When is surgery appropriate?

[RWulys]

Hi Doctors,

Since I knew very little (still do) about the human body prior to You capturing my interest, I thought there was nothing I really had to know about it, and that if anything were to ever happen, I could simply trust my doctor.

That doesnt seem to be the case, now, however. A lot of clinicians operate within the rigid mechanical model and are happy to prescribe surgery… I’m NOT suggesting that trusting doctors is generally a bad idea. I trust Dr Feigenbaum about generally not trusting doctors being a terrible one.

So, essentially, I’m wondering when surgery is legit? How can one, as a layman who plans to remain a layman, go about deciding what to do when “injured”? I know that a sort of meta level theory about everything that pertains to the human body that begins from a few premises and infers everything there is to know, doesn’t work. But, are there some principles to consider when asking whether or not surgery is in place?

If not, could you give a few examples of legit surgeries (especially orthopedic ones)? I’d be happy with the approach that “the evidence suggests that surgery X is legit … the evidence suggests that surgery Y has no benefit when controlled against sham surgery”, if first principles of “legit surgery” can’t be given.

Dr Baraki did say that the orthopedic field isn’t unnecessary, and that there are indeed legit surgeries (like hip fractures and septic joints).
He also said that he was glad that Tim K got his bicep tendon repaired, so I’m guessing that that particular operation is a good idea?

I’ve dislocated my shoulder probably 10-15 times within the last decade (“momentary” dislocation IE it popped out and in… sorry for the terms) throwing lazy, tired left hooks in sparring. Incoming opinions on proper measures have obviously been diverse. The pain tends to dwindle within hours, and I’ve never changed the way I train because of it. Regression to the mean, I suppose. So yeah…

So, any principles on OR examples of legit (mainly orthopedic) surgeries? Cruciate ligaments? Bicep tendons? Shoulders?

[Austin_Baraki]

@RWulys

So, essentially, I’m wondering when surgery is legit? How can one, as a layman who plans to remain a layman, go about deciding what to do when “injured”? I know that a sort of meta level theory about everything that pertains to the human body that begins from a few premises and infers everything there is to know, doesn’t work. But, are there some principles to consider when asking whether or not surgery is in place?

Surgery is “legit” when the benefits outweigh the risks, when compared to the available non-surgical interventions. Ideally, we have controlled evidence supporting such interventions as well, although this is not always available.

This may be an unsatisfying answer, but beyond the content we have put out on injury, we can’t give you a set of rules for this stuff. It’s complicated, which is why doctors go through so much training in order to be entrusted with such decisions, for better or worse. You can try reading AAOS clinical practice guidelines, but this may be challenging as a layperson as well.

@RWulys

If not, could you give a few examples of legit surgeries (especially orthopedic ones)? I’d be happy with the approach that “the evidence suggests that surgery X is legit … the evidence suggests that surgery Y has no benefit when controlled against sham surgery”, if first principles of “legit surgery” can’t be given.

Dr Baraki did say that the orthopedic field isn’t unnecessary, and that there are indeed legit surgeries (like hip fractures and septic joints).

I would point out that even many types of fractures are managed non-operatively, particularly when equivalent outcomes can be achieved with less risk.

We have discussed the evidence on various types of surgeries in our content here, at http://thelogicofrehab.com , and in our research review. These include things like arthroscopic meniscectomy, FAI surgery, rotator cuff surgery, surgery for osteoarthritis, and various types of spine surgery specifically for low back pain.

@RWulys

He also said that he was glad that Tim K got his bicep tendon repaired, so I’m guessing that that particular operation is a good idea?[/B]

Again, it’s complicated. In general for our audience, sure, that’s a good idea to do for long-term functional outcomes. On the other hand, if I’m seeing my usual older hospitalized patient with multiple complex medical conditions that tilt the risk / benefit ratio of surgery, we may come to a different conclusion and recommendation. Same goes for many discussions around ACLs, joint osteoarthritis, etc. etc.

[RWulys]

@Austin_Baraki

Surgery is “legit” when the benefits outweigh the risks, when compared to the available non-surgical interventions. Ideally, we have controlled evidence supporting such interventions as well, although this is not always available.

Boom.

This may be an unsatisfying answer, but beyond the content we have put out on injury, we can’t give you a set of rules for this stuff. It’s complicated, which is why doctors go through so much training in order to be entrusted with such decisions, for better or worse. You can try reading AAOS clinical practice guidelines, but this may be challenging as a layperson as well.

I completely understand.

I would point out that even many types of fractures are managed non-operatively, particularly when equivalent outcomes can be achieved with less risk.

We have discussed the evidence on various types of surgeries in our content here, at http://thelogicofrehab.com , and in our research review. These include things like arthroscopic meniscectomy, FAI surgery, rotator cuff surgery, surgery for osteoarthritis, and various types of spine surgery specifically for low back pain.

I’ve tried to take as much of it in as possible.

Again, it’s complicated. In general for our audience, sure, that’s a good idea to do for long-term functional outcomes. On the other hand, if I’m seeing my usual older hospitalized patient with multiple complex medical conditions that tilt the risk / benefit ratio of surgery, we may come to a different conclusion and recommendation. Same goes for many discussions around ACLs, joint osteoarthritis, etc. etc.

Absolutely. To be clear, I didn’t mean to imply that I inductively inferred every single incision endobutton repair (or any other type of operation) to be good for all ruptured distal bicep tendons, under all circumstances. I was basically looking to see which types of surgeries could be beneficial, or whether all (orthopedic) surgery is a lie. Not that I really thought that to be a real possibility, but… it seemed from the stuff I’d read that most of it (like meniscus, ACL, rotator cuff) is unnecessary, in addition to being riskier than non-surgical interventions, of course.

I totally get that a set of when surgery is a good idea-axioms, can’t be given. And that the types of surgeries that can sometimes be preferable, sometimes aren’t. As a code and math nerd (or any other layman) who’s unwilling to become an expert in something as paraconsistent as the human body, what do you suggest I do if I find myself with something torn or broken and hurting a lot (besides coming to this forum)? Not that I don’t generally trust medical doctors, but how do I determine whether the shoulder or ACL surgery that my doctor is hinting at, is, or could be, a good idea? Like, maybe it depends on the type of surgery (as well as on specific circumstances, of course). It just feels weird to hope to remain completely intact until the information that you’re privy to becomes part of the orthopedic zeitgeist.

[Austin_Baraki]

@RWulys

As a code and math nerd (or any other layman) who’s unwilling to become an expert in something as paraconsistent as the human body, what do you suggest I do if I find myself with something torn or broken and hurting a lot (besides coming to this forum)? Not that I don’t generally trust medical doctors, but how do I determine whether the shoulder or ACL surgery that my doctor is hinting at, is, or could be, a good idea? Like, maybe it depends on the type of surgery (as well as on specific circumstances, of course). It just feels weird to hope to remain completely intact until the information that you’re privy to becomes part of the orthopedic zeitgeist.

Given the condition that you’re not going to become an expert in this stuff, I’m not sure it’s something you’ll be able to confidently determine for yourself.

So, I suppose I’d recommend a consultation with an expert whose opinion you trust (this may be our rehab staff, someone local to you, etc.), or getting multiple opinions on the matter and seeing where that leads you.

[RWulys]

@Austin_Baraki

Given the condition that you’re not going to become an expert in this stuff, I’m not sure it’s something you’ll be able to confidently determine for yourself.

So, I suppose I’d recommend a consultation with an expert whose opinion you trust (this may be our rehab staff, someone local to you, etc.), or getting multiple opinions on the matter and seeing where that leads you.

Well yeah, makes sense.

Since the slope of the learning curve will depend on the individual, I guess the better question than “How long does it take to become an expert?”, would be Would/Do you ever recommend a layperson become an “expert” / sufficiently versed that they may be able to determine these things for themselves? I enjoy reading, but consuming 15,000+ pages of material seems an inferior investment to a consultation with You. So, extremely roughly, how much would have to be learned? I suspect there’s a reason why you offer consultations, but…

[Austin_Baraki]

@RWulys

Since the slope of the learning curve will depend on the individual, I guess the better question than “How long does it take to become an expert?”, would be Would/Do you ever recommend a layperson become an “expert” / sufficiently versed that they may be able to determine these things for themselves?

No, I don’t / wouldn’t recommend this, as I don’t think a layperson can actually become an expert in such things without any formal training / mentorship.

[RWulys]

Thank you, and merry christmas!