Abstract
OBJECTIVE
To determine the clinical effectiveness of common elective orthopaedic procedures compared to no treatment, placebo or non-operative care, and assess the impact on clinical guidelines.
DESIGN
Umbrella review of meta-analyses of randomised controlled trials or, other study designs in the absence of meta-analyses of randomised controlled trials.
DATA SOURCES
Ten of the commonest elective orthopaedic procedures, namely: arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement were studied. MEDLINE, EMBASE, Cochrane Library, and bibliographies were searched until September 2020.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that have compared the clinical effectiveness of any of these orthopaedic procedures with no treatment, placebo, or non-operative care.
DATA EXTRACTION AND SYNTHESIS
Summary data were extracted by two independent investigators and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews Instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check if recommendations for each procedure reflected the body of evidence.
MAIN OUTCOME MEASURES
The quality and quantity of the evidence behind the commonest orthopaedic interventions were assessed, and comparisons were made to the strength of the recommendations in relevant national clinical guidelines.
RESULTS
Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. There were no randomised controlled trials that specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care.
CONCLUSIONS
Although they may be effective overall or in certain sub-groups, there is not a strong high-quality evidence base demonstrating that many commonly performed elective orthopaedic procedures are better than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.
To determine the clinical effectiveness of common elective orthopaedic procedures compared to no treatment, placebo or non-operative care, and assess the impact on clinical guidelines.
DESIGN
Umbrella review of meta-analyses of randomised controlled trials or, other study designs in the absence of meta-analyses of randomised controlled trials.
DATA SOURCES
Ten of the commonest elective orthopaedic procedures, namely: arthroscopic anterior cruciate ligament reconstruction, arthroscopic meniscal repair of the knee, arthroscopic partial meniscectomy of the knee, arthroscopic rotator cuff repair, arthroscopic subacromial decompression, carpal tunnel decompression, lumbar spine decompression, lumbar spine fusion, total hip replacement, and total knee replacement were studied. MEDLINE, EMBASE, Cochrane Library, and bibliographies were searched until September 2020.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Meta-analyses of randomised controlled trials (or in the absence of meta-analysis other study designs) that have compared the clinical effectiveness of any of these orthopaedic procedures with no treatment, placebo, or non-operative care.
DATA EXTRACTION AND SYNTHESIS
Summary data were extracted by two independent investigators and a consensus was reached with the involvement of a third. The methodological quality of each meta-analysis was assessed using the Assessment of Multiple Systematic Reviews Instrument. The Jadad decision algorithm was used to ascertain which meta-analysis represented the best evidence. The National Institute for Health and Care Excellence Evidence search was used to check if recommendations for each procedure reflected the body of evidence.
MAIN OUTCOME MEASURES
The quality and quantity of the evidence behind the commonest orthopaedic interventions were assessed, and comparisons were made to the strength of the recommendations in relevant national clinical guidelines.
RESULTS
Randomised controlled trial evidence supports the superiority of carpal tunnel decompression and total knee replacement over non-operative care. There were no randomised controlled trials that specifically compared total hip replacement or meniscal repair with non-operative care. Trial evidence for the other six procedures showed no benefit over non-operative care.
CONCLUSIONS
Although they may be effective overall or in certain sub-groups, there is not a strong high-quality evidence base demonstrating that many commonly performed elective orthopaedic procedures are better than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.
| Original language | English |
|---|---|
| Article number | n1511 |
| Journal | BMJ |
| Volume | 374 |
| Issue number | 1 |
| DOIs | |
| Publication status | Published - 8 Jul 2021 |
Bibliographical note
Funding Information:disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol for the submitted work; AWB has received research grants and MRW has received research grants, lecturing fees, and textbook royalties outside the remit of the submitted work; no other relationships or activities that could appear to have influenced the submitted work.
Funding Information:
Contributors: AWB, MRW, and SKK designed the study. SKK, RLD, and MRW contributed to data collection, analysis, and interpretation. SKK wrote the first draft of the manuscript. All authors interpreted data and drafted, reviewed, and approved the submitted manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. AWB is the guarantor. Funding: This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol (BRC-1215-20011). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in considering the study design or in the collection, analysis, and interpretation of data, the writing of the report, or the decision to submit the article for publication.
Publisher Copyright:
© 2021 BMJ Publishing Group. All rights reserved.
Keywords
- arthroscopy
- anterior cruciate ligament reconstruction
- anterior cruciate ligament injuries
- tibial meniscus injuries
- meniscectomy
- rotator cuff injuries
- rotator cuff tear arthropathy
- shoulder impingement syndrome
- carpal tunnel syndrome
- laminectomy
- spinal stenosis
- intervertebral disc disease
- arthroplasty, replacement, hip; osteoarthritis
- arthroplasty, replacement, knee
- orthopedic procedures
- orthopedics
- review
- umbrella review
- meta-analysis