We are aware of media coverage this week about a research study investigating the evidence behind several orthopaedic operations. We are concerned at the conclusions of this study, which suggest that various orthopaedic procedures lack evidence of benefit. This study has taken a narrow view of the evidence available for orthopaedic operations.
In particular, total hip replacement is one of the most effective of all medical and surgical treatments. It has been described as the ‘Operation of the 20th Century’, and has totally revolutionised the care of patients who previously were crippled by arthritis. It has transformed the lives of many millions of patients, reducing their pain and improving their mobility.
The study also highlights other orthopaedic procedures where it suggests there is a lack of evidence.
We recognise that this research may be causing some uncertainties for patients, particularly those awaiting or considering surgery. Overall, however, we do not consider this study should cause any concern about the current practice of orthopaedics in the UK, as it does not consider the full range of research evidence available. If any patients awaiting surgery have any questions they should discuss these with their clinician at their next appointment.
Bob Handley, Orthopaedic Surgeon and President of the British Orthopaedic Association, commented:
“Total hip replacement is one of the most successful and cost-effective of all operations, not just in orthopaedics. We would like to reassure all patients that there is an extensive evidence base to support this procedure, and links to further information are provided at the end of this statement.”
Professor John Skinner, Orthopaedic hip surgeon and Vice President of the BOA, further explains:
“Randomised controlled trials (RCTs) have great research value but can assess only one thing; uncertainty relating to benefit or superiority of a treatment. If there is no uncertainty, RCTs have no place and there is no uncertainty at all regarding the benefit of total hip replacement in the treatment of end stage hip arthritis. To look for Randomised trial meta-data to prove the value of such a beneficial procedure and be critical that none exists, because it isn’t needed, defies logic.
“This study looks at Randomised Trials and supposes that all operations should have been compared in a trial against no treatment or placebo. Many of the operations now have clear and obvious benefit from simple experiential evidence, and therefore do not need such evaluation of fundamental benefit.
“An appropriate analogy may be that no one has, nor should they perform a randomised trial to see if wearing parachutes are better than not wearing parachutes, when jumping out of aeroplanes.”
Tim Wilton, Orthopaedic Surgeon and Medical Director of the National Joint Registry (NJR) said:
“In the UK, the National Joint Registry has collected data from over 1.25million primary hip operations in the last 18 years. NJR reports show year-on-year the life-changing benefits people have gained from this procedure. This includes the demonstration that ‘on average’ the main Patient Reported Outcome Measure score for hips (Oxford Hip Score) is doubled within six months of the operation.
“The current rules within the NHS ensure that patients cannot even be referred to an orthopaedic surgeon for consideration of hip (or knee replacement) until they have received many months of pain killers and physiotherapy treatments which have failed to resolve the problem.
“The evidence base is further backed up by the many stories and positive anecdotal evidence from the patients with whom we regularly engage through our work, who state that hip replacement has transformed their lives. In view of this huge body of evidence many doctors treating these patients would regard the proposed randomised controlled studies as completely unethical in patients who currently receive Total Hip Replacement in the UK.”
Patient Representative of the National Joint Registry, Gillian Coward said:
“Primary care support pathways and patient self-management programmes already include various kinds of activities and non-surgical remedies for patients with joint issues to moderate pain and generate relief. Surgery has always been the ‘last resort’ solution offered in the treatment chain. If a patient is referred for joint surgery it is almost always because their pain is no longer under control, joint damage has had significant impact on their mobility and quality of life and these and other complementary non-surgical remedies simply cannot resolve the problem. Timely surgical intervention has a successful track record with these patients.”
Further information about hip replacement:
NHS webpages about hip replacement: https://www.nhs.uk/conditions/hip-replacement/
Versus Arthritis webpages about hip replacement: https://www.versusarthritis.org/about-arthritis/treatments/surgery/hip-replacement-surgery/
NICE guidance on hip, knee and shoulder replacement: https://www.nice.org.uk/guidance/ng157/informationforpublic
About the BOA
The BOA is the General Medical Council recognised specialty association for trauma and orthopaedic surgery. The organisation celebrated its 100 year anniversary in 2018 and currently has over 5,000 members. The BOA's principal objectives are excellence in trauma and orthopaedic surgical practice, training, education and research.
Trauma and Orthopaedic Surgery is a highly cost effective form of treatment which aims to restore pain free mobility for patients. By restoring mobility, Trauma and Orthopaedic surgery can not only help people stay active for longer, but deliver major economic savings; enabling people to return to work, or live more independently.
Given the growing musculoskeletal disease burden, and the transformative impact surgery can have for the right patients, the BOA believes surgeons, commissioners and colleagues across the NHS should work together to increase surgical capacity.
About the NJR
The NJR, which covers England, Wales, Northern Ireland, the Isle of Man and the States of Guernsey, collects information on hip, knee, ankle, elbow and shoulder joint replacement surgery, across both the NHS and independent sector. Data collection began in April 2003 and data submission for NHS organisations was made mandatory from April 2011. Now with over 3 million procedure records, the NJR is the largest orthopaedic registry in the world with an international reputation. Recognised as a ‘global exemplar’ of an implantable medical devices registry, the NJR monitors the performance and effectiveness of joint replacement implants in different types of joint replacement surgery, in order to provide an early warning of issues relating to patient safety and improve clinical standards; thus benefiting patients, clinicians and the orthopaedic sector as a whole.