For orthopedic surgeons, the threshold for surgery is rarely set by an X-ray — it’s set by the patient.
While most orthopedic conditions can first be treated conservatively, five surgeons say the decision to operate ultimately belongs to the person living with the pain, and arrives when conservative measures no longer hold.
Ask Orthopedic Surgeons is a weekly series of questions posed to orthopedic surgeons and leaders around the country about clinical, business and policy issues affecting orthopedic care. Becker’s invites all orthopedic surgeons and specialists to respond.
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Note: Responses were lightly edited for clarity and length.
Question: How do you decide when conservative treatment has run its course and surgery is the right call?
Joshua Alpert, MD. Orthopedic Surgeon of Fox Valley Orthopedics (Geneva, Ill.): When it comes to orthopedic surgery, we generally try to avoid surgery unless it’s an urgent situation such as a broken bone sticking out of the skin, a fully torn tendon or when a joint that’s out of alignment. Many orthopedic conditions can at first be treated conservatively. Often as a surgeon, we explain to the patient all of the conservative options available to them which often consist of physical therapy and different kinds of injections such as Cortisone or stem cells. We often will try brace treatment with rest as often we just have to give it time for these orthopedic issues to heal on their own.
Once a patient has tried and failed these conservative options, and they are still in pain that’s affecting their life, that is when we discuss surgical intervention for the orthopedic problem. Some patients will try these conservative options for many years and then decide that surgery is the next step for them, other patients will try these conservative options for only a few months and know their own body well enough to understand that the conservative options will not work and surgery is the next best step.
The most important part of deciding between conservative and surgical options often is having an open, straightforward discussion between the patient and the physician and informing the patient of the treatment options that are available to them.
Armin Arshi, MD. Orthopedic Surgeon at DISC Newport Beach (Calif.): The transition from conservative management to surgical intervention is rarely defined by an X-ray alone; it is defined by the erosion of a patient’s functional independence. I consider conservative treatment to have run its course when a patient’s quality of life is no longer manageable through activity modification, injections or physical therapy. When patients ask me if they are truly “ready” for a joint replacement, I always pose the thought that “nobody ever died of hip or knee pain.” This reinforces that the timing of surgery is a deeply personal, patient-centered discussion. Surgery becomes the right call when the patient decides they are no longer willing to accommodate the limitations imposed by their joint. If the pain has become a constant factor that dictates their daily schedule and social withdrawal, we move forward with the understanding that the goal is not just to treat an image on a screen, but to restore the patient’s ability to live life on their own terms.
Jeffrey Carlson, MD. Orthopedic Spine Surgeon at Orthopaedic & Spine Center (Newport News, Va.): Most patients come seeking the least invasive treatment for their diagnosis. There are certain diagnoses that offer no conservative treatment for the condition, and this will involve difficult conversations. When there are multiple options, the patient and doctor need to come to a mutually agreeable plan. There are certainly times when I think I know the best way forward, and the patient chooses to diverge from what I think is the best direction. Sometimes their path works for them and sometimes not, but it is their choice. Ultimately, conservative care is completed when the patient decides that they are not going to get better on their current chosen treatment regimen. Shared decision-making is only viable when the physician is sharing their knowledge and the patient is making the decision.
Robin Gehrmann, MD. Orthopedic Surgeon and Sports Medicine Specialist of RWJBarnabas Health Medical Group (Madison, N.J.): I typically recommend a three-to-six month course of conservative treatment for patients experiencing bone or joint pain. This includes anti-inflammatory medication, physical therapy and injection therapy, such as steroid treatment or other injections such as Platelet-Rich Plasma (PRP). If after trying these measures, their pain and mobility are still limiting their everyday activities, such as sleeping and getting dressed, then we begin to think about surgical options. For those who elect not to have surgery or who don’t qualify for surgery due to age or other health conditions, we’ll consult with a pain management specialist to manage their pain with non-operative techniques, such as nerve blocks.
Naudereh B. Noori, MD. Orthopedic Surgeon of UCI Health (Irvine, Calif.): In general, surgery is considered when conservative treatments — such as physical therapy, supportive footwear, activity modification, over-the-counter pain medications, injections or bracing — have not provided enough relief. However, some conditions, including certain fractures or tendon injuries, may require earlier surgery because delaying treatment could lead to a poorer outcome.
The decision to proceed with surgery is always individualized and made through a shared decision-making process. If pain continues to significantly limit a patient’s daily activities, function or overall quality of life, surgery may be the best option to relieve pain, restore function and help them return to the activities that are important to them. We carefully discuss the expected benefits, potential risks, recovery process and the patient’s personal goals so they can make an informed decision that aligns with their needs and preferences.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.