp
https://www.stoneclinic.com/blog/conservative-care-vs-operative-care
Torn rotator cuffs present a different set of decisions. The tear patterns are diverse and patient responses to them equally variable. We see many partial tears that do extremely well without surgery. We now augment the healing with injections of bioactive factors, which recruit stem cells to the site of the tear.  While we don’t yet have definitive data on the efficacy of this therapy (other than cost), it does not appear to do any harm. Partial tears that don’t respond to non-operative care can be repaired at a later date. Complete rotator cuff tears also present a challenging set of decisions. While our intuition is that the complete tear should be repaired early, before the tissue scars and retracts; so many patients do well with cuff tears that guessing who will and who won’t benefit from repair is tough. For young patients, the decision is easier. The force needed to rupture a young rotator cuff is so high that the natural effective healing is probably not enough. So the younger the patient, the earlier we perform the repair. And for older patients? We often leave the choice up to them. Night pain and persisting weakness are usually the symptoms that drive them back into the office for repair.”
Back Pain
https://www.spine-health.com/conditions/lower-back-pain/conservative-vs-surgical-care-lower-back-pain