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Meta-Analysis
. 2021 Jul 7:374:n1511.
doi: 10.1136/bmj.n1511.

Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence

Ashley W Blom  1   2 , Richard L Donovan  2 , Andrew D Beswick  2 , Michael R Whitehouse  3   2 , Setor K Kunutsor  3   2
Affiliations
Meta-Analysis

Common elective orthopaedic procedures and their clinical effectiveness: umbrella review of level 1 evidence

Ashley W Blom et al. BMJ. .

Abstract

Objective: To determine the clinical effectiveness of common elective orthopaedic procedures compared with 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 most common elective orthopaedic procedures-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 compared the clinical effectiveness of any of the 10 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 whether recommendations for each procedure reflected the body of evidence.

Main outcome measures: Quality and quantity of evidence behind common elective orthopaedic interventions and comparisons with the strength of 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. No randomised controlled trials 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 subgroups, no strong, high quality evidence base shows that many commonly performed elective orthopaedic procedures are more effective than non-operative alternatives. Despite the lack of strong evidence, some of these procedures are still recommended by national guidelines in certain situations.

Systematic review registration: PROSPERO CRD42018115917.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform 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.

Figures

Fig 1
Fig 1
Jadad decision algorithm
Fig 2
Fig 2
PRISMA flow diagram. ACL=anterior cruciate ligament
Fig 3
Fig 3
Overall findings of umbrella review by outcome measures and orthopaedic procedures. ACL=anterior cruciate ligament; IKDC=International Knee Documentation Committee; KOOS=Knee Injury and Osteoarthritis Outcome Score
See this image and copyright information in PMC

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