Knee, shoulder and hip surgeries are the most common of the millions of orthopedic surgeries performed every year in the U.S. But is surgery always the go-to recommendation for orthopedic injuries – those injuries related to the bones and joints? If you see a surgeon, is surgery imminent?
Dr. Matthew Spivey at Novant Health Orthopedics & Sports Medicine - Clemmons specializes in orthopedic sports medicine for shoulders, knees and hips. He treats all ages, and, in his mind, everyone is an “athlete” in some way. Spivey answers a few key questions about orthopedic surgery.
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When you have a joint injury or joint pain, how do you know it’s actually time to see a doctor?
A few symptoms merit at least seeing a primary care doctor or someone at an urgent care. If someone has a significant event or injury where their joint was normal leading up to it and now that joint is experiencing pain, swelling or limited movement, they should probably see a doctor. Also, if they can’t bear weight on it, if it’s a knee or a hip for example, they should see a doctor. It would help to get an X-ray to at least make sure nothing is going on that’s going to get worse.
When you’re referred to an orthopedic surgeon, does the discussion always turn to surgery?
Based on an individual patient’s situation, I try to always talk about both the operative and nonoperative options. For example, injuries like hip fractures, large acute rotator cuff tears and anterior cruciate ligament (ACL) ruptures are structural mechanical problems that, even if they can heal without surgery, can lead to dysfunction or problems down the line.
We explain the concept and the risks of deciding against surgery, and the potential benefits of surgery. Part of my job is to teach patients every day about risks and benefits of different approaches. I think it’s important that they are empowered to make well-informed decisions about their care.
Surprisingly, even an ACL tear doesn’t automatically require surgery. What do you base your recommendation on?
The ACL gives your knee stability in the front to back plane, and additional structures around the knee contribute to that. So, you generally don’t need an ACL that functions normally to do straight-line walking, standing, day-to-day activities and to live a more sedentary lifestyle where you’re not doing higher impact exercise. It’s possible to do quite well without a functional ACL.
But people who do sprinting, cutting, pivoting, side-to-side movements, higher velocity movements and change of direction definitely need a functional ACL. It depends on your activities. If a tennis player doesn’t choose ACL surgery for example, they are likely to experience some degree of knee instability front to back and where rotation is involved, so they risk additional injury to structures in the knee like the meniscus, cartilage or another ligament.
And over a long period of time, they may be at increased risk of developing post-traumatic arthritis in the knee.
Why is there generally a waiting period when orthopedic surgery is recommended?
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If you take someone with an ACL injury, for example, and rush them off to surgery right away, their knee is very swollen and stiff with a limited range of motion at the time of surgery. The surgery itself is basically a second injury to the joint, and doing it too early after injury brings a high risk of developing severe stiffness and lost range of motion. When surgery happens too soon after the injury, there are some cases where patients even need a second surgery to remove scar tissue to help regain normal knee mobility.
It can be frustrating to delay surgery, but it’s worth taking a couple of weeks for prehab and physical therapy to restore functional range of motion of the knee. When the patient is back to walking as normally as possible and their quadriceps strength is back to baseline, they can have a better surgical outcome.
What orthopedic injuries can you allow to heal on their own, without surgery?
A good example of a condition in the shoulder is tendonitis (inflammation of the cords connected to muscle and bone) of the rotator cuff. It’s very common for some folks to get irritation and some tearing of surface fibers; bursitis (inflammation of the fluid-filled cushions called bursa around many tendons and joints) is similar.
Many patients with these conditions can get better without surgery. Typically, one treatment or another can improve inflammation, whether that’s medication or an
This doesn’t mean patients should not seek treatment for this kind of condition. We hope that physical therapy and rehabilitation will be effective and that these patients will see gradual improvement and resolution of the problem. But, if after a course of therapy you’re not seeing improvement or the condition is getting worse, we might need to think about getting an MRI or considering surgery. Surgery can be a backup option.
To sum it up, what are some nonoperative surgical approaches to orthopedic injuries?
Short-term rest and activity modification, injections, physical therapy, anti-inflammatory medications. It’s all tailored to a patient’s situation. We can sometimes start with very simple things like a patient potentially changing the way they exercise and stay healthy.
With arthritis in the knee and hip for example, weight-bearing and repetitive pounding type exercises or even long walks can contribute to pain and swelling. That patient might try swimming, water aerobics or other low-impact exercises to get their heart rate up without making their joints so sore and painful. That’s more sustainable.
Do you often see patients who need surgery resisting it?
Most patients want to avoid surgery if they can, and that’s very reasonable. There is always some degree of risk with every surgery. It’s really about helping patients decide if the risk-benefit ratio is in their favor. We’re always here to talk through their options.
